Protocols for Treatment of Pressure Ulcers

By: Lawrence O. Kollenberg, D.P.M.

By definition, stage I ulcers are an area of the skin which is erythematous, yet the dermis remains intact. Erythema generally remains present even 30 minutes after pressure is released. To these ulcers, I will apply a hydrating material such as a good quality skin cream. In patients with extremely dry skin, ointment base preparations such as BarriCare® or Aquaphor® improve the hydration status of the patient. I utilize BarriCare® most often because of its penetrating ability. It also provides vitamin A, vitamin D, and vitamin E, which will not only assist with hydrating the skin, but will also supply nutrition required by the skin for redevelopment of epithelial cells over time. I will usually continue an ointment based product on the average patient for about two to three weeks to ensure that the skin is fully hydrated. In patients with especially thin skin, often I will continue the application of the vitamin based ointments which clinically seems to thicken the skin overtime. Additionally I depressurize on the site and these areas will commonly heal in without incident of further breakdown..

In other cases, I have used Lac-Hydrin® successfully. Lac-Hydrin®, like Care Creme®, will penetrate and rehydrate the skin. This process is also seen with LyphaZome®. Again Care Creme®, like BarriCare® does have vitamins in an Aloe base which seems to assist with thickening the skin somewhat in geriatric patients with thin skin. I feel that this is of significant importance for these patients. I have seen no real advantage to Lac-Hydrin® over the others, except for the fact that it does hydrate the skin, although it is much more expensive.

I do not recommend using a harsh soap such as Liquid Dial Soap® or other bar soaps, as these have a tendency towards drying out the skin. Instead, I recommend utilization and application of CC-500® antimicrobial dermal wound cleanser that will assist with rehydration of skin as opposed to drying out the skin.

Stage 2 ulcers are considered to be a partial thickness break in the skin with tissue loss through the epidermis and down to the dermal-epidermal junction, but not invading through the dermal tissues. Typically, a shallow crater or possibly a blister may be formed. These wounds are cleansed with a dermal cleansing agent. Technicare®, does penetrate the dermis and has been shown to be therapeutically effective as a dermal cleanser for up to six hours as opposed to a lot of the topical dermal cleansers. I have used and applied Carra-Klenz™, MicroKlenz™, both marketed by Carrington, MicroKlenz™ acts with an emulsifying agent directly to the areas. Saf-Clens® by Convatec shows adequate cleaning of the wounds as well. It does not seem to create as much of an emulsification as is seen with MicroKlenz™, CC-500® or Technicare®.

These types of ulcers can be treated with hydrogels regularly and routinely. I have used Curasol, Carrasyn®, Spand-Gel and Iamin® for these types of ulcerations. I have found that the different hydrogels have some slight variations to them such as Spangel creating a mineral oil mixture, which maintains hydration a little bit better. The Iamin® gel is a thicker hydrogel base and provides copper as a nutrient directly to the area. Carrasyn® provides glycosaminoglycans directly to the area for building proteins and amino acids directly in the wound site. I have successfully utilized and applied foam dressings such as Allevyn by Smith and Nephew and Hydrasorb® by Convatec. I maintain foam dressings in place by applying transparent wound dressings such as Proclude®, CarraFilm, Op-Site* etc. This results in maintaining hydration to these areas. I have found these dressings to be similar in rate of healing.

Regarding collagen type dressings I have applied Fibracol® and BioCore's Kollagen directly to the sites. I have found that the fastest wound healing in Stage 2 ulcerations occurs with BioCore's Kollagen followed by Fibracol®. Fibracol® does seem to cause a little bit more pain upon serial debridement and causes and increase in inflammatory reaction when compared with BioCore's Kollagen. These wounds, if well maintained, generally are easy to get to heal. With the collagen based product by BioCore, I have commonly seen them heal in about a week. With Fibracol® it has taken about ten days. With the foams, and hydrogels epthelialization occurs in about three weeks.

Stage 3 ulcers can become somewhat recalcitrant to healing. They are full thickness tissue loss extending through the dermis and into the subcutaneous tissues, but not down to the muscle or bone. There may be undermining with sinus tract formation. Commonly they are exudative. Necrotic tissue with or without an infection can be present. A lot of your venous stasis ulcers are classed as stage 3 ulcerations. I have treated stage 3 ulcers with multiple different products. Again hydrogels foams and hydrocolloids are slow. I have used the collagens, BioCore's Kollagen Medifil® particles and SkinTemp®. Typically if it is an infected stage 3 ulcer, I prefer to use the Medifil® particles because I can impregnate antibiotics directly into the site, thus assisting with controlling the infection that is present to the area. I have seen these types of ulcers stagnate. I will not hesitate to mix a hydrogel in combination with the Medifil® particles. I have used Dermagran® by DermaSciences for zinc, Iamin® for copper and Carrasyn® for providing amino acids directly to the site. I will from time to time, if I feel that there is fungal involvement such as yeast, mix an anti-yeast type medication as well directly into the area. I like to try and maintain these with good hydration. If there is heavy exudate from the area, I have applied a calcium alginate directly over the Medifil® particles in combination. I have also used transparent adhesives with and without foam products in combination with the collagens. I have found that the healing rate of stage 3 ulcers is slower with use and application of the hydrogels and foams without collagen as compared to with the collagens. Most infected stage 3 ulcers can be closed in about 10-12 weeks providing that there is adequate vasculature directly to the area with use of hydrogels. With use of collagens it typically takes about six weeks. As always, I do begin all of my skin cleansing with dermal wound cleansers on a daily basis. When wounds are infected, my preference is Technicare®. When they are not infected, I will typically go with CC-500®. I have used extensively the Saf-Clens® as well as the MicroKlenz and Carrington's Carra-Klenz directly to the area.

Stage 4 ulcers are defined as full thickness tissue loss extending through the dermis and through subcutaneous tissue down to the fascia and commonly involves muscle and/or bone. It is a very deep crater. If bone is involved, commonly I will see osteomyelitis that is present with it. If there is confirmed osteomyelitis from tissue biopsy, I will impregnate antibiotics directly into BioCore's Kollagen to have a high concentration of antibiotic delivered directly to the area. I have found that foam dressings help to keep patients comfortable. When used as a secondary dressing, if they are heavily exudating I will commonly use Ex-U-Dry® to assist with absorbing the moisture and especially with infectious drainage directly from the site. Assuming that there is an ABI of 0.45 or greater, I find that typically with infection and necrosis that these wounds can be healed in about 16 weeks. I find that if there is minimal to mild amount of exudate, calcium alginates do not play a good role in these types of ulcers, as calcium alginates require moisture and heavy exudate in order to be active. In order to stimulate that process, I have applied hydrogels beneath the calcium alginate directly in the area and had adequate wound healing. It does take about 20-22 weeks utilizing this combination. All wounds must be de-pressurized. I follow de-pressurization guidelines not only as in the clinical practice guideline number 3 for pressure ulcers in adults from the area of health care policy and research, but also as shown in "Paddings and Strappings of the Foot" by Kaplan, et.al., "Review of Shoes, Orthoces and Related Biomechanics" from Clinics in Podiatric Medicine and Surgery, April 1994, "Diabetic Foot" of Clinics in Podiatric Medicine and Surgery, January 1995, as well as the combinations from pressure ulcers, Guidelines for Prevention and Nursing Management by McIlburst and Segrin, as well as many medical literature articles.

In closing, management for wounds of this magnitude requires a combination of good clinical evaluation, history, physical examination and decision making process. To quote Charles R. Baxter, M.D., "Wound care must be done my way." Dr. Baxter is referring to the fact that sometimes you have to throw everything including the "kitchen sink" into wounds to obtain closure. There is no ideal wound care dressing that works on all wounds. It requires good clinical judgment in combination with a team approach to achieve wound closure.

BarriCare®, Care-Tech® Laboratories, St. Louis, MO.
Aquaphor®, Beiersdorf, Inc., Norwalk, CT.
Lac-Hydrin®, Westwood-Squibb, Princeton, NJ.
Care Creme®, Care-Tech® Laboratories, St. Louis, MO.
LyphaZome®, Fountain Pharmaceuticals, Clearwater, FL.
Liquid Dial Soap®, Dial Corporation, Phoenix, AZ.
CC-500®, Care-Tech® Laboratories, St. Louis, MO.
Technicare®, Care-Tech® Laboratories, St. Louis, MO.
Carra-Klenz™, Carrington Laboratories, Irving, TX.
MicroKlenz™, Carrington Laboratories, Irving, TX.
Saf-Clens®, ConvaTec, Princeton, NJ.
Curasol™, Healthpoint Medical, Fort Worth, TX.
Carrasyn®, Carrington Laboratories, Irving, TX.
Spand-Gel, Medi-Tech International Corporation, Brooklyn, NY.
Iamin®, Procyte Corporation, Kirkland, WA.
Allevyn, Smith & Nephew
Hydrasorb®, ConvaTec, Princeton, NJ.
Proclude®, Calgon Vestal Laboratories, Inc., St. Louis, MO.
Carra™Film, Carrington Laboratories, Irving, TX.
Op-Site*, Smith & Nephew,
Fibracol®, Johnson & Johnson, Arlington, TX.
Kollagen™, BioCore Medical Technologies, Inc., Topeka, KS.
Medifil® Particles, BioCore Medical Technologies, Inc., Topeka, KS.
Aquaphor®, Beiersdorf, Inc., Norwalk, CT.
SkinTemp®, BioCore Medical Technologies, Inc., Topeka, KS.
Dermagran®, DermaSciences, Old Forge, PA.
Ex-U-Dry®, Ex-U-Dry Wound Care Products, Inc., Bronx, NY.