Pressure ulcers occur in patients who are immobile for a long period or suffer a sustained pressure over an area of skin for a stretch of time. These are difficult to diagnose early and notoriously challenging to treat.

The ulcers begin as a reddish or dark discoloration of the affected skin. This phase is called Stage I of the ulcer. As the ulcer progresses without detection and treatment to stages II, III and IV, there may be deeper involvement including muscles, bones and joints as well.

Pressure ulcers, in addition, are complicated by presence of other long term disorders like diabetes, heart failure, malnutrition etc. Treatment of pressure ulcers thus needs treatment of these underlying conditions.

Another important factor in management of pressure ulcers in prevention since pressure ulcers are difficult to treat. Prevention of pressure ulcers forms an important part of management of pressure ulcers.

Aims of therapy of pressure ulcers

Aims of therapy of pressure ulcers are (1-6):

• Removal of the pressure over the affected area(s)
• Protecting the surrounding healthy skin
• Improving the body’s immunity and permitting a favourable condition in the body to facilitate natural healing process.
• Providing pain relief
• Removing and curing infections
• Removal of dead and necrotic tissues that are affected with the ulcer
• Treating the patient to control diabetes, high blood cholesterol, malnutrition and anemia etc.

Treatment of pressure ulcers

The pressure ulcer is freed of pressure. It is inspected regularly for changes. Regular re-positioning and inspection of other bony prominences and vulnerable sites is important. Therapy for pain with pain relievers and antibiotics are used.

Dressings and promoting healing

Specific treatment includes dressings, removing damaged skin and promotion of healing.

Those with infections need antibiotics and special anti-bacterial dressings to kill bacteria and help in healing.

Older types of dressing with gauze, paraffin gauze and simple dressing pads are not recommended. Dressings prescribed in cases of pressure ulcers include hydrocolloids, hydrogels, foams, films, alginates, soft silicones:

• Hydrogels – These are gels that keep the wounds moist and help in cleaning the wounds.
• Hydrocolloids – These are adhesive dressings that forms a gel over the wound and attached itself to the surrounding healthy skin.
• Foams may be used to absorb and retain fluid and keep the ulcer dry and help in healing.

Barrier creams should not be used with superficial pressure ulcers.

Other therapies for pressure ulcers

Other therapies include electrical stimulation that sends tiny jolts to induce healing.

Sometimes surgical therapy is recommended. This includes removal of the dead and damaged skin. This is called debridement. This is done by cutting away areas of dead tissue. Debridement may also be done using tissue dissolving enzymes.

Large ulcers may need more extensive operative therapy. The areas after healing may also require cosmetic therapy with skin grafts from other healthy parts of the body to be placed over the healing ulcers.

Pressure ulcers are often slow to heal, because of continued adverse factors such as pressure or poor nutrition. Vitamin C (500mg twice daily) is thought to reduce the surface area of pressure ulcer and Zinc sulphate (220 mg thrice daily) also helps in wound healing. These are supplemented with improved general nutrition.

Prevention of pressure ulcers

Pressure ulcers may develop very fast especially in some individuals. Development of a pressure ulcer may take even as short a time as an hour if the person is unable to move for even a very short time.

Once developed the ulcers may progress soon to deeper tissues and may lead to pain and longer hospital stays.

In extreme cases, pressure ulcers can become life threatening. Severe infections like blood poisoning or sepsis and bone infections may be seen.

Ways to prevent pressure ulcers

Pressure ulcers may be prevented by regular vigilance and awareness. Some steps in prevention of pressure ulcers include:

• Continuous movements - Continuous movement and re-postitioning of the patient relieves the pressure on areas that are vulnerable to pressure ulcers. There should be a repositioning timetable to record the changes in position.  A patient with an ulcer is made to lie in such a way that there is no pressure on the ulcer to prevent its worsening. There should be advice regarding correct sitting and lying positions, good posture, foot support and use of equipments to prevent pressure.
• Mattresses and cushions - These are of various types to prevent pressure sores. Low-air loss beds may be used. These are waterproof but absorb excess water. Some of these can also pulsate and oscillate from time to time to redistribute pressure. There are also Air-fluidized beds. Here the patient floats on silicone coated glass beads that have heated air forced among them. These reduce friction and shear.
• Regular Skin assessment - The whole skin should be assessed regularly to check for signs of pressure ulcer development. Scales and tools are used to detect early changes. Some tell-tale signs include red patches of skin that do not fade, blisters, or damage to the skin, warm or cool or hard skin patches with or without swelling.
• Self care - Regular skin inspection and posture change routine is developed by the patient with the help of his or her care giver and healthcare professional to prevent ulcers.
• Diet - Patients are advised to eat a healthy and balanced diet. Some supplements may be prescribed if there is a deficiency. (1-6)