Pressure ulcers represent a significant burden to global healthcare. The incidence of decubitus ulcers is estimated to be between 5 and 15% in the United States. Even though pressure ulcers, decubitus ulcers, and bedsores are popular terms, the National Pressure Ulcer Advisory Panel (NPUAP) recommends the use of the term pressure injury. 

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What Are Pressure Ulcers?

Pressure ulcers or pressure injuries are defined as damage resulting to skin and subcutaneous tissue over a bony prominence as a result of sustained pressure. Patients who are at an increased risk of developing pressure injury are elderly, immobile, or have neurological deficits. These patients are unable to change their position promptly which increases the incidence of pressure injury in this cohort. Given the high prevalence of pressure ulcers in nursing home care facilities and hospitalized patients, wound care specialists and podiatrists should familiarize themselves with the different staging systems and best management principles for pressure ulcers.

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Stages Of Pressure Ulcers

The staging system which is used to describe the appearance of pressure ulcers was developed by the national pressure injury advisory panel. It is known as the NPIAP staging system. Despite the use of the term “stage”, this classification system does not describe a stepwise progression of the pressure injury. Following are the stages of pressure ulcers:

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• Stage 1 - Non-Blanchable Erythema: In stage one, the skin is intact with a localized area of redness. It is non-blanchable, and depending on the skin color, might appear differently. Compared to the surrounding tissue, it might be painful or warmer to touch. As the skin is intact during this stage it would not be considered an ulcer.
• Stage 2 - Partial Thickness Loss Of Skin: It presents as a shallow ulcer with a reddish moist wound slough. As it is characterized by a partial loss of skin, adipose tissue and deeper structures are not visible. 
• Stage 3 - Full Thickness Skin Loss: In this stage, the adipose tissue is usually visible. There might also be the presence of slough or eschar In the wound bed. Tendons, muscles, and bones are usually not visible. The depth of stage 3 ulcers varies depending on the anatomical location.
• Stage 4 - Full Thickness Tissue Loss: In this stage, muscle, tendons, ligaments, or cartilage might be visible because of the full thickness tissue loss. There is a presence of slough and eschar along with undermining and tunneling.

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Management Of Pressure Ulcers

The management and treatment of pressure ulcers require a collaborative approach. Wound care specialists and podiatrists need to involve other members of the health care team for the best management. 

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Patient Assessment

The management of pressure ulcers requires a thorough and complete assessment of a patient's medical history, nutritional status, skin, and wound characteristics. It is important to properly document the characteristics of the wound such as its possible etiology, duration, location, the appearance of wound exudate, and peri-ulcer skin. It is also essential to recognize the elements in the patient’s environment that could be impacting healing.

Pain Relief

Pressure ulcers can be very painful for the patient. Therefore it is important to provide adequate analgesia. Pain could be due to local factors such as ischemia, infection, or skin trauma. Oral painkillers might be effective for people with mild pain. However, consider prescribing opioids for more severe pain. Ibuprofen releasing wound dressings can also be used.

Infection Control

While it is common for wounds to be colonized with bacteria, only clinically symptomatic wound infections should be treated. The presence of infection can significantly impede wound healing. Therefore it is important to treat any symptomatic infection. Consider prescribing systemic antibiotics in the presence of cellulitis or other signs of deep tissue infection.

Nutrition Optimization

The patient's nutritional status should be determined by a registered dietitian. The majority of patients with pressure ulcers are malnourished. Therefore it is important to ensure adequate protein intake and nutrition for optimum wound healing. If patients are unable to tolerate oral intake, total parenteral nutrition should be considered. Vitamin C and zinc supplements are also routinely used.

Pressure Redistribution

The majority of pressure ulcers occur due to friction or trauma from sustained pressure. To avoid the incidence of pressure ulcers, patients should be routinely mobilized. Pressure can also be redistributed by the use of special pressure-relieving support surfaces. There are three main groups of these devices which could be either static or dynamic. Group one devices include air, foam, and gel mattresses. The group two devices are powered by electricity. Group three devices only consist of air-fluidized beds.

Wound Treatment For Specific Pressure Ulcer Stages

The specific management of pressure ulcers is guided by their staging. Some of the common wound care principles for different ulcer stages are briefly described below:

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• Stage 1: The treatment is usually conservative. To protect the stage one injuries, cover them with a dressing or film.
• Stage 2: These ulcers require little wound debridement. Use a moist wound dressing to optimize healing.
• Stage 3: As these wounds tend to be deeper use absorbent dressings. Following debridement,  these ulcers would require coverage with a skin graft or flap.
• Stage 4: As with stage 3 ulcers, these wounds would also require debridement and coverage with skin flaps.

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Management Of Periwound Skin

Periwound skin is the skin immediately surrounding the wound. The health and integrity of peri-wound skin are important considerations in wound care. This is because peri-wound skin problems can directly impede wound healing. Some common problems that patients might experience include wound maceration, allergic reactions, and eczema. Some factors that can affect peri-wound skin and their management are described below:

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• Periwound maceration: Macerated skin appears whitish and boggy, and results when there is an excessive exudate. To avoid periwound skin maceration ensure that the dressing is absorbent enough. In addition, ensure frequent dressing changes to avoid moisture-associated skin damage.
• Wound exudate: Excessive wound exudate on periwound skin will require cleansing. The wound can be cleaned using either tap water or sterile saline.
• Adhesive-related damage: To protect the skin from adhesive-related damage, apply a barrier cream or emollient on the periwound skin. Choose a gentle adhesive dressing for fragile periwound skin

Urinary and fecal incontinence: Protect the peri-wound skin from urinary and fecal contaminants. Colostomy can help divert the direction of stools from the wound site.