Treating pressure ulcers

A pressure ulcer develops if too much pressure is put on one part of the body for too long. Less blood reaches the tissue and it dies. Relieving the pressure can prevent these ulcers. And once a pressure ulcer has developed, it can only heal if the pressure is reduced. This can be done by

• repositioning that part of the body regularly,
• getting up, walking around and sitting down as much as possible, and
• using mattresses that are soft or provide alternating pressure.

People who are bedridden are usually repositioned every 2 to 4 hours. If possible, they shouldn’t lie on the pressure ulcer. This is hard to prevent for some pressure ulcers, like on the tailbone. It is easier to manage this if the ulcer is on a heel, for instance. Then you can place a cushion under the person’s calves.

Mattresses with soft surfaces or alternating pressure help distribute the pressure over a larger body surface area. That relieves the pressure on parts of the body especially prone to pressure ulcers. Special cushions can be used for sitting. In Germany and other countries, health insurers or long-term care insurers cover the costs of many of the aids needed at home if they have been prescribed by a doctor. Family members can also learn various positioning techniques in caregiving courses.

The wound can be cleaned when the dressing is changed. When medically cleaned, the wound is rinsed – normally using a saline (salt) solution.

In severe pressure ulcers, doctors or nurses also remove dead or inflamed tissue. This is known as debridement. The tissue is removed using instruments such as tweezers, a sharp spoon-like instrument called a curette, or a scalpel. An enzyme-based gel is sometimes applied too, to help clean the wound.

Debridement is often painful. So the area around the wound can be numbed beforehand, for instance with a local anesthetic in a cream. If you think that the pain is going to get really bad, you can also take a painkiller or even have general anesthesia before the debridement starts.

Once the wound has been cleaned, it is covered with a dressing. Most wounds are kept moist, Various types of dressings can be used to do this. They include the following:

• Polymer dressings
• Hydrogel dressings
• Hydrocolloid dressings
• Dressings containing silver or alginates
• Foam dressings

A dressing is typically left on the wound for a few days. This is done to absorb extra fluid and to prevent infection. The dressing should be changed if it’s clear that it can’t soak up any more wound secretions, if it slips out of place, or if fluid leaks out of the bandage.

It is now rare to pack a wound with moist gauze because it can stick to the wound and needs to be changed quite often.

A pressure ulcer might not heal even if it has been carefully treated with wound dressings, cleaning and repositioning. If a wound doesn’t get any better after two weeks, it’s usually a sign that it’s infected.

The following treatments are used for poorly healing (chronic) wounds:

• Antibiotics or antiseptics: Antibiotics are usually taken as tablets, but are sometimes applied to the wound in an ointment or placed on the wound using a dressing. Antiseptics are also effective against infections. In addition to antiseptic wound dressings, various antiseptic agents can be used to clean infected wounds.
• Negative pressure wound therapy: In this type of therapy the wound is covered with an airtight seal. A pump is connected to the a thin tube on the bandage to continuously remove fluid from the wound. This creates a vacuum near the wound, which increases the flow of blood through the wound. It helps keep the wound moist too, which is also meant to improve the healing process.
• Growth factors: This therapy aims to stimulate the growth of cells. One approach involves putting some of the patient’s own blood into a machine to increase the concentration of blood plasma (platelet rich plasma, PRP). The blood that is prepared in this way is then applied to the wound as a gel. Some studies suggest that growth factors can improve healing in chronic wounds such as venous leg ulcers. But there hasn’t been enough research on whether they also help pressure ulcers.
• Electrical stimulation (electrotherapy): Electrodes are placed on the skin to transmit electrical signals though the body. This is done to improve the flow of blood and help replace dying cells. Studies suggest that electrotherapy can support wound healing.

Ultrasound and electromagnetic therapy are also sometimes used. It is not clear whether they can help chronic wounds to heal better, though.

Surgery is sometimes recommended to treat poorly healing or very severe wounds. The following surgical procedures are used:

• Skin graft: In this procedure, skin is taken from another part of your body – usually your thigh – and transplanted onto the wound. This skin connects to the surrounding tissue and closes the wound.
• Skin flap: The pressure ulcer is removed. The missing tissue is replaced by grafting or moving tissue from the body, such as subcutaneous fatty tissue or muscle flaps. That may include neighboring tissue or tissue from other parts of the body. Tissue from the pelvis, buttocks or thighs is commonly used in this procedure.

It usually takes a few weeks for the skin to heal after one of these procedures.

Wound pain can make daily life hard, cause sleeping problems and also be extremely difficult emotionally. The pain can wear you down and even make you feel depressed over time.

Proper wound care and the right positioning can prevent pain or at least reduce it. If that isn’t enough, medication such as acetaminophen (paracetomol) or ibuprofen can relieve mild to moderate pain. Some dressings contain painkillers too. Doctors can prescribe stronger painkillers as needed.

It is important for medical professionals to take care to keep the pain as low as possible when changing the bandage – for instance by using wound dressings that don’t stick as much to the wound. Another option is to rinse the wound with a salt solution first, so the dressing comes off more easily.

People who have chronic pain can benefit from pain management therapy and psychological support. The aim of psychological treatments for pain management is to help people cope better with the pain in everyday life.