Treating pressure ulcers 

* Note - whilst many diabetic ulcers also are- strictly speaking pressure ulcers- we have written a seperate chapter on the treatment of diabetic ulcers. 

Treating stage 1 pressure injuries

Stage 1 pressure injuries are those where the outer layer of the skin is still intact. There is usually no exudate.  The treatment is primarily to offload the area immediately. If the pressure injury is on the back of the patient this means you have to establish a treatment plan with a patient repositioning regime.  If available a pressure reducing mattress should be used.  If the pressure area is on an elbow or a heel you may not necessarily need a special mattress of course - this depends on the general condition of the patient.  In these cases it may be sufficient to pad the offended areas and to make sure that the patient is not lying on these body areas.

Figure 1/2  Stage 1 pressure injury over the sacrum (above) and on the heel ( below).  Both injuries need immediate offloading.  The patient with the sacral pressure injury should be provided with a dynamic air mattress if this is available The heel should be covered with a mulitlayered foam dressing AND a oplan for how to keep it off the mattress at all times. All images:©LuAnn Reed, MSN, CRRN, RNC, WCC, Drake Center Cincinatti Ohio

If we know that the skin damage is primarily due to shearing and friction we may use a hydrocolloid dressing to protect the skin from further damage. Hydrocollids are self-adhesive, thin dressings with almost see-through " skin-like" consistency.  Hydrocolloids are so thin however that they do not provide enough relief from pressure.  Also, if the skin is moist and we place a hydrocolloid on top of it we can risk serious skin-breakdown due to maceration and a stage 1 skin injury can suddenly turn into a stage 2 situation or worse.

 

In most cases it will almost be impossible to tell if the injury was cause by friction or pressure or a combination of both.  Therefore we usually choose a product which re-distributes pressure and reduces friction/shear simultaneously.  Most multilayered polyurethane foam dressing perform well here.  Most of these have an inner silcone layer which make them gentle to apply and remove and they breathe fairly well avoiding moisture related damage. They are not too costly and in the case of stage 1 skin injuries we can often leave them in place for a week. They can easily be lifted off partially and replaced to inspect the skin beneath daily which is the international recommendation.

Other product groups are silicone pads like the Dermapad series from Smith and Nephew and a wide range of self-adhesive foam products which can be used to cushion for example tricky areas like around the ears and other facial areas if the patient is prone to pressure there. 

 

We would again like to highlight compressed wool felt. It is a unique and versatile product that can be cut into any shape and sites very well.  It can be used in most areas of the body but when it comes to cushioning areas under the sole of the feet or around toe areas we think that nothing exceeds it. It is fairly cheap and the technique for applying it is not difficult to learn

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Figure 3 Stage 1 pressure injuries have to offloaded immediately.  The main product groups here are hydrocolloids ( really only advisable for shear/friction skin damage), silikone pads/strips, selv adhesive simple one-layered foam  dressings ( indication: pressure relief in tricky areas like around the ears, over nose), compressed woolen felt and multilayered polyurethane foam dressings.

Treating stage 2 pressure injuries

Figue 4 Stage 2 ulcers are characterized by the outer layer of the skin being broken but the wound is still quite superficial. Note that blisters are also categorized as stage 2 skin injuries!  Again- the treatment is immediate offloading - every hour counts!  Multilayered polyurtehane foam dressings are a good choice for these injuries. They provide absorption of exudate and some redistribution of pressure. 

Stage 2 ulcers usually have some yellowish areas in the wound bed - these represnet fibrin or necrosis of superficial layers of subcutaneous fat. Often we do not need to debride this as the bodies own debridement  mechanism ( autolysis) will manage to take care of this over time.  If we choose to rinse the wound we can use regular tap water if we live in areas where the tap water is of drinking quality.  In other areas you will have to use boiled water or ready made 0,9% saline solution to rinse the wound. You generally do not need any fancy or antipseptic solutions here.  Dont get hung up on how you are going to rinse or what you are putting on the ulcer- think more about what you are going to take off the ulcer ( pressure!) - i.e. about how you are goin to offload the ulcer!

If there are blackish or thick yellow parts you may want to debride sharply. Remember- the more superficial the ulcer is - the more nerve endings there are - and the more painful any debridement is.  Stage 2 ulcers are usually quite painful to debride and you should apply some form of topical analgesic ( for example lidocaine spray, gel etc.) about 30 minutes before debridement. 

In general stage 2 skin injuries do not have much exudate but please still protect the skin edges from moisture. You can use zinc paste or ointment for this or any other barrier product at each dressing change.

We find that multilayered polyrethane foam dressing are the number one choice dressing for these cases as they fullfill most needs. They have a cushioning effect, the absorb mositure and they have som evaporation from the surface of the dressing giving an optimal climate for healing.  How often you have to change the dressing is dependent on how much exudate there is. In some cases also stage 2 ulcers can have quite a lot of exudate makeing it necessary to change the dressing daily. In most cases however, we manage with changing the dressing about twice weekly. 

Some caregivers use hydrocolloid dressings in cases with stage 2 injuries. Hydrocolloids have less evaporation than foam bandages- that is they are more occlusive. This makes for a moister wound environment beneath the dressing which may give better conditions for autolysis.  If you absolutely know what you are doing hydrocolloids can work very well but in the wrong hands they can also lead to a catastrophy and risk of infection. In our opinion multilayered foam dressings are a much safer choice and they also provide better pressure relief.  If the wound is quite dry and you want to speed up autolysis you could add a few drops of honey or some other wound gel into the wound bed before covering it with a foam dressing. 

What can you do if you have neither a hydrocolloid dressing, foam dressing or any of the other alternative available to you? In these cases you will have to work with what you have. Slightly exagggerated but still true: we could get pressure injuries to heal with papaer towels if that is the only thing we have available but it would be very impractical meaning we would have to change the improvised dressing very often. We are not saying you should use paper towels :) - what we are saying is that your choice of dressing is not too important - your offloading is though.  Even with no resources at hand you can offload effectively as long as you make a proper plan.  

Again, off loading is the most important treatment, your choice of dressing is only secondary! Many caregivers unfortunately still think that a multi-layered foam dressing will provide enough off-loading.  It will not!  You cannot place a heel with a pressure injury covered with a foam dressing back on the mattress. You have to do seomething to keep the heel elevated at all times.  This can be a cushion under the leg or a more fancy orthotic. 

Behandling av trykksår grad 3

Figure 5/6 (Above: Stage III pressure ulcer on the sacrum.  Below: Stage III pressure ulcer on the heel. Remember - to be classified as a stage III injury there must no be visible fascia or bone.

In stage III ulcers we usually see a mixture of greyish, yellowish necrotic tissue, fibrin and maybe if we are lucky some areas of healthy granulation tissue.  Remember the following principle- and this applies to all wounds:  the wound will not heal properly until the necrotic tissue is removed.  Only then will the wound bed summon its forces and decide to build up granulation tissue. If you dont have the necessary equipment or skills you may have to rely on the autolytic debridement process which usually takes some weeks. If the necrotic layers are thic,however this can even take months and we will shorten the time to heal considerably if we do a sharp debridement. Also, if the wound is smelly or there are signs of infection we should try to debride it sharply. 

 

Although stage III ulcers usually are less painful to debride than stage I ulcers we mostly will still need to apply topical analgesic to debride the ulcer (lidocaine spray, gel etc.).  Since these products only numb superficially you may not be able to do a thorough debridement with this method. It will be more effective to inject lidocaine into/just beneath the necrotic tissue. More specifically - you stick the needle into the necrotic tissue at several locations and advance it slowly until you think that you are just a the bottom of the necrotic tissue.  Inject the local anestheisa slowly to avoid pain for the patient. If you are not comfortable advancing the needle deep into the necrotic layer you can advance the needle less deep and debride less at each setting ( staged debridement technique).

 

When we debride stage III and stage IV ulcers sharply it is not rare to get some bleeding.  Do not panic when this happens.  Take a compress and hold it with slight pressure against the bleeding site for a minmum of three minutes, preferably five minutes. Do NOT be tempted to take a look after a minute or so or you may have to start all over again. In almost all cases the bleeding has stopped after 3-5 minutes unless the patient is using stronger blood thinning medication. That is why we ALWAYS have to ask the patient beforehand if they are using blood thinners. Aspirin like blood thinners are ok but stronger types can give you a problem- in these cases we usually do a staged debridement and  debride a little at each session to be on the safe side.  

 

In some cases the necrotic layer may be so thick that it needs surgical debridement and a referral to a bigger clinic to perform this under some form of anesthesia ( sedation, spinal anesthesia, narcosis or local nerve blocks) 

If the necrotic layer is not too thick we can rely on the bodies own autolytic processes.  As we mentioned eralier these processes work quite slowly and will require some patience over a few weeks.  If we remove most of the necrotic tissue sharply and leave small rests to autolysis we shorten the healing time considerably. If the necrotic tissue appears quite dry and there isn`t a lot of exudate we can activate autolysis by applying honey or other wound gels to the wound bed.  Do NOT use hydrocolloid dressings to facilitate autolysis in cases with stage III or IV ulcers!  The risk of infection using these dressings here is too high!

Most stage III ulcers are so deep that we cannot just put a foam dressing on them - we usually need something to fill the wound - we call this a wound filler. This is an important principle - wound beds like to be in contact with something- they dont tend to be happy if the dressing is just floating above it.  Explained in a different way - when you lie in your bed you also like to have your blanket or duvet in direct contact with you - you will unlikely sleep well if your cover is hovering a few centimetres above you.  So what can you use as a wound filler?  If there is not too much exudate you can use honey or some type of wound gel.  You could also apply some honey or wound gel on the bottom side of a cotton compress and place this in a "fluffy" manner into the wound and then cover this with a mulitlayered foam dressing.   By the way - the wound filler is your primary dressing, what you have on top of that is your secondary dressing. 

White granulated sugar is receiving increasing attention as a wound dressing in several western countries. This is in reality a rennaisance of this concept beacuse the idea of using sugar to treat wounds is old. However, it was actually a Zimbabwean - Dr Moses Murandu- who reintroduced this concept in the UK from about 2012 onwards and it has gained many followers. We have ourselves used white granulated sugar as a wound filler with success in many patients.  Why does it work? For one the high osmotic strain has a strong antibacterial effect.  The same osmotic strain also seems to stimulate the wound to heal faster. Why is white granulated sugar used- can regular brown sugar be used aswell?  Unrefined brown sugar is thought to contain some impurities whilst white refines sugar is simply a more pure form of the product.

 

What are the downsides of using sugar?  For one the osmotic effect causes the wound to exudate more- at least in the start. You will have to accomodate for this with frequent dressing changes and good absorbant dressings.  Because the wound can have higher amounts of exudate there is a higher risk of wound edge maceration - barrier products are important. Some patients experience a slight itch when sugar residues are lying on the skin edges over longer periods of time. We have seen this in a few patients but it is usually not very disturbing to the patient and barrier products like zinc ointment around the skin edge will help against this.  We read in a blog in resaerchgate about sugar treatment (https://www.researchgate.net/post/Sugar_for_wounds)  that the sweet smell from the sugar plus exudate may attract myasigenic flies - that is flies that can harm healthy tissue- and that this could be an issue in tropical countries. We do not believe that to be a issue - these type of flies will be attracted to the smell of a wound in anyway and will always pose a certain risk in tropical countries.

 

When pouring sugar into a wound it very quickly becomes saturated with fluid and it sort of melts away, losing some of its effect. If using sugar - in our experience it is wise to apply it often- preferably several times daily - you do not need to rinse the wound each time unless it is smelly. Just fill it with sugar to the rim, make sure you have a good barrier product around the skin edges to prevent maceration  and cover it with a good absorbant dressing. The technique is so easy that you can teach family/ other relative/neighbours to treat the patients wound. 

One, not immediately apparent downside to using sugar, is patient acceptance. Whilst many patients in western countries may find it exciting to try a "medieval" method of treating wounds, some patients in Africa may lose faith in you because they see this method as too simple.  They didn`t travel four hours in a cramped minivan to your clinic just to hear that they should sprinkle sugar into their wound. Nor will your businessman patient in Nairobi be excited about the prospect of using sugar from the corner shop in his wound when he can afford a more fancy dressings. So if you want to use sugar you will have to figure out a way to make the product more appealing depending on the cultural factors in your region. 

In veterinary medicine using sugar in woundcare has been  a standard procedure for many years. Some have combined sugar with iodine but this practice is now mostly abandoned.  We do not see the need to combine anything with the sugar. the high osmotic strain posed by sugar is enough to keep microbes at bay. 

Lets face it- sugar treatment of wounds poses a real threat to more conventional dressings.  Sugar is readily available everywhere, it is cheap and easy to use. We believe that a lot of criticism of sugar in woundcare actually comes from companies producing honey or other dressings in competititon with sugar. We have ourselves actively used sugar treatment in many of our patients since 2019 and have in some cases seen excelent results in situations where conventional dressings have failed. Sugar will not solve all of your woundcare problems. No dressing we currently have available will solve all these problems. But sugar is without question an excellent alternative for many african patients especially when other dressings are not available due to strained resources. 

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Figure 7 A screenshot of an article in Mail Online (UK) from 2013 reporting on the use of granulated sugar at a hospital in Birmingham. The picture on the right shows Dr Moses Murandu and one of the patients who received the sugar treatment. Copyright mail online UK and Caters News Agency

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Video 1  A short interview with Dr Moses Muranda on his work with sugar dressings. Click on the image above to go the website of medsugarclinic.com where the video is available

What are our choices amongst the more "conventional" wound fillers? Many colleagues like to use hydrofiber dressings (Aquacel®) as wound fillers.  These are made of cellulose and swell up into a jelly when they get into contact with wound exudate. So if you are dealing with an ulcer with a lot of exudate you can place the hydrofiber dry into the ulcer.  On the other hand, if you have a surprisingly dry ulcer ( rare) then you can premoisten the hydrofiber with saline, wound gels or honey.  Hydrofiber is also available impregnated with colloidal silver (Aquacel®- Ag). Since many pressure ulcers have a heavy bacterial burden it is often wise to use these for a few weeks until the ulcer has cleaned up more.  Alginates are anothe product class that behave very similarly to hydrofiber dressings. Alginates are also sold with or without colloidal silver impregnation. 

There are some other interesting special dressings which do really well as a wound filler if you or the patient have the financial resources to use these.  One of these are  Polymem®  foam dressings.  they may look like a regular foam dressing at first sight but are quite different.  Whereas most foam dressings do not contain any active substances, Polymem contains an active surfactant (which aids with cleaning/debriding the wound over time) and glycerin which keeps the woundbed at an optimal moisture level.  This combination of substances has proven very effective and with some patience it speed up the autolytic debridement process considerably.  Polymem WIC® is used as a wound filler and you can cut it into pieces so that it covers most areas of the ulcer but do not "overstuff" the ulcer with it as Polymem Wic will swell up as it absorbs moisture.  Also, Polymem products tend to increase the amount of exudate especially in the first days of use - this is a result of the cleansing process - so make sure to use a good absorbant dresing over it and dont have too long dressing change intervas in the start.

Another product that does really well in pressure ulcers as a wound filler is Sorbact®.  This is another unique product- it doesnt contain active substances as such but works on a principle where microbes are trapped in the netting of the dressing. For some reason ( which we still do not understand fully) it does a good job with aiding the autolytic debridement process.  Again- just fill the ulcer in a "fluffy" manner with the Sorbact and place an aborbant dressing over. 

Yet another useful product as a wound filler is Kerlix™ AMD  gauze.  Kerlix™ AMD rolls are impregnated with PHMB (Polyhexamethylene Biguanide), a powerful yet safe antiseptic that has a broad range effectiveness against gram positive and gram negative microorganisms including some multi-drug resistant strains such as MRSA. The gauze comes in big rolls which make them very cost efficient. If there is low exudate you can premoisten the Kerlix gauze with saline and wring them out before placing them- yes, in a fluffy and not stuffed manner - into the wound. Again, you will have to use an absorbing seconday dressing over this. 

Another method of treating deeper pressure ulcers is using negative pressure or NPWT (negative pressure wound therapy).  There is really no other modality which can turn around a stagnating ulcer and stimulate granulation tissue like NPWT.  However, the ulcer has to be quite clean, free from most necrotic tissue and not smelly. It is obviously not a cheap treatment and will only be available to a selct few patients on the continent. It is possible to improvise and find cheaper work around solutions if you really want to use NPWT but do not have the resources. We have written a thorough chapter on NPWT - please refer to that for all details. 

At each dressing change we normally rinse pressure ulcers as the bacterial burden is often high. Especially pressure ulcers in the sacral rea- that is close to the anus- tend to be critically colonized with intestinal bacteria, staphyloccus aureus and other pathogenic bacteria. This is usually NOT an indication to give antibiotics and our aim should always be to keep bacteria under control by other means like rinsing the ulcers and using dressings with antibacterial properties.  When rinsing stage III and stage IV ulcers we cannot recommend tap water even if it is drinking water quality. This is because tap water can contain some  bacteria and we really do not want to add any more to these deep ulcers risking a deep infection. You can use regular saline if you have nothing else but if available we recommend an antibacterial solution which at the same time is skin friendly. Concerning rinsing agents- be aware that we do not want to try to get the ulcer sterile - this will in any case be impossible to achieve and we might even harm the wound bed in the process. We know that chlorhexidine is still used by some to rinse wounds- we consider this as outdated and from waht we know from existing research it may harm healthy cells. There are a lot of safe alternatives for example 3,5% vinegar, super oxidized water ( which by the way can be made really cheap with simple technology), polyhexanide solutions (Prontosan®) or hydrogen peroxide.  The latter has come under some dispute where a few studies apparently show that it too may not be ideal for healthy tissue and that the antibacterial effect is limited but many still use it and we must admit that we also like it.  Granulation tissue always appears "healthier in colour" after treating rinsing with hydrogen peroxide - it is also cheaply available in Africa making it a good choice.  We have written a seperate chapter on rinsing solutions - please refer to that for more details. 

Using medicinal maggots to clean/debride ulcers is  unfortunately not commonly practiced in Africa. It is possible to rear the correct type of flies (green bottle flies) in an easy way, sterilize the eggs and place the sterile eggs directly in to the wound.  Nothing debrides as elegantly and precise as maggots do and usually this is quite painless for the patient. As far as we know it is possible to obtain medicinal maggots in South Africa but on the rest of the continent it is not easy to purchase these/ get them delivered. In the seperate chapter on debridement we give you a step by step procedureon how to rear your own medicinal maggots and how to use these correctly.

Figure 8  Here medicinal maggots have been placed in an ulcer on the heel of a patient. The picture is taken at the time of removal.  Maggots have a unique and highly effective way of debriding wounds- usually the treatment is painless/almost painless. Unfortunately medicinal maggots are not available in most of Africa  so a work-around solution would be to rear these yourself.  Refer to our chapter on debridement on how to do this. 

Below we have made a list of useful dressings for treating stage III and Iv pressure ulcers.  We have not mentioned all of these in the text here - please refer to our chapter on dressings if you would like to read more about each product. 

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*Note Iodosorb contains iodine and should therefore not be used in patients with serious renal disease ot thyroid disease. 

**Kerlix is a cotton gauze and sometimes small threads of cotton may be left behind in the wound bed. Do not use it if there are deep crevaces or undermining if you cannot ensure that all rests can be removed

***NPWT = negative pressure wound therapy

Table 1  A list of some useful dressings to use with stage III and IV  pressure ulcers

Treating stage IV pressure ulcers

Whilst stage III ulcers often can be managed quite well in primary health care, stage IV ulcers are certainly more difficult.  In stage IV ulcers the depth goes below the fascia and there may be exposed  tendons or bone. There is a high risk of developing osteomyelitis - infection of the bone.  As a general recommendation in western countries patients who have a stage IV ulcer which has not improved significantly within 6 weeks at the latest should be referred to a higher level of care. Patients with significant necrosis and those with signs of infection should also be referred. An exception to these recommendations are bed ridden patients in poor condition with reduced life expectancy - in these cases palliative wound care may have to be used.

In cases where the patient has a big stage IV sacral ulcer and at the same time a serious anal  incontinence problem  the  only chance you have to get control over the ulcer is to divert stool away from the back area by operating the patient with a stoma. In some cases it may be feasible to control the fecal incontinence ( especially if the patient has consistent diarrhoea) with a fecal management system which in principle are large diamater catheters placed into the anal canal and held in place by a inflatable cuff there. 

Note that there are possibilities to treat big pressure ulcers in younger patients in otherwise good conditon with surgical flap techniques - we explain some of these techniques later on in this chapter.  As always when we discuss wound care in Africa it is obvious that these resource demanding surgeries will only be available to a select few patients.  These type of plastic surgeries are carried out a large clinics or university hospitals and pressure ulcers are not always prioritized here. Also- it is not just a matter of operating the ulcer and then the problem is solved. On the contrary, closing an ulcer with surgical excision and a flap demands that teh patient can off-load the area for many months afterwards which requires a high level of patient compliance.

Figur 9 Stage IV pressure ulcer in the gluteal area.  It may not seem apparent from the image that this is a stage IV ulcer but upon examining the ulcer we could probe down to bone in the centre and the undermined area to the right. Infact - this patient had a severe osteomyelitis at the time the picture was taken. We were not aware of this - the wound does not look infected- right?  This is a key point - we can usually not see osteomyelitis with our eyes and we have to keep a high level of suspicion when we have stage IV ulcers even if they don not look "too bad". 

Many caregivers underestimate how easily an osteomyelitis can develop in stage Iv ulcers and how serious this can get. Sometimes the osteomyelitis can affect a large area of a bone and it can lead to septicemia if left untreated. If the patient has an osteomyelitis the ulcer will never heal - we repeat- NEVER.  And this is actually a clever method nature has developed to protect itself- as long as there is a drainage channel ( i.e. the ulcer) the osteomyelitis is often under control.  If the body would close the ulcer over an active osteomyelitis the patient would most likely develop a serious septicemia. 

Sometimes we can see osteomyelitis with our eyes - if the bone at the bottom of the wound is greyish and looking dead there is most likely an osteomyelitis lurking in the depth.  If there is destruction of the bones surfaces you can be very sure that the patient has an osteomyelitis.  If you palpate the bone with your gloved finger and it feels soft/spongy that is also a sure sign of osteomyelitis.

 

To verify that the patient has an osteomyelitis an x-ray is normally done. In advanced cases a normal x-ray can be a good method to detect osteomyelitis.  If the x-ray reveals nothing, however, this does not rule out osteomyelitis with certainty and then normally an MRI scan has to be done.  MRI is the most sensitive method for detecting osteomyelitis, especially if combined with intravasal contrast methods. As you will appreciate an MRI scan is simply not available for most patients with pressure ulcers in Africa and many will not even have acces to an x-ray.  In this sittuation you will have to rely on your clinical sense and may have to start the patient on a several week long antibiotic regime form your findings of the wound examination. 

Figure 10 MRI scan of a heel bone with a stage IV pressure ulcer. The whitish area indicates the extent of the infection in the heel bone ( calcaneus) 

Figure 11 MRI scan of the gluteal area  with a pressure ulcer at the ischiadic tuberosity - a classical site for developing serious pressure ulcers.  The arrrows point to areas of destruction in the bone (irregular edges) due to an osteomyelitis. The black area beneath is the cavity of the ulcer which is in direct contact with the bone.  

The treatment of osteomyelitis is antibiotics usually administered over the course of many weeks, sometimes months. It is incorrect to just administer a broad spectrum antibiotic and hope for the best.  This will only give you antibiotic resistancy problems. The best method is to take a bacterial culture from the affected bone  ( bone biopsy) to determine which bacteria we are dealing with. A bacterial swab of the wound bed is usually not good enough. At the wound bed we find a collection of all sorts of bacteria - in many cases only one of these is the main culprit for the osteomyelitis. If you do not have the skills or resources to get a bone biopsy done then you can -  as a emergency procedure- clean the ulcer as good as possible, rinse it thoroughly with saline solution and first then take a bacterial swab of the wound bed at the precise location where you have bone beneath. With some luck this may help you to eliminate the other " unimportant bacteria" and that you are left with the real culprits on your swab.  

 

In elderly patients in poor condition it may not be useful to even try antibiotics. because these patients often have poor immune system and equally poor circulation and may never get riod of their osteomyelitis despite many weeks /months of antibiotics. We may even harm the patient with antibiotics - for examlple if they have diarrhoea or opportunistic fungal infections as a side effect of the antibiotic treatment.  In these cases you may just ahve to rely on palliative wound care - offload the ulcers, keep them as clean as possible and have a nutritional plan. 

 

With respect to debridement and choice of dressings this is identical to what we do with stage IV ulcers with a few exceptions.  Stage IV ulcers are usually less painful to debride but also a bit more "scary" to debride for many caregivers as we are often quite deep. 

In stage Iv ulcers we have to be very careful when using NPWT.  An important prinicple with NPWT is that all areas of the wound need to be in contact with the wound filler. if there are deep pockets or fistulas which are not in contact with the filler pus develop here leading to septicemia.  Also- putting a NPWT dressing on an untreated osteomyelitis can cause sepsis!  In other words- using  NPWT wrongly here can cause death!  The most modern NPWT pumps which also provide instillation ( that is- irrigating the wound with rinsing solutions or even antibiotic laden solutions) are safer to use but these are not available to the majority of patients in Africa. 

If you are using medicinal maggots in complicated stage IV ulcers be aware that the maggots can hide in sinuses and undermined areas and that you most likely will not get out all the larvae at dressing change.  This is not necessarily a major problem - the remaining larvae will usually develop into pupae and emerge fromt he wound as flies later on - it is mostly more of a " cosmetic" issue than a medical complication. However, most supplieres in western countries now sell maggots in small bags with tiny perforations (bio-bags)  which contain the maggots making them easier to handle.

What about unstageable ulcers?

If the ulcer is covered in black eschar or other thick necrosis it is impossible to estimate its depth and you will not be able to stage it. These are called unstageable ulcers.  Unless the patient is in palliative care you need to debride it to see the true depth of the ulcer and to prevent infection. These usually require some skill in debridement and if you do not have the training or resources you should refer the patient to a higher level of care when possible. There is some debate on whether you should remove a black, dry eschar from for example a heel. Most woundcare practitioners will recommend debriding it - leaving it on will carry a higher risk of osteomyelitis developing in the depths because we simply don\t know how deep the extent of the tissue damage is. This is also what we practice at our workplace and what we teach at conventions. The exception to this is a bedridden patient in a palliative setting where we not necessarily should  debride and debridement could even be contraindicated. 

Below follow a series of images of different unstageable pressure ulcers where we come with some suggestions for treatment to give you a general ideaof how to approach these challenges.

 

Never, never underestimate an unstageable ulcer.  It is unstageable so for all you know it could be a stage 4 ulcer even though it looks dry and harmless on the surface. 

Figure 12  Unstageable pressure ulcer on the back of the heel. The ulcer is covered in yellow necrotic tissue and slough which represents necrotic skin and necrotic subcutaneous fat.  There is some granulation on the edges but do not be fooled by that- the centre of the ulcer could be very deep.  We have to debride it - there are no obvious signs of infection and here we could do a serial debridement  removing some dead tissue at each session  Copyright: Medetec 

Figure 12 Ikke Unstageable pressure ulcer on the back of the heel. We see dry black eschar covering most of the wound - this is "mummified" dead skin. Again, do not underestimate this ulcer - most likely it is very deep, maybe even stage 4. Using local anestheisa carefully injected at multiple locations from the edges under the black necrosis this can be debrided quite painlessly if you proceed gently.  

Figure 13  Another unstageable pressure injury on a heel.  Here we see a blister in the major part of the injury and some may be tempted to call this a stage 2 injury. We do not agree with that - we have to remove the blister and see what is below to be able to stage this. Again: never, never underestimate the extent of tissue damage of a pressure injury! Copyright: 2003 AAWC http:/woundeducators.com)

Figure 14   Unstageable  pressure ulcer over right gluteal area. We see dry eschar covering most of the wound, some yellow necrosis on the right side. This is most likely at least a stage III pressure ulcer but we cannot be sure until we have debrided it. 

©LuAnn Reed, Drake Center Cincinatti Ohio

Advanced surgical treatment of pressure ulcers

A selection of patients may be good candidates for plastic surgery techniques to excise the ulcer and close it with some sort of flap. The ideal patient is younger with few other comorbidities and in good nutritional status. Even in western countries many health care workeres are not aware that these possibilities exist and too few patients are referred to specialized centres for this type of surgery.  Also at some university clinics in Africa this type of surgery is performed but it is usually reserved for special cases.  Most patients will also not have the resources to pay for this sort of treatment. Nonetheless, to give you a complete picture of the treatment possibilities we find it useful to describe some of these techniques briefly here.

 

There as mentioned earlier, strict criteria about who is applicable for this type opf surgery - age, nutrition status and compliance are some of these criteria.  the patient must be able to cooperate well after the surgery and completly offload the operated area for many weeks, sometimes months.  The skin and circulation condition around the ulcer area has to good.  If osteomyelitis has been detected underneath this must have been treated by a long course of antibiotics before attempting the surgery.  Even under optimal conditions the success rate is only around 70-80% and the recurrence rate is high.  

It is important to realize that you cannot simply excise the ulcer and suture the edges together - this will never go well and if it does it will be close to a miracle. Instead the surgical technique has to involve mobilizing skin, subcutaneous fat, fascia and preferably muscle  to cover the defect. 

Which technique the surgeon employs depends mostly on where the ulcer is located.  If skin, subcutaneous fat and fascie are used as a flap then this is called a fasciocutaneous  flap and it is crucial that perforating arteries which cross the fascia layeraand supply blood to the skin  are transferred along with the flap.An ultrasound probe can help find these arteries before surgery starts. These flaps are also called perforator flaps.  When muscle is moved in addition to the above techniques this is called a myocutaneous flap.  The latter have a better success rate because muscle is usually well circulated tissue.  

Figure 15   Demonstration of how perforating arteries are marked on a patient before deciding where to rotate the flap from.  The patient in the picture actually does not have a pressure ulcer but  an excised pilonidal sinus but the principle is the same © Taylor E M 

Figure 17 A)  Pressure ulcer over the sacrum and marking of a fasciocutaneous flap from the left gluteal area. B) During surgery where the flap is mobilized. We cannot see this on the image but the skin flap is actually attached to a perforating artery which was marked out before.  This artery is crucial for supply of blood to the skin of the flap.under operasjonen hvor hudlappen flyttes. C) Result some months after surgery. All images copyright © Masaki Fujioka, Nagasaki Medical Centre

Figure 18 Pressure ulcer over the sacrum closed by a so called "O-H" fasciocutaneous flap technique

© Fabiano Calixto Fortes de Arruda

Figure 19  Pressure ulcer over the sacrum closed by a so called  V-Y bilateral fasciocutaneous advancement flap. 

© Fabiano Calixto Fortes de Arruda

In the gluteal area, over the sacrum and trochanteric hip regions we usually have big muscles with good blood supply which is of help when making flaps here. Lower down on the foot- for example the heel area - this is more challenging because the closes muscles are in the calf of a leg. This is quite a distance from the heel. We refer to specialized literature if you are interested to read more about these techniques. 

Figure 20  Pressure ulcer on the back of the heel. The ulcer is excised and covered with a so called propeller fasciocutaneous flap. Copyright: © 2015 The Korean Society of Plastic and Reconstructive Surgeons