Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
pressure-reducing aids + repositioning
Treatment for all patients should include pressure relief, good hygiene practice, and skin care, particularly in the sacral region.
Pressure relief is critical to pressure ulcer treatment and is achieved through repositioning and use of an appropriate support surface. Patients should not be positioned on their wound. Guidelines recommend that repositioning frequency should be determined with consideration to the individual's level of activity, mobility and ability to independently reposition.[17] In many institutions, repositioning every 2 hours is the standard of care for at-risk individuals. This may, however, be difficult to achieve in a busy clinical setting, and use of prompting systems to encourage scheduled repositioning should be encouraged.[40][95]
Appropriate pressure-reducing aids, including mattresses and wheelchair or seat cushions, should be immediately provided. Little evidence supports the use of a specific support surface over other alternatives.[59][57]
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hygiene and cleansing + dressings
Treatment recommended for ALL patients in selected patient group
The aim of topical treatment is to achieve a clean wound bed, an essential precursor to healing.[69][70] If erythema or pus are seen, a wound swab may be taken to obtain evidence of infection. While commonly used, wound swabs have not been shown to be useful in the management of potential infected pressure ulcers. Consequently, guidelines do not recommend routine use of wound swabs.[17]
The presence of excess moisture may exacerbate damage caused by frictional or shear force, so it is important to ensure that the skin of incontinent patients is regularly cleansed and dried and protective creams applied as appropriate.
There is little evidence to suggest which type of wound-cleansing solution or technique, dressing, or topical agent, is most likely to heal pressure ulcers.[71][72]
Once the wound has been cleansed the choice of dressing is influenced by several factors, including the depth and size of the wound and the amount of exudate produced.[73]
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A hydrocolloid dressing typically will provide a suitable environment to promote healing. Topical therapy should be chosen using a structured approach and determined by local policies and formularies.[74][75][73] Honey-impregnated dressings may be helpful in bacterial infection.[76]
dietary optimisation
Treatment recommended for ALL patients in selected patient group
All patients at risk of pressure ulcers or who have pressure ulcers should be referred to a dietitian to ensure adequate total calorie and total protein intake.[60] A full nutritional assessment should be performed.[61]
An abbreviated nutritional assessment, as defined by the Nutrition Screening Initiative, should be performed at least every 3 months for patients at risk for malnutrition.[62] These include patients who are unable to take food by mouth or who experience an involuntary change in weight.
If normal feeding mechanisms and dietary supplements are insufficient to meet the nutritional needs of the patient, nutritional support (usually by tube feeding) should be used to place the patient into positive nitrogen balance (approximately 30-35 kcal/kg/day and 1.25 to 1.50 g of protein/kg/day). As much as 2 g of protein/kg/day may be needed in some instances, together with vitamin and mineral supplements, where deficiencies are suspected or confirmed.
Additional protein or amino acid supplementation may enhance healing; however, there is limited evidence to support this.[48][63] One small trial found that a nutritional formula enriched with arginine, zinc, and antioxidants led to improved healing.[64] Anabolic steroids have been used to promote weight gain and healing in patients with chronic wounds. However, a randomised clinical trial of oxandrolone in spinal cord injury patients with pressure ulcers failed to show any benefit compared with placebo.[65]
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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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