Types of pressure ulcers and their treatment

The damage may be caused either due to pressure or moisture, but it’s usually a combination of both.

Moisture ulcer is always caused by moisture. The edges of the ulcer are often spread and irregular. Moisture damage is never the cause of necrosis. It often develops on skin wrinkles as a surface damage to the skin.

A pressure ulcer is often developed over the bone protrusion. The edges of the ulcer are usually well defined and necrosis may develop.

Pressure ulcers are usually classified into 4 stages:

Stage I: Non-blanchable redness

Intact skin with redness on a clearly defined area, usually over a bony prominence, that does not blanch upon pressure. Darkly pigmented skin may not show this symptom, although the skin tone is different compared to the adjacent skin areas. The spot may be tender and painful, firm or soft and either warmer or colder than the rest of the skin.

This stage of pressure ulcers may be a sign that the patient is in the risk zone of developing deeper pressure ulcers.

It is necessary to relief the affected part of pressure against the base, to protect it with a comfortable soft pad (pressure pillow, protector, mattress topper). Bed linen has to be clean, dry, soft and tightly pulled. Regular patient hygiene (using quality medical cosmetics and incontinence aids), a diet rich with proteins, encouraging active exercise or doing passive exercises, changing the patient’s position every 2 hours is a must in pressure ulcers prevention and treatment. A diet rich with proteins, an increased intake of fluids and vitamin C is recommended.

Stage II: Partly damaged skin

Partly damaged skin presenting as an open ulcer (well defined round or oval wound), with a red pink wound bed, with no fibrin clustering. It may also present as an intact or open/ruptured blister filled with serum or blood. Presents as a shiny or dry shallow ulcer without fibrinogen clustering or a surface haematoma.

This stage should not be used to describe skin tears, tape burns, dermatitis linked with incontinence or maceration.

The damage spreads from skin surface into deeper skin layers. The point of care is to detect the affected spot as soon as possible, to release the pressure, to keep the environment clean and dry, soft and comfortable. Dietary recommendations, intake of fluids and vitamin C the same as in stage I.

Stage III: Extensive skin damage

All skin layers are affected. Subcutaneous fat tissue may show in the sore, but not bone, tendon or muscle. Also, fibrin clustering may show, although not so extensive that would cover the depth of the sore. It may include undermining and tunnelling. The depth of pressure ulcers of this stage may vary, depending on their anatomic position. Dorsum of the nose, ears, back of the head and ankles have no fat tissue, so ulcers of this stage on these spots may shallow. As opposed to them, the areas having more subcutaneous fat tissue may develop very deep ulcers. The bone/ tendon is not visible or directly palpable.

There is a threat of infection. Quick hygienic and dietary procedures (refer to stage II) may prevent further development of pressure ulcers.

Stage IV: Extensive damage to deeper tissues, including bones, tendons and muscles

Fibrin or necrosis may show, often with undermining or tunneling of tissues. The depth of pressure ulcers of this stage may vary, depending on their anatomic position. Dorsum of the nose, ears, back of the head and ankles have no fat tissue, so pressure ulcers of this stage on these spots may shallow. Pressure ulcers of this stage may include muscles and supporting structures (e.g. fascia, tendons or joint capsules), meaning that osteomyelitis or osteitis are likely to occur. The exposed bone and muscle are visible or may be directly palpable. Severe necrosis is qualified as stage IV, even if the skin is intact, which may be the case with heels for instance.

It is important that the personnel caring for the patient and checking skin status is able to assess and categorize the different stages of pressure ulcers. The status is assessed depending on the depth of damage.

Severe infections may occur. Besides the above indicated hygienic and dietary measures, surgical treatment of the ulcer will be necessary.

For the treatment/healing of pressure ulcers, stress for new tissue has to be avoided, meaning that “peace and quiet” are needed for the wounds to heal.

Pressure ulcers in terminal phases of illness

Pressure ulcers are often developed in underweight patients in terminal phases of illness. In this case, the primary goal is to eliminate pain and discomfort. With such patients, their comfort is a decisive factor when making decisions about the measures to be introduced and further treatment.

KTU (Kennedy Terminal Ulcer) is a frequent, although not well known pressure ulcer type that appears not long before the end of life. The change on the skin has an irregular shape, typically butterfly-, pear- or horseshoe-shaped, dark red/ yellow/ black coloured. Skin changes occur suddenly, in spite of preventive measures, advancing very quickly, sometimes developing into a deep pressure ulcer within only twenty-four hours. this happens because the skin does not function normally any more, along with the rest of body organs and blood circulation deteriorates. A combination of reduced nutritive status, increased body temperature and a generally weak physical status increases the risk of KTU development.