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Pressure sores (ulcers) present as injuries to the skin and underlying tissues. They develop locally, as a result of long-term pressure, and usually above prominent bony structures such as:

• Sacrum (tailbone),
• Elbows,
• Back,
• Heels,
• Back of the head, and
• Buttocks

For further information on this topic, you may be interested to learn more about the HealthCert Professional Diploma program in General Dermatology.

The management of pressure sores requires a multidisciplinary approach. While dermatologists play a vital part in the early stages of treatment, other medical and non-medical professionals often participate in prevention and complications’ management. These include:

• Primary care physicians
• At-home wound care nurses
• Infectious diseases specialists
• Surgeons
• Dietitians
• Psychologists
• Podiatrists
• Physiotherapists
• Social workers

Overview

Pressure sores occur in bedridden patients and those with limited movement ability. It is essential that primary care doctors assess the risk of pressure sores development in such patients, regardless of the causes of impaired mobility, and take preventive measures.

If the changes are already present, the physicians need to document their size and clinical features. They should clean the injuries with water or saline solution, look for signs of infection, and apply moist but not wet dressing before suggesting further treatment.

Prevention

Both intrinsic and extrinsic factors increase the risk of pressure sores. Intrinsic factors include:

• Limited mobility due to physical or cognitive impairment,
• Poor nutrition,
• Changes related to skin ageing, and
• Various comorbidities (diabetes, malignancies, dementia, and so on).

Extrinsic factors stem out from the relationship between the patient’s inability to move and the immediate environment, such as:

• Friction,
• Pressure from hard surfaces (bed, wheelchair, etc.),
• Shear due to involuntary muscle movements, and
• Moisture (incontinence, excessive sweating, etc.).

Preventive measures mainly focus on relieving direct pressure, skincare and dietary changes, and regular screening for early-stage skin changes.

The most valuable preventive measures are:

• Frequent repositioning of the patient.
• The use of pressure-relieving cushions and mattresses.
• Keeping the skin clean using non-aggressive skincare ingredients.
• Moisturising the skin regularly.
• A well-balanced diet and proper hydration (at least two liters of water per day).

Management

Management depends on the stage of skin changes. Here we can differentiate:

1. Clean sores without infection (cellulitis) – IV stages

• Stage I – protective dressing.
• Stage II – cleansing and a moist dressing.
• Stage III – cleansing, using moist and absorbent dressings such as gel or foam, and a surgical consultation.
• Stage IV – same management as stage III, potential biopsy sample to rule out infections, preventive topical antibiotics if there is no improvement after 14 days.

2. Clean sores with local or systemic infections

• Local infections require regular cleansing, dressing changes (moist and absorbent), and topical antibiotics.
• A biopsy to determine tissue culture and systemic antibiotics may become necessary if sepsis develops or there are no improvements after 14 days.

3. Necrotic tissue

• Surgical debridement is necessary if necrotic tissue is present. Depending on the particular case, the debridement may be:
  • Mechanical, autolytic, or enzymatic (non-urgent) or
  • Sharp if sepsis is present (urgent).

Complications

The common infectious complications of pressure sores include:

• Cellulitis
• Bacteremia
• Sepsis
• Osteomyelitis
• Meningitis
• Endocarditis
• Sinus tracts

Aside from local and systemic infections, there are also non-infectious complications of pressure sores. These are:

• Heterotopic bone formation,
• Amyloidosis,
• Pseudoaneurysm,
• Perinealurethral fistula,
• Marjolin ulcers, and
• Systemic complications of topical treatment.

– Dr Rosmy De Barros

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References

• Lima Serrano M, González Méndez MI, Carrasco Cebollero FM, Lima Rodríguez JS. Risk factors for pressure ulcer development in Intensive Care Units: A systematic review. Med Intensiva. 2017 Aug-Sep;41(6):339-346. English, Spanish. doi: 10.1016/j.medin.2016.09.003. Epub 2016 Oct 22. PMID: 27780589.
• Kottner J, Cuddigan J, Carville K, et al. Prevention and treatment of pressure ulcers/injuries: The protocol for the second update of the international Clinical Practice Guideline 2019. J Tissue Viability. 2019;28(2):51-58. doi:10.1016/j.jtv.2019.01.001
• Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015;162(5):370-379. doi:10.7326/M14-1568
• Wong D, Holtom P, Spellberg B. Osteomyelitis Complicating Sacral Pressure Ulcers: Whether or Not to Treat With Antibiotic Therapy. Clin Infect Dis. 2019;68(2):338-342. doi:10.1093/CI