Pressure Ulcer Management

Wound Dressing Selection

Apply hydrocolloid or foam dressings to reduce wound size and promote healing, as these are superior to gauze dressings and cost-effective compared to advanced biological dressings, according to the American College of Physicians 1, 2
Select dressings based on exudate control, comfort, and cost rather than antimicrobial properties, as antimicrobial dressings are not recommended as the sole intervention to accelerate healing 3, 4

Perform sharp debridement to remove all necrotic tissue, surrounding callus, and biofilm from the wound bed, which allows accurate assessment of ulcer depth and eliminates physical impediments to healing, as recommended by the American College of Physicians 4
Debride frequently with a scalpel to maintain a clean wound bed, though exercise caution in ischemic ulcers without signs of infection as aggressive debridement can worsen tissue damage, according to the American College of Physicians 4, 5

Provide protein or amino acid supplementation to reduce wound size, particularly in patients with nutritional deficiencies, as this improves the rate of wound healing when used in conjunction with standard therapies, as recommended by the American College of Physicians 2, 7
Ensure adequate caloric intake and correct nitrogen balance, as vitamin C supplementation alone has not shown benefit compared to placebo, according to the American College of Physicians 7, 3

Use alternative foam mattresses rather than standard hospital mattresses, which provides a 69% relative risk reduction in pressure ulcer incidence, as recommended by the American College of Physicians 3
Avoid expensive advanced support surfaces like alternating-air and low-air-loss beds, as the quality of evidence for these is limited, harms are poorly reported, and they add unnecessary costs without proven superiority, according to the American College of Physicians 6, 1, 3
Air-fluidized beds are superior to standard hospital beds for reducing pressure ulcer size, though evidence on complete wound healing remains limited, as reported by the American College of Physicians 7

Use electrical stimulation as adjunctive therapy to accelerate wound healing for stage 2 to 4 ulcers, as moderate-quality evidence shows it accelerates healing rate when added to standard treatment, as recommended by the American College of Physicians 1, 2, 3
Be aware that frail elderly patients have more adverse events associated with electrical stimulation (primarily skin irritation) than younger patients, according to the American College of Physicians 2, 7

Evaluate for infection requiring antibiotic therapy if the ulcer shows signs of deep tissue involvement, cellulitis, or drainage, as recommended by the American College of Physicians 4, 5
Direct antibiotic therapy against Gram-positive and Gram-negative organisms as well as anaerobes when infection is present, according to the American College of Physicians 5

Consider surgical repair for advanced-stage pressure ulcers, though evidence is insufficient to determine the superiority of one surgical technique over another, as reported by the American College of Physicians 7
Recognize that dehiscence is more common when bone is removed during surgery and in patients with ischial ulcers compared to sacral or trochanteric ulcers, according to the American College of Physicians 2, 7
Rotation flaps are associated with the lowest complication rates (12%) compared to other surgical flap procedures like tensor fascia lata flaps (49%), as reported by the American College of Physicians 7

Do not continue standard therapy beyond 4 weeks without considering advanced wound therapy if the ulcer shows inadequate improvement (less than 50% reduction in size), as recommended by the American College of Physicians 3, 5
Do not perform aggressive debridement in ischemic ulcers without signs of infection, as this can worsen tissue damage, according to the American College of Physicians 3, 4
Do not neglect vascular assessment when pedal pulses are absent or ulcers fail to improve, as ankle-brachial index <0.6, toe pressure <50 mmHg, or TcPO2 <30 mmHg indicate need for revascularization, as recommended by the American College of Physicians 4
Assess footwear meticulously if the ulcer is on the foot, as ill-fitting shoes are the most frequent cause of ulceration even in patients with other underlying pathology, according to the American College of Physicians 3, 4
Do not overlook underlying osteomyelitis or deformities in diabetic foot ulcers that may require surgical offloading procedures, as recommended by the American College of Physicians 5