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The pressure to prevent pressure ulcers

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By Warren R. Heymann, MD, FAAD
Aug. 24, 2022
Vol. 4, No. 34

Dr. Warren Heymann photo
Pressure ulcers (PUs, aka decubitus ulcers, pressure sores, bed sores) are due to prolonged pressure, characteristically over bony prominences such as the sacrum, occiput, ischial tuberosities, greater trochanters, heels, and lateral malleoli. (1,2) Interestingly, in the COVID-19 era, with patients being placed in the prone position to improve their respiratory status, facial pressure ulcers (possibly accompanied by purpura) may develop. (3) Advanced PUs may prove fatal. (1,2) Physical burdens on patients and societal economic burdens of PUs are staggering.

The first step in managing PUs is being confident of the diagnosis, excluding such mimickers as diabetic ulcers, venous ulcers, pyoderma gangrenosum, and underlying osteomyelitis. PU are staged as follows (2):

  • Stage I: Intact skin with the presence of non-blanchable erythema.

  • Stage II: Partial-thickness skin loss involving the epidermis and dermis.

  • Stage III: Full-thickness skin loss extending to subcutaneous tissue but not crossing the fascia beneath it.

  • Stage IV: Full-thickness skin loss extending through the fascia with considerable tissue loss, possibly involving loss of muscle, bone, tendon, or joint.

Although PUs may be appreciated in all age groups and clinical settings, the incidence of PUs in hospitalized patients ranges from 9% to 18%, most commonly in the elderly. (4) It has been estimated that costs attributed to U.S. hospital-acquired PUs could exceed $26.8 billion (in 2016 dollars). Approximately 59% of these costs could be disproportionately attributable to Stages 3 and 4 full-thickness wounds, occupying clinician time and hospital resources. (5)

Image for DWII on pressure ulcers
Image for DWII on pressure ulcers
Image from JAAD 1998; 38: 517-538.

The etiology of PU, while seemingly straightforward, is deceptively complex. Constant and prolonged pressure (combined with friction, shearing forces, and moisture) is essential, but it is the multifactorial contributors — loss of sensory perception, nutritional status, peripheral vascular disease, congestive heart failure, mental acuity, and others — that foster PU development and challenges therapy. As little as two hours of immobility is sufficient to create a microenvironment of ischemia that may result in tissue necrosis and ulceration. (1,2)

It has been estimated that the cost of treating PU is 2.5 times greater than prevention. (3) The principles of managing PU include: 1) elimination of relative/sustained pressure; 2) repositioning the patient regularly and frequently; 3) removal of necrotic debris; 4) maintenance of a moist wound environment; 4) addressing and correcting underlying contributing factors; 5) screening for nutritional deficiencies and providing adequate nutritional support and supplementation; and 6) wound care with topical agents/and or dressings. (1)

The key preventive strategies for PU include patient education, risk assessment, nutritional evaluation, repositioning, skin protection, and incontinence management. (4)

Beeckman et al sought to determine whether silicone foam dressings, in addition to standard prevention, reduce the incidence of PUs (category [stage] 2 or worse) compared with standard prevention alone. The authors performed a multicenter, randomized controlled medical device trial conducted in eight Belgian hospitals. At-risk adult patients were centrally randomized (n = 1633) to study groups based on a 1 : 1 : 1 allocation: experimental groups 1 (n = 542) and 2 (n = 545) — pooled as the treatment group — and the control group (n = 546). The experimental groups received PU prevention according to hospital protocol, and a silicone foam dressing on the relevant body sites. The control group received standard of care. The primary endpoint was the incidence of a new PU of category 2 or worse at the studied body sites. In the intention-to-treat population (n = 1605), PU of category 2 or worse occurred in 4.0% of patients in the treatment group and 6.3% in the control group [relative risk (RR) 0.64, P = 0.04]. Sacral PUs were observed in 2.8% and 4.8% of the patients in the treatment group and the control group, respectively (RR 0.59, P = 0.04). Heel PUs occurred in 1.4% and 1.9% of patients in the treatment and control groups, respectively (RR 0.76, P = 0.49). The authors concluded that silicone foam dressings reduce the incidence of PUs of category 2 or worse in hospitalized at-risk patients when used in addition to standard of care. The results showed a decrease for the sacrum, but no statistical difference for the heel and trochanter areas. The authors emphasized that while the use of silicone adhesive multilayer foam dressings might be a useful adjunct, the cornerstone of PU prevention remains the current standard guidelines. (6)

In an accompanying editorial to Beeckman et al, Coyer agrees that despite their efficacy, prophylactic dressings are not a stand-alone intervention. Clinicians should not develop a false sense of security by being overly reliant on such dressings. (7)

Everyone is pressured by PU — the patient, clinician, and society at large. With increased longevity, the burden of PUs is likely to increase. Further research in PU prevention is essential.

Point to Remember: Pressure ulcers have the potential to be devastating — for the patient and society. While new devices such as silicone adhesive multilayered dressings may help prevent sacral decubitus ulcers, they do not supplant basic concepts of pressure ulcer prevention.

Our expert’s viewpoint

Robert S. Kirsner, MD, PHD, FAAD
Chair & Harvey Blank Professor
Dr. Phillip Frost Department of Dermatology & Cutaneous Surgery
University of Miami Miller School of Medicine

Pressure injuries (PI), previously called pressure ulcers (PU), while the most common chronic wound in the United States (U.S.), are less commonly seen by outpatient physicians because of the nature of the populations affected. (8) Treating PI is difficult, costly, and the stakes are high. Since risk factors are well known and every hospitalized patient in the US is assessed for the likelihood of them developing a PI using PI risk assessment tool (most commonly the validated Braden Scale), prevention is critical. PI prevention teams exist in most hospitals as care for hospital acquired PI is not reimbursed, thought by many to be preventable. (9) The Braden scale measures the patient’s sensation and perception, their mobility, nutritional status, activity, skin moisture, and the friction and shear they are prone to. The lower the score in each category (8-11) and lower resultant cumulative score the increase likelihood of developing a PI. (10)

Along with compression for patients at risk for venous leg ulcers, and proper footwear for patients with diabetic neuropathy to prevent diabetic foot ulcers, prevention of pressure ulcers, though proper offloading of pressure prone areas, is among the best studied preventative strategies in wound care. (11) Based on initial clinical observations over the past decade, the use of silicone dressings has emerged to join offloading, as well studied approaches, to prevent PIs in a variety of at-risk patient populations. While it is not likely that all silicone dressings are equal, the most studied dressings are multi-layer products that re-distribute pressure within the bandage and reduce moisture, friction, and shear. Experimental modeling and several well performed randomized controlled trials support their use. (12)

Dermatologists, with our expertise in the physiology of the skin, are the perfect specialists to recommend evidence-based strategies to improve patients’ outcomes and save lives. (13) If we engage in the management of PIs, patients and our specialty will benefit — societal health will improve, costs will be reduced, and dermatologists will be more visible in the house of medicine.

  1. Parish LC, Karadag AS, Parish JL. Decubitus (pressure) ulcers. In Lebwohl MG, Heymann WR, Coulson IH, Murrell DF (eds). Treatment of Skin Disease, Sixth Edition. Elsevier (in press)

  2. Zaidi SRH, Sharma S. Decubitus Ulcer. 2021 May 7. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 31971747.

  3. Rrapi R, Chand S, Lo JA, Gabel CK, Song S, Holcomb Z, Iriarte C, Moore K, Shi CR, Song H, Di Xia F, Yanes D, Gandhi R, Triant VA, Kroshinsky D. The significance of pressure injuries and purpura in COVID-19 patients hospitalized at a large urban academic medical center: A retrospective cohort study. J Am Acad Dermatol. 2021 Aug;85(2):462-464. doi: 10.1016/j.jaad.2021.03.051. Epub 2021 Mar 20. PMID: 33753253; PMCID: PMC7979268.

  4. Wung Buh A, Mahmoud H, Chen W, McInnes MDF, Fergusson DA. Effects of implementing Pressure Ulcer Prevention Practice Guidelines (PUPPG) in the prevention of pressure ulcers among hospitalised elderly patients: a systematic review protocol. BMJ Open. 2021 Mar 12;11(3):e043042. doi: 10.1136/bmjopen-2020-043042. PMID: 33712523; PMCID: PMC7959222.

  5. Padula WV, Delarmente BA. The national cost of hospital-acquired pressure injuries in the United States. Int Wound J. 2019 Jun;16(3):634-640. doi: 10.1111/iwj.13071. Epub 2019 Jan 28. PMID: 30693644; PMCID: PMC7948545.

  6. Beeckman D, Fourie A, Raepsaet C, Van Damme N, Manderlier B, De Meyer D, Beele H, Smet S, Demarré L, Vossaert R, de Graaf A, Verhaeghe L, Vandergheynst N, Hendrickx B, Hanssens V, Keymeulen H, Vanderwee K, Van De Woestijne J, Verhaeghe S, Van Hecke A, Savoye I, Harrison J, Vrijens F, Hulstaert F. Silicone adhesive multilayer foam dressings as adjuvant prophylactic therapy to prevent hospital-acquired pressure ulcers: a pragmatic noncommercial multicentre randomized open-label parallel-group medical device trial. Br J Dermatol. 2021 Jul;185(1):52-61. doi: 10.1111/bjd.19689. Epub 2020 Dec 28. PMID: 33216969; PMCID: PMC8359283.

  7. Coyer F. Silicone adhesive multilayered foam dressings for pressure ulcer prevention. Br J Dermatol. 2021 Jul;185(1):4-5. doi: 10.1111/bjd.19873. Epub 2021 Mar 4. PMID: 33661525.

  8. https://npiap.com/

  9. Pieper B, Kirsner RS. Pressure ulcers: even the grading of facilities fails. Ann Intern Med. 2013;159:571-2.

  10. Bergstrom N, Braden B. Predicting pressure sores in those at risk. Am J Nurs. 1989 Jan;89(1):35

  11. Gould L, Stuntz M, Giovannelli M, Ahmad A, Aslam R, Mullen-Fortino M, Whitney JD, Calhoun J, Kirsner RS, Gordillo GM. Wound Healing Society 2015 update on guidelines for pressure ulcers. Wound Repair Regen. 2016;24:145-62.

  12. Moore ZE, Webster J. Dressings and topical agents for preventing pressure ulcers. Cochrane Database Syst Rev. 2018 ;12:CD009362.

  13. Kirsner RS. Skin care: from skin health to ulcer prevention. Ostomy Wound Manage. 2006;52:23-4.

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