Pressure Sores

Treatment Overview

Treatment focuses on preventing pressure sores from getting worse and on restoring healthy skin.

Steps to treat pressure sores include:

• Managing the tissue load. Tissue load includes pressure, shear (such as when you slide down in a chair and your skin pulls and folds), and friction (rubbing).⁷ All of these forces can damage your skin and deeper tissues.
• Keeping the sore area clean and covered, and not letting it dry out.
• Keeping healthy tissue around the sore clean and protecting it from moisture.
• Eating a healthy diet.
• Avoiding smoking. Smoking dries out the skin and reduces blood supply to the skin, so it can help pressure sores form and also slow the healing process.

Early treatment can help prevent damage from pressure sores. After a sore progresses to a more serious stage, it becomes difficult to treat and can lead to complications.

Most stage 1 and stage 2 pressure sores will heal within 60 days with proper treatment.⁴ Stage 3 and 4 pressure sores can take months or even years to heal. Even though progress is slow, continued care and treatment can prevent complications such as further tissue damage, infection, and pain.

Pressure sores occur most frequently in people who are confined to beds or chairs. In many cases, a person with a pressure sore also has one or more medical conditions that may affect treatment and healing. These conditions include diabetes, kidney disease, and heart disease.

Manage tissue load.

Relieving and spreading out pressure is the most important part of preventing and treating pressure sores. When pressure is in one spot for long periods of time, the blood flow to that area is decreased. This damages or kills the cells, and creates a sore. Pressure can be relieved and spread in several ways. Often a combination of these is best. To relieve and spread pressure:

• Use special support surfaces. There are mattresses, bed covers, and chair cushions designed to help reduce and spread pressure. They can use materials including foam, air, water, beads, and fiber. Your doctor and other health professionals, such as nurses and physical therapists, will help find the right support surface for you.
  • Avoid using doughnut-type devices to cushion any area, or boots filled with air to support the heels. These devices may actually cause or aggravate pressure sores.⁵
• Change positions often, or help a person at risk of pressure sores change often. Most people change positions many times an hour, even if they are sitting down. All these movements and adjustments help relieve pressure. A person who cannot easily move themselves or who does not have normal feeling in their body or mental awareness to tell them when to change positions is at risk of pressure sores. These people need a regular schedule for position changes and usually need help being turned or repositioned. Most experts recommend changing positions at least every 2 hours.
• Avoid positions that put pressure directly on an existing pressure sore.
• Avoid positions that will allow you to slide, slip, or slump. Recliner chairs are likely to allow slipping.
• Watch for pressure from parts of wheelchairs, braces, or other equipment, or from body parts pressing and rubbing together. For example, the knees or ankles of a person who spends long periods in bed can rub together and cause sores. Work with your health provider to be sure there is either no pressure or that there is good padding between the skin and other surfaces.
• Avoid sliding. This causes friction (rubbing) on the skin that can lead to sores.

Protect and treat the sore area.

The basics of wound care are cleaning, covering, and keeping slightly moist to provide the best chance for wound healing.

• A stage 1 pressure sore still has the skin intact. Keep it clean, do not allow moisture such as body fluids to stay on the skin, and protect the skin with a mild cream or lotion. Special creams or lotions called moisture barriers are also available. These are very good if there are problems with bowel or bladder control and a person is often wet from body fluids.
• To help prevent infection and promote healing, dead tissue is debrided (removed) often, usually by your doctor or another health professional. If there is dead tissue in the pressure sore, it gives bacteria a good place to grow and can cause infection. Dead tissue in the wound can also slow the growth of healthy tissue.
  • Sometimes it is best to leave the dead tissue or scab in place and let it act as a sort of bandage. Your doctor may do this if the tissue is very stable, or if the sore is not likely to heal.
• The pressure sore must be cleaned every time the bandage (dressing) is changed. Saline (a saltwater solution available at the drug store) is often used for cleaning, but there are many cleansing products. Your doctor will recommend a cleansing solution for you. Do not use antiseptic solutions such as Betadine, Hibiclens, or hydrogen peroxide.⁸ These can damage new and normal tissue.
• Your doctor will recommend a bandage (dressing) for the pressure sore. There are many types of bandages. The general idea is to keep the wound a little moist and not let it dry out between bandage changes, and to keep the moist part of the bandage right down in the sore, placed loosely against the healing tissue. Over time, your doctor may use several different types of bandage, as the pressure sore heals. The moist bandage is covered with a dry bandage to help keep the sore clean and to keep the healthy skin around the pressure sore dry.
• Several other treatments are sometimes used in treating pressure sores. These are found most commonly in clinics that specialize in treating serious wounds. Researchers continue to study these and other treatments for pressure sores and other wounds. Some insurance will not cover the newer treatments without special approval. Treatments include⁹:
  • Electrical stimulation. Gentle electrical current is used in and near the wound to help make tiny blood vessels and new tissue grow.
  • Negative-pressure wound therapy (sometimes called "vacuum-assisted closure"). A sterile sponge is placed in the sore and covered with a sticky bandage that does not allow any air in. The small vacuum is then turned on and kept on at all times until the next treatment. The vacuum pulls drainage from the wound to help keep germs from collecting and growing there, and gently pulls the blood supply close to the surface of the sore to bring nutrients to the sore and to make new tissue grow.
  • Hyperbaric oxygen therapy. The person is put in a chamber while 100% oxygen is pumped in at high pressure. This may be used to increase the oxygen level in the blood so more oxygen reaches skin and tissues, which can prevent tissue death, promote healing, and help fight infection. This treatment is not approved for treating the pressure sores themselves, but is approved for conditions that can occur with pressure sores, such as bone infection (osteomyelitis) or a surgical closure of the sore that is not healing.
  • Growth factor. Proteins that help new cells grow are applied to the pressure sore.
• Skin grafts are sometimes needed. Skin grafts help new skin grow at the site of the sore if the wound extends into muscle and deeper tissues. The wound may be surgically closed to promote healing after a skin graft.

Protect healthy skin.

In addition to avoiding pressure, take steps to protect healthy skin.¹⁰

• Bathe as often as needed to be clean and comfortable.
• Use gentle soap to bathe, and use warm (not hot) water.
• Use moisturizing creams or lotions to keep skin soft and keep it from getting dry.
• Check your skin every day for signs of pressure sores. Look closely for changes in color or for sores. Pay special attention to the common areas where pressure sores develop, such as over the tailbone and heels.
• If you have problems with bowel or bladder control:
  • Clean your skin right away if it becomes soiled or wet.
  • Use a protective barrier cream, lotion, or ointment to protect your skin from wetness.
  • Use pads or briefs that absorb moisture and pull it away from your skin.

Eat a healthy diet.

Good nutrition is important to both preventing and treating pressure sores. Focus on getting enough liquids, calories, protein, and vitamins, and on controlling your weight. Both increases and decreases in body weight can help cause pressure sores.^{1, 9} Talk to your doctor or a registered dietitian about a healthy diet for you.

Treat infection as needed.

Open sores, such as pressure sores, are easy places for infections to start. Your doctor will be watching for signs of infection, and you can help watch for these signs. Tell your doctor if you notice:

• Redness or warmth in the skin around the sore, or red streaks leading away from the sore area.
• Tenderness around the sore.
• Pus in the drainage from the sore.
• A bad smell from the sore or from the bandage.
• Fever.

To treat an infection, you may use medicine such as antibiotics, along with special care of the wound. You and the people around you will also be taught to take steps to keep germs from spreading to other parts of your body or to other people. These steps include keeping the sore covered at all times except during treatment, good hand washing before and after caring for the pressure sore, and properly wrapping and throwing away used bandages.

Treat pain as needed.

Pain may or may not be a problem with pressure sores. If you do have pain, talk to your doctor. Some people with pressure sores do not need any pain medicine, some need pain medicine just when the sore is being treated, and some need pain control medicine on a regular schedule.

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Author:	Shannon Erstad, MBA/MPH	Last Updated: March 15, 2007
Medical Review:	Martin Gabica, MD - Family Medicine Margaret Doucette, DO - Physical Medicine and Rehabilitation, Wound Care, Hyperbaric Medicine
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