Background    Fast Fact #40 discussed the staging and prevention of pressure ulcers; this Fast Fact discusses their management.  The first step in deciding how to manage pressure ulcers is an assessment of whether the wound is likely to heal. If the patient has a prognosis of months to years, adequate nutrition, and blood flow to the tissue, then healing is possible. If the patient has a prognosis of days to weeks, anorexia/cachexia, and/or the wound has inadequate perfusion, then symptom control alone is appropriate and uncomfortable/burdensome treatments are not appropriate.

Debridement    Always provide adequate analgesia!  Necrotic tissue must be removed for ulcer healing; surgical debridement is the fastest and most effective method when there is healthy surrounding tissue. Note: If the patient is close to dying, and/or the wound will never heal, then debridement should not be attempted. Debridement gels (such as Hypergel, Santyl, Nu-gel) are applied onto an ulcer under an occlusive dressing (such as DuoDerm), are available for ulcers that do not require surgery or when surgical debridement is incomplete.  These products come with or without enzymes to encourage autolytic or enzymatic debridement.  For minimally necrotic ulcers, occlusive dressings such as DuoDerm, changed weekly, promote autolysis.

• Of note: wet to dry dressings are no longer recommended as dressing changes often cause pain when granular tissue and new epithelial cells are traumatically removed.

Antimicrobials   Ulcer healing is delayed if there is bacterial infection within the wound bed.  Erythema, purulent exudate, and fever are signs of infection.  Cleansing and application of topical antibiotics may be sufficient for superficial infection with minimal surrounding erythema.  Systemic antibiotics are indicated for deep/surrounding tissue infection, or if ulcer healing is delayed.

• All wounds should be cleansed with antimicrobial solution.
• Cleanse wounds that are expected to heal with non-cytotoxic fluids, such as hypochlorous acid (Puracyn, Plus, Vashe).
• Cytotoxic fluids (e.g., Betadine) will kill granulation tissue and should be reserved for wounds not expected to heal (ischemic wounds with dry eschar).

Dressings   Living tissue requires moisture for transport of oxygen and nutrients.  A moist ulcer environment promotes the migration of fibroblasts and epithelial cells; growth factors are present in the serous exudate that speed healing.  In contrast, a dry environment is conducive to necrosis and eschar. In short, moisture balance is key.  Think of your wound in one of four categories of dressing selection listed in the table below:

Deep and Wet Absorbent filler plus absorptive cover dressing	Deep and Dry Moisture retentive filler plus secondary dressing
Alginate or hydrofiber or gauze Plus Gauze/tape or adhesive foam	Gel impregnated gauze fluffed into a wound bed Plus Transparent film dressing or adhesive foam
Shallow and Wet May require a primary and a secondary dressing	Shallow and Dry
Foam boarder dressing or sheet alginate or hydrofiber Plus Roll gauze	Sheet hydrogels, hydrocolloids, transparent film dressing, non-adherent contact layer Plus Gauze layer

References

1. Walker P. The pathophysiology and management of pressure ulcers. In:Topics in Palliative Care, Volume 3. Portenoy RK, Bruera E, eds. New York, NY: Oxford University Press; 1998: pp 253-270.
2. Walker P. Update on pressure ulcers. Principles & Practice of Supportive Oncology Updates. 2000; 3(6):1-11.
3. Wound, Ostomy, and Continence Nurses Society. (2022) Wound Management: Core Curriculum. (2nd edition). Wolters Kluwer.

Conflicts of Interest: The authors have disclosed no relevant conflicts of interest.
Version History:  This Fast Fact was originally edited by David E Weissman MD. 2nd Edition published August 2005; 3rd edition May 2015. Additional revisions occurred in April 2021. 4^th edition reviewed and edited by Kelly Stone, MSN, A-GPCNP, CWCN-AP November 2023.