Treating pressure ulcers 

* Note - while many diabetic ulcers also are- strictly speaking, pressure ulcers too- we have written a separate 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 patient's general condition.  In these cases, it may be sufficient to pad the offending 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 multilayered foam dressing AND a plan for how to keep it off the mattress at all times. All images:©LuAnn Reed, MSN, CRRN, RNC, WCC, Drake Center Cincinnati 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. Hydrocolloids are self-adhesive, thin dressings with almost see-through " skin-like" consistency.  However, hydrocolloids are so thin 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 caused by friction or pressure, or a combination of both.  Therefore we usually choose a product that re-distributes pressure and reduces friction/shear simultaneously.  Most multilayered polyurethane foam dressings perform well here.  Most of these have an inner silicone layer which makes them gentle to apply and remove, and they breathe reasonably 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 that can 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 sits very well.  It can be used in most body areas, 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 relatively cheap and the technique for applying it is not difficult to learn

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

Treating stage 2 pressure injuries

Figure 4 Stage 2 ulcers are characterized by the outer layer of the skin is 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 polyurethane 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 represent fibrin or necrosis of superficial layers of subcutaneous fat. Often we do not need to debride this as the body's 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.  You will have to use boiled water or ready-made 0,9% saline solution to rinse the wound in other regions. You generally do not need any fancy or antiseptic solutions here.  Don't 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., how you are going 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 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 polyurethane foam dressing is the number one choice for these cases as they fulfill most needs. They have a cushioning effect, absorb moisture, and have some 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, stage 2 ulcers can also have quite a lot of exudate, making 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 know what you are doing, hydrocolloids can work very well, but they can also lead to a catastrophe and risk of infection in the wrong hands. 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 alternatives available to you? In these cases, you will have to work with what you have. Slightly exaggerated but still true: we could get pressure injuries to heal with paper 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, however.  Even with no resources at hand, you can offload effectively as long as you make a proper plan.  

Again, offloading is the most necessary 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 something to keep the heel elevated at all times.  This can be a cushion under the leg or a more fancy orthotic. 

Treating stage 3 pressure injuries

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 not 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 don't have the necessary equipment or skills, you may have to rely on the autolytic debridement process, which usually takes some weeks. However, if the necrotic layers are thick, 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 are usually less painful than stage I ulcers, we often 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 anesthesia slowly to avoid pain for the patient. If you are uncomfortable advancing the needle deep into the necrotic layer, you can advance the needle less deeply and debride less at each setting ( staged debridement technique).

 

When we sharply debride stage III and stage IV ulcers, 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 minimum 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 uses more potent 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. On occasion, we have experienced heavy bleeding when patients were using anticoagulation medication like warfarin or NOAK anticoagulants!  We have written more about debridement and anticoagulant in the chapter on "Debridement." 

 

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 body's autolytic processes.  As we mentioned earlier, 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 much 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 don't tend to be happy if the dressing is just floating above it.  Explained differently - 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 centimeters 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 gauze, place this in a "fluffy" manner into the wound, and then cover this with a multilayered foam dressing.   By the way - the wound filler is your primary dressing; what you have on top of that is your secondary dressing. 

Gauze soaked with povidone-iodine is a good choice for treating stage III and stage IV pressure ulcers. This is a cheap and effective dressing provided that it is changed daily.  The key to success when using povidone iodine gauze is frequent dressing changes. You will also need a secondary absorbent dressing to keep the iodine soaked gauze in place. 

 

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Figure 7 Regular cotton gauze soaked in 10% povidone-iodine is an excellent way to treat stage III and IV pressure ulcers.  The product is non-toxic at these concentrations and can be safely used for several weeks until the ulcers clean up.  The key to success is changing the iodine-soaked gauze regularly- at least daily. 

White granulated sugar is receiving increasing attention as a wound dressing in several western countries. This is, in reality, a renaissance of this concept because 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 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 as well?  Unrefined brown sugar is thought to contain some impurities, while refined white 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 at the start. You will have to accommodate this with frequent dressing changes and good absorbent dressings.  Because the wound can have higher amounts of exudate, there is a higher risk of wound edge maceration - barrier products are essential. Some patients experience a slight itch when sugar residues lie on the skin edges over more extended periods. 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.  In a blog in research gate about sugar treatment (https://www.researchgate.net/post/Sugar_for_wounds), we read 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 an issue - these types of flies will be attracted to the smell of a wound anyhow and will always pose a 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 effects. 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 suitable absorbent dressing. The technique is so easy that you can teach family/ other relatives/neighbors to treat the patient's wound. 

One not immediately apparent downside to using sugar is patient acceptance. While many patients in western countries may find it exciting to try a "medieval" method of treating wounds, some African patients 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 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. 

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

Let's 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 wound care actually comes from companies producing honey or other dressings in competition with sugar. We have actively used sugar treatment in many of our patients since 2019 and have, in some cases, seen excellent results in situations where conventional dressings have failed. Sugar will not solve all of your wound care 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 8 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 to 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 jelly when they contact wound exudate. So if you are dealing with an ulcer with much exudate, you can place the Hydrofiber dry into the ulcer.  On the other hand, if you have a surprisingly dry ulcer ( rare), 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 another 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 that do really well as a wound filler if you or the patient have the financial resources to use these.  One of these is 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 wound bed at an optimal moisture level.  This combination of substances has proven very effective, and with some patience, it speeds 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 absorbent dressing over it, and don't have too long dressing change intervals in the start.

Another product that does really well in pressure ulcers as a wound filler is Sorbact®.  This is another unique product- it doesn't 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 fully understand), it does an excellent job aiding the autolytic debridement process.  Again- just fill the ulcer in a "fluffy" manner with the Sorbact and place an absorbent dressing over it. 

Yet another useful product as a wound filler is Kerlix™ AMD  gauze.  Kerlix™ AMD rolls are impregnated with PHMB (Polyhexamethylene Biguanide). This powerful yet safe antiseptic has a broad range of effectiveness against gram-positive and gram-negative microorganisms, including some multi-drug resistant strains such as MRSA. The gauze comes in big rolls, which makes them very cost-efficient. If there is little wound 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 secondary dressing over this. 

Another method of treating deeper pressure ulcers is negative pressure or NPWT (negative pressure wound therapy).  No other modality can turn around a stagnating ulcer and stimulate granulation tissue like NPWT.  However, the ulcer must 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 select few patients on the continent. If you want to use NPWT but do not have the resources, it is possible to improvise and find more inexpensive workaround solutions. We have written a thorough chapter on NPWT - please refer to that for all details. 

We usually rinse pressure ulcers at each dressing change as the bacterial burden is often high. Especially pressure ulcers in the sacral area close to the anus tend to be critically colonized with intestinal bacteria, staphylococcus aureus, and other pathogenic bacteria. This is usually NOT an indication to give antibiotics. 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 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 that, 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 some still use chlorhexidine to rinse wounds- we consider this outdated, and from what we know from existing research, it may harm healthy cells. There are many safe alternatives, such as 3,5% vinegar, super oxidized water ( which, by the way, can be made cheap with simple technology), and 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. However, many still use it, and we must admit that we also like it.  Granulation tissue always appears "healthier in color" after treating rinsing with hydrogen peroxide - it is also cheaply available in Africa, making it a good choice.  We have written a separate chapter on rinsing solutions - please refer to that for more details. 

Unfortunately, using medicinal maggots to clean/debride ulcers is not commonly practiced in Africa. It is possible to rear the correct type of flies (green bottle flies) easily, sterilize the eggs and place the sterile eggs directly into 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/or get them delivered. In the separate chapter on maggot therapy,  we give you a step-by-step procedure on how to rear your own medicinal maggots and how to use these correctly.

Figure 9  Here, medicinal maggots have been placed in an ulcer on a patient's heel. 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 "maggot therapy"  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 or 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 crevices 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

While 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 - an infection of the bone.  As a general recommendation, in western countries, patients who have a stage IV ulcer that has not improved significantly within six 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 is bedridden 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 severe 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 diarrhea) with a fecal management system. These are large-diameter catheters placed into the anal canal and held in place by an inflatable cuff. 

Note that there are possibilities to treat big pressure ulcers in younger patients in otherwise good condition with surgical flap techniques - we explain some of these techniques later 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 plastic surgeries are carried out in 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 the patient off-loads the area for many months afterward, which requires high patient compliance.

Figure 10 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 the bone in the center and the undermined area to the right. In fact - this patient had severe osteomyelitis when 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 do not look "too bad." 

Many caregivers underestimate how easily osteomyelitis can develop in stage Iv ulcers and how serious this can get. Sometimes osteomyelitis can affect a large area of a bone, leading to septicemia if left untreated. If the patient has 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 severe 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 osteomyelitis lurking in the depth.  If there is destruction of the bones surfaces, you can be very sure that the patient has 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 osteomyelitis, an x-ray usually is done. A standard x-ray can be a good method to detect osteomyelitis in advanced cases.  However, if the x-ray reveals nothing, this does not rule out osteomyelitis with certainty, and then usually, 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 not available for most patients with pressure ulcers in Africa, and many will not even have access to an x-ray.  In this situation, you will have to rely on your clinical sense and may have to start the patient on a several week-long antibiotic regime from your findings of the wound examination. 

Figure 11 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 12 MRI scan of the gluteal area with a pressure ulcer at the ischiatic tuberosity - a classical site for developing severe pressure ulcers.  The arrows point to areas of destruction in the bone (irregular edges) due to 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 many weeks, sometimes months. It is incorrect to administer a broad-spectrum antibiotic and hope for the best.  This will only give you antibiotic resistance 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. Suppose you do not have the skills or resources to get a bone biopsy done. In that case, as an emergency procedure, you can clean the ulcer as well as possible, rinse it thoroughly with saline solution, and 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.  

 

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

 

Concerning 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 essential principle with NPWT is that all areas of the wound need to be in contact with the wound filler.  Pus can develop in deep pockets or fistulas that are not in contact with the filler, leading to septicemia.  Also- putting an NPWT dressing on untreated osteomyelitis can cause sepsis!  In other words- misusing NPWT here can cause death!  The most modern NPWT pumps, which also provide installation ( that is- irrigating the wound with rinsing solutions or even antibiotic-laden solutions), are safer to use, but these are not available to most 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 significant problem - the remaining larvae will usually develop into pupae and emerge from the wound as flies later on - it is mostly more of a " cosmetic" issue than a medical complication. However, most suppliers 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 ulcer's true depth and 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 wound care practitioners will recommend debriding it - leaving it on will carry a higher risk of osteomyelitis developing in the depths because we 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 do not necessarily debride, and debridement could even be contraindicated. However, we know that some experienced wound care experts prefer to keep dry eschar in place, arguing that it is an excellent biologic dressing.  We respect that approach and know it can lead to good results. 

Below is a series of images of different unstageable pressure ulcers where we come up with some suggestions for treatment to give you a general idea of 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 13  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 center 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 14  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 anesthesia carefully injected at multiple locations from the edges under the black necrosis, this can be debrided quite painlessly if you proceed gently.  This is the type of dry eschar that can cause some discussion amongst experts. Should this really be debrided or can we leave it in place? In our experience, leaving it in place will take more time until healing.  But again, some of the leading experts in the field of wound care will argue for keeping the eschar in place.  This is certainly the option to choose if you are not very experienced in debridement.  As long as there are no obvious signs of infection, you can keep the eschar in place. 

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Video 1  Dr. Jeffrey Niezgoda demonstrates the management of a stable pressure heel ulcer.  If there are no signs of infection this dry eschar may be left in place, acting as a biological dressing.  If you click on the image above the link will take you to the video on youtube. This is an age-restricted video and you will have to log in to youtube to view this. WE strongly recommend the videos by Dr. Niezgoda- they are highly informative and always show relevant cases.  

Figure 15  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 disagree with that - we have to remove the blister and see what is below to be able to stage this. Again, never underestimate the extent of tissue damage of a pressure injury! Copyright: 2003 AAWC http:/woundeducators.com)

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Figure 16   Unstageable pressure ulcer over the right gluteal area. We see moist eschar covering most of the wound, some yellow necrosis around this. This is most likely at least a stage III pressure ulcer, but we cannot be sure until we have debrided it. On the left buttock is a stage II ulcer. 

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 workers are not aware that these possibilities exist, and too few patients are referred to specialized centers for this type of surgery.  This type of surgery is performed at some university clinics in Africa, but it is usually reserved for exceptional cases.  Most patients will also not have the resources to pay for this treatment. Nonetheless, to give you a complete picture of the treatment possibilities, we find it useful to describe some of these techniques briefly here.

 

As mentioned earlier, strict criteria about who is applicable for this type of surgery - age, nutrition status, and compliance are some criteria. The patient must be able to cooperate well after the surgery and completely offload the operated area for many weeks, sometimes months.  The skin and circulation condition around the ulcer area has to be 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 involves mobilizing skin, subcutaneous fat, fascia, and, preferably, muscle to cover the defect. 

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

Figure 17   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 18 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 marked out before.  This artery is crucial for the supply of blood to the flap's skin. C) Result from some months after surgery. All images copyright © Masaki Fujioka, Nagasaki Medical Centre

Figure 19 Pressure ulcer over the sacrum closed by a so called "O-H" fasciocutaneous flap technique

© Fabiano Calixto Fortes de Arruda

Figure 20  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 21  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

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Figure 22  You can read more about flap surgery to treat pressure injuries in this illustrative article from the Nigerian Journal of Plastic surgery. Click on the image to get to the article. copyright: Sudhanshu Punia et al. Nigerian Journal of Plastic Surgery, 2018