Assessment and Treatment of Coccyx Pressure Wounds

Initial Assessment

The American College of Physicians recommends using the NERDS/STONES assessment tools to systematically evaluate the wound for infection, which includes checking for Nonhealing, Exudate, Red friable tissue, Debris/discoloration, Smell (NERDS) and Size increasing, Temperature elevation, probes to bone (Os), New breakdown, Erythema/Edema, Exudate and Smell (STONES) 1, 2
The assessment should include staging the wound (Stage II-IV) to determine depth and tissue involvement, with moderate-quality evidence supporting this approach 3, 4
Probe to bone should be performed, and if positive, obtain imaging (MRI, CT, or ultrasound) to evaluate for osteomyelitis and determine extent of soft tissue infection 1, 2
Evaluate for secondary infection signs, including wound dehiscence, bridging, undermining to other structures, and pocketing 1, 2
Obtain wound cultures only when infection is suspected using quantitative tissue biopsy (gold standard) or semiquantitative swab with Levine technique 1, 2
Assess nutritional status for protein deficiency, with the American College of Physicians recommending protein or amino acid supplementation to reduce wound size 3, 4

Perform sharp debridement to remove necrotic debris, planktonic bacteria, and biofilm, with the Infectious Diseases Society of America recommending this as the critical first step 2
Apply topical antimicrobials when infection is present, including iodine preparations, medical-grade honey, and silver-containing dressings, with the Centers for Disease Control and Prevention recommending judicious use of antimicrobials 1, 2
Use collagen matrix dressings to reduce protease activity and excessive inflammation while promoting dermal fibroblast proliferation, with the Wound Healing Society recommending this approach 1, 2
Apply hydrocolloid or foam dressings as the primary dressing choice for reducing wound size, with the American College of Physicians recommending these dressings as superior to gauze 3, 4, 5, 6
Consider electrical stimulation as adjunctive therapy to accelerate wound healing, with moderate-quality evidence supporting its use for Stage 2-4 ulcers 3, 4, 5

Provide protein or amino acid supplementation to reduce wound size, particularly in patients with nutritional deficiencies, with the American College of Physicians recommending this approach 3, 4, 5
Do not routinely supplement with vitamins or trace elements, unless documented deficiency exists, with the International Working Group on the Diabetic Foot strongly recommending against vitamin supplementation for wound healing 7

Use support surfaces in all settings (sleeping, seating, transportation) to prevent recurrent injury, with the National Pressure Injury Advisory Panel recommending this approach 2

Do not use povidone iodine routinely, as it may impair healing compared to non-antimicrobial dressings 1, 2
Do not culture wounds without clinical signs of infection, as this leads to inappropriate antibiotic use 1, 2
Do not rely on inflammatory signs alone for infection diagnosis, as bacterial burden, virulence, and host immune status all affect presentation 1, 2
Do not use dextranomer paste, as it is inferior to other dressings 5
Avoid vitamin C supplementation, as no benefit has been demonstrated 5

The American College of Physicians recommends hydrocolloid dressings for reducing wound size in pressure ulcers, though this is a weak recommendation based on low-quality evidence 8, 9
Hydrocolloid dressings for pressure ulcers should be changed based on clinical need rather than a fixed schedule, typically ranging from every 1-7 days depending on exudate levels, with most changes occurring every 1.5-3 days for moderate to heavily exuding wounds 8
Extend dressing change intervals to 3-7 days once exudate levels decrease and the wound demonstrates appropriate healing progression 8
Intact dressing adherence without leakage or edge lifting supports extended wear 8
Do not use a rigid schedule—base frequency on clinical assessment rather than arbitrary time intervals 8