Are there best practices for preventing and managing pressure ulcers?
Clinical Applications
Dr. Schwarzenberger is the former physician editor of DermWorld. She interviews the author of a recent study each month.
By Kathryn Schwarzenberger, MD, January 1, 2020
In this month’s Clinical Applications column, Physician Editor Kathryn Schwarzenberger, MD, talks with Joshua Mervis, MD, and Tania J. Phillips, MD, about their recent JAAD article "Pressure ulcers: Prevention and management."
Dr. Schwarzenberger: You wrote a wonderfully comprehensive review on pressure injury/pressure ulcers. It seems like this is an enduring problem for some of our patients. Do we know anything new about the pathogenesis of pressure ulcers?
Drs. Mervis and Phillips: Certainly, the tenet that sustained pressure leading to ischemia and ultimately tissue necrosis remains fundamental. The highest pressures often occur between bone and muscle, so that deep tissue necrosis can occur even when the skin is intact. By the time skin ulceration is observed, deep tissue injury has already occurred. One new hypothesis regarding the pathogenesis of pressure ulcers concerns the possibility of reperfusion injury, with return of blood supply after a period of ischemia. Reperfusion of ischemic tissue may cause increased formation of reactive oxygen species and trigger an inflammatory response. Shear and friction can also contribute to tissue hypoxia by disrupting local capillary flow.
Dr. Schwarzenberger: Who gets pressure ulcers and how quickly do they arise? Do we see them in the acute care setting, or are they limited to nursing home patients?
Drs. Mervis and Phillips: The time to pressure ulcer formation likely varies by body site, nutritional status, and other site-specific factors. Pressure ulcers can occur in anyone. In healthy individuals, a feedback response to sustained pressure prompts a change in body position. This response is commonly absent or diminished in people with impaired mobility or sensation, such as with spinal cord injuries, other neurologic impairment, sedation, and postoperative immobilization. In the elderly, natural skin changes such as dermal and epidermal thinning, decreased epidermal turnover, and flattening of the dermoepidermal junction make aging skin more susceptible to shear and friction.
Pressure ulcers are not limited to nursing home patients. It’s true that some of the highest prevalence is seen in nursing home patients (around 25% in those admitted to hospitals), but pressure ulcers are very common in the acute care setting as well. Hospital-acquired pressure ulcers remains a serious issue, occurring in around 7.5% of all patients. Pressure ulcers are also very commonly seen in long-term acute care facilities (around 25%) and other acute care facilities (around 15%).
Dr. Schwarzenberger: It seems like this is one situation in which prevention is preferable to treatment. Are they ultimately preventable?
Drs. Mervis and Phillips: Although this remains a somewhat controversial topic, most pressure ulcers are preventable. In rare circumstances, a patient may be so sick or unstable that the risk of pressure redistribution strategies outweighs the benefits. There is ongoing debate about skin changes/breakdown that occur at the very end of life and whether these wounds should be classified as pressure ulcers.
Dr. Schwarzenberger: What do we know about the role of nutrition in the cause, as well as the management, of pressure ulcers?
Drs. Mervis and Phillips: Malnutrition, eating problems, and weight loss are associated with pressure ulcer development. Loss of muscle bulk and body mass with subsequent accentuation of bony prominences may increase risk of ulceration due to pressure effects. In patients without evidence of malnutrition, there is no data to support any specific interventions intended to boost nutritional status, such as protein or vitamin/nutrient supplementation.
Dr. Schwarzenberger: We have so many wound dressings available these days. Does one work better than the others?
Drs. Mervis and Phillips: The two things to consider here are dressings for prevention and dressings for treatment. Prophylactic dressings may minimize the effects of friction and shear. There is some limited evidence that hydrocolloid and foam dressings applied to at-risk areas may lower the incidence of pressure ulcers. Dressings can also prevent skin breakdown secondary to maceration in incontinent patients. Moreover, these preventative measures may reduce cost when compared with the cost of treatment.
When choosing a wound dressing, one should always seek to promote a moist wound healing environment. Finding a balance between exudate absorption and moisture retention is key. The antibacterial properties of silver- or honey-containing dressings may reduce bioburden in the short term, but there is no evidence to support long-term use of these dressings. Ultimately, dressing choice should be tailored to the individual and frequently reassessed over time.
Dr. Schwarzenberger: What do you feel is the role of the dermatologist in managing pressure ulcers? What can we handle and when should we involve our surgical colleagues?
Drs. Mervis and Phillips: In general, wound healing is a multidisciplinary field. Dermatologists should at least be comfortable managing stage 1 and 2 pressure ulcers in the typical outpatient clinic setting. Stage 3 pressure ulcers may require wound healing facilities and advanced therapies not typically available in the dermatology office. Particularly for more extensive stage 3 or 4 pressure ulcers, where a skin flap may be required, our surgical colleagues should be consulted.
Joshua Mervis, MD, and Tania J. Phillips, MD, work in the Department of Dermatology at Boston University School of Medicine. Drs. Mervis and Phillips have no relevant financial or commercial interests. Their article appeared in JAAD.
Disclaimer: The views and opinions expressed in this article do not necessarily reflect those of DW.
