Pressure Ulcer Management: Evidence-Based Approaches for Prevention and Treatment

Pressure ulcers, also known as pressure injuries or bedsores, represent a significant challenge in healthcare settings, particularly for immobile patients. These localized injuries to the skin and underlying tissue, typically occurring over bony prominences, can lead to severe pain, infection, increased hospitalization, and mortality. The global prevalence of pressure ulcers in acute care settings has been estimated at approximately 8.4% to 14.8%, with incidence rates varying by care setting and patient population (European Pressure Ulcer Advisory Panel [EPUAP] et al., 2019). Effective management hinges on a proactive, evidence-based strategy encompassing prevention, early detection, and appropriate treatment. This article details current best practices and the latest clinical evidence for managing pressure ulcers, offering actionable insights for healthcare professionals.

Understanding Pressure Ulcers: Etiology and Staging

Pressure ulcers develop when sustained pressure, often combined with shear and friction, compromises blood flow to the skin and underlying tissues. This ischemia leads to cellular hypoxia and necrosis. Key contributing factors include:

• Immobility: Patients unable to reposition themselves are at highest risk.
• Sensory Deficit: Reduced sensation prevents individuals from recognizing discomfort and repositioning.
• Moisture: Incontinence (urine/feces) or perspiration can macerate the skin, increasing susceptibility.
• Nutrition: Poor nutritional status, particularly protein deficiency, impairs tissue resilience and repair.
• Friction and Shear: Sliding across surfaces can damage skin layers and impede blood flow.

The National Pressure Injury Advisory Panel (NPIAP) categorizes pressure ulcers into stages, a classification system that has been widely adopted internationally and forms the foundation of clinical decision-making in wound care (EPUAP et al., 2019):

• Stage 1: Non-blanchable Redness: Intact skin with a localized area of non-blanchable erythema, deeper tissue may be involved if dark-skinned.
• Stage 2: Partial Thickness Skin Loss: Open superficial ulcer with a shallow, red-pink wound bed without slough. May present as an intact or open/ruptured serum-filled blister.
• Stage 3: Full Thickness Skin Loss: Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
• Stage 4: Full Thickness Tissue Loss: Exposed bone, tendon, or muscle. Slough or eschar may be present. These ulcers often involve undermining and tunneling.
• Unstageable: Obscured Full Thickness Tissue Loss: Full thickness tissue loss where the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) or eschar (tan, brown, or black) in the wound bed, obscuring the true depth.
• Deep Tissue Pressure Injury (DTPI): Localized, discolored intact skin or a blood-filled blister caused by damage of underlying soft tissue from prolonged pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, and warmer or cooler as compared to adjacent tissue.

Prevention Strategies: The Cornerstone of Management

Prevention is universally recognized as the most effective strategy for managing pressure ulcers. The 2019 International Clinical Practice Guideline emphasizes that comprehensive prevention programs should be individualized and multidisciplinary, involving nurses, physicians, therapists, and patient/family education (EPUAP et al., 2019). Key elements include:

1. Risk Assessment

Regular, systematic assessment using validated tools (e.g., Braden Scale, Norton Scale) is crucial to identify individuals at risk. The Braden Scale, which evaluates sensory perception, moisture, activity, mobility, nutrition, and friction/shear, remains the most widely validated and utilized instrument in clinical practice (EPUAP et al., 2019). Assessments should be conducted at regular intervals and upon any change in patient condition.

2. Repositioning and Offloading Pressure

• Regular Repositioning: Patients should be turned and repositioned at least every two hours, or more frequently based on individual risk and tolerance. Utilization of specialized support surfaces (e.g., high-specification foam mattresses, alternating pressure air surfaces) is critical for redistributing pressure.
• Heel Protection: Heels are highly vulnerable due to minimal subcutaneous tissue and prolonged pressure. Offloading devices such as heel protectors or suspension systems should be employed.
• Avoid Head Elevation: Elevating the head of the bed greater than 30 degrees can cause shear forces on the sacrum and coccyx, increasing pressure ulcer risk.

3. Skin Care and Moisture Management

• Gentle Cleansing: Use mild, pH-balanced cleansers. Avoid harsh soaps and vigorous scrubbing. The skin’s natural acidic pH (approximately 4.0-5.5) serves as a protective barrier against microbial colonization, and alkaline cleansers can disrupt this defense mechanism.
• Moisturizing: Apply emollients to dry skin to maintain hydration and barrier function.
• Incontinence Management: Prompt cleansing and drying of skin exposed to moisture. Use of moisture barrier ointments or films can protect the skin.

4. Nutrition Support

Adequate protein, calories, vitamins (especially C and A), and minerals (like zinc) are vital for tissue integrity and repair. Nutritional assessments and supplementation may be necessary for at-risk individuals. The clinical guideline recommends that patients at risk for pressure injuries receive high-calorie, high-protein nutritional supplements in addition to their usual diet (EPUAP et al., 2019).

5. Friction and Shear Reduction

• Repositioning Techniques: Use lifting devices and draw sheets to minimize friction and shear during repositioning.
• Protective Dressings: Consider protective films or dressings over high-risk areas.

Treatment Approaches: Evidence-Based Interventions

When a pressure ulcer develops, a staged approach to treatment is required, focusing on wound bed preparation, managing exudate, controlling infection, and promoting healing. The TIME framework (Tissue, Infection/Inflammation, Moisture, Edge) provides a structured approach to wound bed preparation that guides clinical decision-making (EPUAP et al., 2019).

1. Wound Assessment

A thorough assessment of the ulcer is the first step. This includes determining the stage, size (length, width, depth), presence of undermining/tunneling, wound bed characteristics (granulation, slough, eschar), exudate amount and type, and signs of infection. Regular reassessment using validated tools such as the Pressure Ulcer Scale for Healing (PUSH) tool enables clinicians to track healing progress and adjust treatment plans accordingly.

2. Debridement

Removal of non-viable tissue (slough and eschar) is essential for wound healing. Evidence supports various debridement methods:

• Sharp/Surgical Debridement: Rapid removal of necrotic tissue by a surgeon or trained clinician.
• Enzymatic Debridement: Application of topical enzymes to break down necrotic tissue.
• Autolytic Debridement: Utilizing the body’s own enzymes under a moisture-retentive dressing.
• Mechanical Debridement: Using wet-to-dry dressings (less favored due to potential trauma) or irrigation devices.

The choice of method depends on the wound characteristics, patient condition, and clinician expertise. The clinical guideline recommends debridement of necrotic tissue when appropriate and when the wound bed characteristics support this intervention (EPUAP et al., 2019).

3. Infection Control

Clinical signs of infection (redness, warmth, swelling, purulent drainage, increased pain, fever) require prompt intervention. While prophylactic antibiotics are generally not recommended for pressure ulcers, therapeutic antibiotics may be indicated for established infections. Topical antimicrobial agents, such as those containing silver or HOCl, can also be considered to reduce bacterial burden (Sakarya et al., 2014). Sakarya et al. (2014) demonstrated that stabilized HOCl solution achieved complete eradication of all tested microorganisms within 12 seconds, with dose-dependent favorable effects on fibroblast and keratinocyte migration compared to povidone-iodine. More recently, Gold et al. (2020) concluded that topical stabilized HOCl provides powerful microbicidal and antibiofilm properties while simultaneously functioning as a topical wound healing agent, offering clinicians a significant advantage over traditional antiseptics that may impair cellular components of wound healing.

4. Wound Dressings and Moisture Management

The goal is to maintain a moist wound environment conducive to healing while managing exudate. The selection of appropriate dressings should be based on wound characteristics, exudate level, and the stage of healing:

• Stage 1: Protective dressings or films can prevent further injury.
• Stage 2: Moisture-retentive dressings like hydrocolloids, hydrogels, or transparent films are often suitable.
• Stage 3 and 4: Absorbent dressings, foams, alginates, or hydrofibers may be needed to manage moderate to heavy exudate. Negative Pressure Wound Therapy (NPWT) can be highly effective for large, complex wounds with adequate tissue base.

5. Pain Management

Pressure ulcers can be extremely painful. A multimodal approach including pharmacological (analgesics) and non-pharmacological interventions should be employed. Pain assessment should be conducted regularly using validated scales, and management strategies should be individualized to the patient’s needs and preferences (EPUAP et al., 2019).

6. Nutritional Support

As noted in prevention, adequate nutrition is critical for the healing of existing ulcers. High-protein diets (1.25-1.5 g/kg body weight per day), supplements, and hydration are paramount. Adequate caloric intake (30-35 kcal/kg body weight per day) supports the increased metabolic demands of wound healing.

Advanced Therapies and Future Directions

Negative Pressure Wound Therapy (NPWT)

Widely used for Stage 3 and 4 pressure ulcers, NPWT promotes wound healing by managing exudate, enhancing granulation tissue formation, and reducing bacterial load. The clinical guideline recommends NPWT for Stage 3 and Stage 4 pressure injuries when conventional therapy is insufficient (EPUAP et al., 2019).

Bioengineered Skin Substitutes

For recalcitrant wounds, advanced dressings and skin substitutes offer bio-active components to promote healing. These include cellular and acellular matrices that provide scaffolding for tissue regeneration.

Topical Oxygen Therapy

Emerging evidence suggests benefits in selected non-healing wounds by increasing oxygen diffusion to the wound bed. Oxygen plays a critical role in collagen synthesis, angiogenesis, and infection control.

HOCl in Wound Cleansing

The use of HOCl solutions for wound irrigation and cleansing is gaining significant traction due to its antimicrobial efficacy, biofilm disruption, and excellent safety profile, offering an alternative to traditional agents. Research continues to solidify its role in promoting healing in complex wounds. Burian et al. (2022) conducted a randomized controlled trial demonstrating that stabilized HOCl solution increased re-epithelialization by 14% compared to saline control on day 4 in acute wounds (p = 0.00051), while maintaining significantly lower bacterial counts throughout the treatment period. Furthermore, Herruzo et al. (2023) found that a combined HOCl therapy (liquid plus gel formulation) was a key prognostic factor for complete healing in chronic ulcers, with an odds ratio of 4.8 for complete healing compared to other antiseptic monotherapies. Most recently, Fazli et al. (2024) conducted a first-in-human randomized clinical study investigating the safety and tolerability of stabilized HOCl in patients with chronic leg ulcers, confirming that the treatment was safe and well-tolerated while achieving a 98% median reduction in wound bioburden compared to 49% with placebo. These findings collectively support HOCl as a valuable adjunct in comprehensive pressure ulcer management, particularly for wounds with significant bacterial burden or biofilm presence.

Conclusion

Comprehensive pressure ulcer management requires a robust, multi-faceted approach prioritizing prevention through diligent risk assessment and skin protection. When ulcers do occur, timely and accurate assessment followed by evidence-based interventions including appropriate debridement, infection control, moisture-balanced dressings, and nutritional optimization are critical for promoting healing and preventing complications. The growing body of evidence supporting HOCl as an effective antimicrobial and wound-healing agent, demonstrated across multiple randomized controlled trials and clinical studies (Sakarya et al., 2014; Gold et al., 2020; Burian et al., 2022; Herruzo et al., 2023; Fazli et al., 2024), positions it as a valuable tool in the clinician’s armamentarium. Continued research into advanced therapies and existing agents like HOCl promises further improvements in the outcomes for patients suffering from these debilitating conditions. For related care, explore resources in our comprehensive skin-treatment solutions.

Frequently Asked Questions (FAQ)

Q1: What are the main causes of pressure ulcers?

A1: They are primarily caused by sustained pressure on the skin over bony areas, often exacerbated by shear, friction, immobility, moisture, poor nutrition, and sensory deficits.

Q2: How can I prevent pressure ulcers from developing?

A2: Prevention involves regular repositioning (at least every two hours), using pressure-redistributing surfaces, maintaining good skin hygiene and moisture balance, ensuring adequate nutrition, and protecting skin from friction and shear.

Q3: What are the different stages of pressure ulcers?

A3: They are staged from 1 (non-blanchable redness) to 4 (full thickness loss with exposed bone/tendon/muscle), with unstageable (covered by slough/eschar) and deep tissue pressure injury (DTPI) categories also defined.

Q4: What is the role of debridement in pressure ulcer treatment?

A4: Debridement is the removal of non-viable tissue (slough or eschar) from the wound bed. This is crucial for allowing new tissue to grow and for preventing infection. Various methods like surgical, enzymatic, or autolytic debridement can be used.

Q5: Can HOCl be used for pressure ulcer management?

A5: Yes, HOCl can be beneficial for pressure ulcer management, particularly for wound cleansing and reducing bacterial burden. Its antimicrobial efficacy, biofilm disruption, and safety profile make it a valuable adjunct therapy. Clinical studies have demonstrated its effectiveness in promoting re-epithelialization and reducing bioburden in chronic wounds (Sakarya et al., 2014; Burian et al., 2022; Herruzo et al., 2023; Fazli et al., 2024).

Q6: When should I consider advanced therapies like NPWT?

A6: Negative Pressure Wound Therapy (NPWT) is typically considered for Stage 3 and Stage 4 pressure ulcers, especially those that are large, have significant exudate, or are not healing with conventional methods.

References

Burian, E. A., Sabah, L., Kirketerp-Møller, K., Gundersen, G., & Ågren, M. S. (2022). Effect of stabilized hypochlorous acid on re-epithelialization and bacterial bioburden in acute wounds: A randomized controlled trial in healthy volunteers. Acta Dermato-Venereologica, 102, adv00727. https://doi.org/10.2340/actadv.v102.1624

European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, & Pan Pacific Pressure Injury Alliance. (2019). Prevention and treatment of pressure ulcers/injuries: Clinical practice guideline (E. Haesler, Ed.). EPUAP/NPIAP/PPPIA. https://internationalguideline.com/2019

Fazli, M. M., Kirketerp-Møller, K., Sonne, D. P., Balchen, T., Gundersen, G., Jørgensen, E., & Bjarnsholt, T. (2024). A first-in-human randomized clinical study investigating the safety and tolerability of stabilized hypochlorous acid in patients with chronic leg ulcers. Advances in Wound Care, 13(11), 529–541. https://doi.org/10.1089/wound.2024.0040

Gold, M. H., Andriessen, A., Bhatia, A. C., Bitter, P., Chilukuri, S., Cohen, J. L., & Robb, C. W. (2020). Topical stabilized hypochlorous acid: The future gold standard for wound care and scar management in dermatologic and plastic surgery procedures. Journal of Cosmetic Dermatology, 19(2), 270–277. https://doi.org/10.1111/jocd.13280

Herruzo, R., Fondo Alvarez, E., Herruzo, I., Garrido-Estepa, M., Santiso Casanova, E., & Cerame Perez, S. (2023). Hypochlorous acid in a double formulation (liquid plus gel) is a key prognostic factor for healing and absence of infection in chronic ulcers: A nonrandomized concurrent treatment study. Health Science Reports, 6(10), e1497. https://doi.org/10.1002/hsr2.1497

Sakarya, S., Gunay, N., Karakulak, M., Ozturk, B., & Ertugrul, B. (2014). Hypochlorous acid: An ideal wound care agent with powerful microbicidal, antibiofilm, and wound healing potency. Wounds, 26(12), 342–350. https://pubmed.ncbi.nlm.nih.gov/25785777