Local care of pressure-induced skin and soft tissue injury

INTRODUCTION — Pressure-induced skin and soft tissue injuries are a type of breakdown to the skin and underlying tissue when an area of skin is under constant pressure. Shearing forces can also contribute to loss of skin integrity. As a result, pressure and/or shear forces leading to tissue ischemia can result in skin ulceration or deeper tissue injury, the extent of which can be underestimated. Identifying patients at risk for skin failure can help prevent pressure injury. Many factors contribute to the development of pressure-induced injury, including health status of the patient and location of pressure. Proper wound staging is important for developing treatment plans for the patient.

Every effort is made to prevent the occurrence of pressure-induced injury regardless of patient care setting; however, they still occur, and are a frequent source of surgical consultation both in the inpatient and outpatient setting. The general principles of management are similar; however, the resources for managing pressure-induced injuries differ in the outpatient setting.

Local wound care of pressure-induced skin and soft tissue injury including minor wound debridement is reviewed. Surgical management including major wound debridement is reviewed separately. (See "Surgical management of pressure-induced skin and soft tissue injuries".)

WOUND STAGING AND DOCUMENTATION — The wound should be characterized according to the National Pressure Injury Advisory Panel (NPIAP) pressure injury staging system (figure 1 and picture 1 and table 1). The Pressure Ulcer Scale for Healing (PUSH) tool developed by the NPIAP, and other tools such as the Bates-Jensen and Sessing scale, can be used to help assess the wound and follow the wound healing progress. (See "Clinical staging and general management of pressure-induced skin and soft tissue injury".)

Wound documentation, using either photography or manual measurements with a ruler or acetate tracings, should be performed during each office visit and should include characteristics of the wound bed (size, tissue type, drainage, and bioburden) and condition of periwound skin. The following should be included at the initial wound care visit and at subsequent visits:

●Wound measurements, including widest length/width and maximal depth.

●Percentages of each tissue type present in the wound should be described, including granulation/hypergranulation, necrotic tissue including slough, and pale or agranular tissue.

●Description of the edges of the wound, such as denuded, variegated, rolled, unattached, and attached, should also be included.

●Type of drainage, such as serous, serosanguinous, sanguinous, purulent, or exudative.

●Tunnels and undermining should be documented in a clock fashion with measurement of depth.

●Bioburden of the wound bed, including slough or liquefaction necrosis, which can imply a local bacterial infection. Digital photography using ultraviolet light can be used in the outpatient setting to determine the extent of bacterial load in the wound and aide in monitoring the efficacy of treatment [1].

●Description of the periwound tissues such as clean, dry, intact, blistering, erythematous, excoriated, or hyperpigmented. Any swelling to the wound and periwound tissue should be noted.

●In the extremities, the adequacy of perfusion should be accessed via the ankle-brachial index, and if abnormal, additional vascular studies.

●Interdisciplinary wound consultation may be needed if the initial evaluation does not support a diagnosis of pressure-induced injury, or pressure-induced injury may not be the only wound mechanism.

Smartphone applications (ie, apps) are available that can help identify tissue type, aid in performing wound measurements, assist with wound staging, and for prescribing wound supplies and homecare services. Some apps are Health Information Portability and Protection Act (HIPPA) compliant and can be used transfer patient images into their clinic record. Other means of transferring patient photos are through a hospital-based portal system or hospital email, where the patient will send their picture of a wound to the hospital-based system which will be uploaded into their chart for viewing. Advanced imaging analysis via wound electronic medical records can also be used. Some electronic medical record systems have the capability to allow the practitioner to upload a photograph and image processing software will generate wound surface area and identify and compute the amounts of the various tissue types (granulation, areas of ischemia, areas of slough).

It is also important to identify and document risk factors contributing to pressure-induced skin and soft tissue injury that may hinder the progress of wound healing such as:

●History of prior pressure-induced injury and history and method of wound healing

●Medical conditions (eg, diabetes, stroke, multiple sclerosis, cognitive impairment, cardiopulmonary disease, malignancy, and peripheral artery disease)

●Prior hospitalization (eg, critical illness) or emergency department visit and length of stay

●Prior surgery or procedure that required prolonged immobility

●Presence of malnutrition

●Presence of volume depletion or hemodynamic instability

●Urinary or fecal incontinence

●Medical devices applied for diagnostic or therapeutic purposes

●Presence of clinical factors that suggest abuse or neglect

●Prior refusal of care

Nutritional screening (eg, malnutrition screening tool) should be performed on all patients with pressure-induced skin and soft tissue injuries. A complete nutritional assessment is completed for a positive nutritional screen and whenever there is a significant change in the patient's condition [2]. (See "Clinical assessment and monitoring of nutrition support in adult surgical patients".)

Each hospital is mandated to record any pressure injuries incurred while a patient is in the hospital. Logs of prevalence and occurrences are reported to risk management and state tracking records. Pressure injuries should also be documented as avoidable or unavoidable according to the Centers for Medicare & Medicaid Services (CMS) guidelines in the United States. These are defined as follows:

●Avoidable pressure injury is pressure injury that develops and the healthcare provider did not: evaluate the clinical condition or pressure injury risk factors; define and implement intervention consistent with patient needs, goals of care, and recognized standards of practice; or monitor and evaluate the outcome of intervention.

●Unavoidable pressure injuries are those that develop despite all appropriate measures being taken. Unavoidable pressure injuries include those associated with comorbid conditions such as peripheral vascular disease, septic shock, and use of vasopressors.

CARE SETTING — Every effort is made to prevent the occurrence of pressure-induced injury regardless of patient care setting; however, they still occur, and are a frequent source of surgical consultation both in the inpatient and outpatient setting. The general principles of management are similar; however, the resources for managing pressure-induced injuries differ in the outpatient setting.

For outpatient care, telehealth platforms can be used for the initial evaluation of any stage of pressure-induced injury, including evaluation of Stage III and IV and deep pressure-induced injury. Remote wound management is conducted in the outpatient setting and involves either a live face-to-face encounter, telephonic communication, or a hospital-based portal system. In-office management is necessary for pressure-induced skin and soft tissue injuries that cannot be managed via telehealth. Patients who are identified as needing additional services in the clinic (eg, debridement, application of cellular-based product), further evaluation (eg, ultrasound, noninvasive vascular studies), or surgical debridement can be scheduled for an appointment.

Higher stage pressure-induced skin and soft tissue injuries (III, IV and deeper) often require inpatient surgical management with flap reconstruction for wound coverage. Other indications for inpatient management include wounds associated with systemic infection, significant necrosis in the wound, osteomyelitis, deterioration in the patient's functional status, and persistent nonhealing wounds despite optimal outpatient management. (See "Surgical management of pressure-induced skin and soft tissue injuries", section on 'Indications for surgery'.)

For patients being managed at home, wound supplies should be prescribed via a durable medical equipment supplier shipped directly to the patient's home. Homecare services should be ordered to help with dressing changes as needed, and wound supplies should be prescribed beforehand. Pressure redistribution and supportive interventions are recommended to prevent wound progression and are prescribed according to the area of injury [3]. (See 'Pressure redistribution and supportive interventions' below.)

SPECIFIC WOUND MANAGEMENT

Basic principles — Local wound management strategies follow the basic principles of wound management and are implemented to optimize the healing of pressure-induced injuries, recognizing that complete healing may be unrealistic in some patients. (See "Basic principles of wound management".)

Prior to providing care, informed consent should be obtained with the goals/outcome of management (eg, curative, palliative) included. The patient or caregiver should be made aware of the potential for wound progression if compliance with offloading or nutritional measures or other medical care is not followed.

Local care of pressure-induced injury is selected based on the characteristics of the wound bed (size, tissue type, drainage, bioburden), condition of periwound skin, and patient's general health status. In general, with each wound care session:

●Cleanse or irrigate the wound and periwound skin at each dressing change.

●Determine whether debridement is necessary based on the presence of nonviable tissue, and if so, the extent that will be required. Necrotic tissue promotes bacterial growth and impairs wound healing. Debridement can be surgical (excisional, incisional) or nonsurgical (autolytic, mechanical, enzymatic, biologic, chemical). The type of debridement selected should be documented. For minor tissue slough and exudate at the base of a wound, it is not clear whether any particular form of nonsurgical debridement (eg, mechanical, enzymatic, biologic) offers any clear advantage [4]. If surgical debridement is performed, the extent and depth should be described. (See "Basic principles of wound management", section on 'Wound debridement'.)

●Specific dressing management will vary depending on pressure injury stage, quality of the wound, and available resources, which may factor in cost and reimbursement. A topical dressing that promotes moist wound healing is selected (table 2 and table 3) [5]. Healing of pressure-induced injuries is promoted by dressings that maintain a moist wound environment while keeping the surrounding intact skin dry [6-8]. Many different types of dressings are available (table 2). Although varying circumstances may favor choosing one dressing over another, no dressing has been shown to be consistently superior to another in clinical trials [9-12]. A systematic review identified six trials comparing topical treatments with and without antimicrobial activity [13]. Where differences in wound healing were found, these sometimes favored the comparator treatment without antimicrobial properties. (See "Basic principles of wound management", section on 'Wound dressings'.)

•Excess fluid can macerate the wound and inhibit cell proliferation and wound healing [14]. Wounds with excessive drainage will need more absorptive dressings to avoid the buildup of chronic wound fluid. Dressings with absorptive qualities include foams and alginates.

•Dry wounds also lack the wound fluids necessary to provide tissue growth factors for epithelial cell migration and reepithelialization. Wounds that are desiccated will need to have moisture added (eg, gel application). Choices for a dry wound include saline-moistened gauze, transparent films, hydrocolloids, and hydrogels.

●Pack dead space and undermined tunnels with 0.9% saline gauze or with medicated gauze (eg, iodoform, Dakin solution, acetic acid [0.125%, 0.25%], polyhexamethylene biguanide). (See "Basic principles of wound management", section on 'Wound packing'.)

●Avoid antimicrobial therapy unless there is evidence of infection [15]. (See "Clinical assessment of chronic wounds", section on 'Signs of infection'.)

Local care by stage — Local care of pressure-induced skin and soft tissue injury depends on the clinical stage (figure 1 and picture 1 and table 1).

●Management of Stage I and II pressure-induced skin and soft tissue injuries is generally conservative with appropriate wound care and elimination of causative factors that led to the initial injury.

●Higher stage pressure-induced injuries (Stage III, IV and deeper) may require inpatient surgical management to obtain wound closure. Interim wound care may be necessary until wound closure can be obtained when surgical management will involve staged procedures. (See "Surgical management of pressure-induced skin and soft tissue injuries", section on 'Preoperative considerations'.)

Stage I — Stage I pressure-induced injury does not have necrotic tissue and therefore will not require debridement. A foam dressing can be placed overlying the area to protect pressure points [14]. If moisture is detected, a no-sting skin barrier protectant can be applied. Pressure redistribution and supportive interventions are recommended to prevent wound progression [3]. (See 'Pressure redistribution and supportive interventions' below.)

Stage II — Stage II pressure-induced injury requires a dressing that maintains a moist wound environment [8]. These wounds generally require little debridement but should be debrided to viable tissue if the wound bed demonstrates necrotic tissue or bioburden.

Debridement commonly involves autolytic or mechanical debridement, but may use enzymatic, biologic, or chemical methods. Autolytic debridement is appropriate for wounds in which the amount of necrotic tissue is not extensive and there are no signs of infection. Autolytic debridement uses the wound's moisture to hydrate and soften any eschar and slough. Necrotic tissue that is present is degraded by enzymes normally present in the wound base [14,16,17]. Autolytic debridement can usually be achieved using hydrocolloids or hydrogels. If additional autolytic debridement is necessary, collagenase or other enzymes derived from bacteria or plants can be used to accelerate removal of necrotic tissue (eg, Clostridium histolyticum [18], collagenase [19], Varidase [20], papain [21], and bromelain [22]).

Biologic debridement is another option that involves the use of maggot larvae of Lucilia sericata (contained in a biobag to limit migration) to consume necrotic tissue; live tissue is not affected [23]. The use of chemicals (eg, silver nitrate) is common to control bleeding sites and to control hypergranulation tissue. Hydrotherapy is a form of mechanical debridement (eg, directed wound irrigation [eg, Versajet], ultrasonic debridement) which can be used in a clinic setting if such equipment is available. Ultrasonic debridement uses an electromechanical device with integrated aspiration to debride necrotic tissue [24].

Periwound moisture and friction control are addressed during dressing management. Barrier creams or no-sting barrier protectant are used to reduce moisture wound interface, if needed. Importantly, pressure redistribution and supportive interventions are recommended to prevent wound progression [3]. (See 'Pressure redistribution and supportive interventions' below.)

Stage III, IV, and deep — Stage III and Stage IV pressure injuries demonstrating clean and granulating tissue can undergo dressing management. Barrier creams or no-sting barrier protectant are used to reduce moisture at the periwound, if needed. Stage III, IV, or deeper pressure injuries may require surgical debridement of necrotic tissue and possibly treatment of infection. (See "Surgical management of pressure-induced skin and soft tissue injuries".)

Prior to debridement, cross-sectional imaging using computed tomography (CT) or magnetic resonance (MR) can be useful to define the extent of tissue involvement since the area of skin breakdown can be much smaller than the total area affected. Imaging can also help determine if infection is present in the soft tissues or bone (ie, osteomyelitis) [25].

Wound cultures are not routinely performed but should be considered for clinical evidence of infection or lack progress with wound healing. Obtaining a deep tissue biopsy for culture during debridement is more informative than simply performing a swab of the wound [26]. Cultures showing >10,000 colony-forming units per gram of tissue are indicative of tissue infection requiring antimicrobial therapy. Antibiotics may also be used depending on whether they were able to effectively drain and remove all infected tissues with excisional debridement [27].

The presence of necrotic tissue, slough, and biofilm warrants sharp debridement (excisional or incisional). Sharp excisional debridement is routinely performed and may be performed in association with other forms of debridement. Excisional debridement should extend to bleeding viable tissue. In circumstances where this may not be safe, debulking the necrotic tissue can be performed to reduce local infection. When fluctuance is identified, incision and drainage is necessary. Incisional debridement involves lengthening the wound to allow for proper wound packing, if needed.

Sharp excisional debridement in the outpatient setting routinely is accomplished with the use of local anesthetics. Most patients can tolerate surgical management with the use of topical or injectable lidocaine. While other forms of debridement may be less painful, they vary in their effectiveness in reducing the amount of nonviable tissue, including biofilm and slough that is found in deeper pressure-induced wounds.

Practitioners in hospital-based clinics are provided privileges to debride wounds based on their competency. Certified wound care nurses and physical therapists under physician discretion can provide excisional debridement and debulking of nonviable tissue with scissors and forceps. Advanced care practitioners such as physician assistants and nurse practitioners can provide sharp excisional debridement down to bleeding viable tissue.

Debridement in an operative setting under anesthesia provides the fastest and most thorough method of debridement and is generally necessary for those in whom pain cannot be controlled with local anesthetics in a clinic setting; debridement will involve a large amount of tissue; the wound extends to the deep tissues with exposed fascia, muscle, or bone; and incision and drainage of multiple abscesses or evacuation of large hematomas will be necessary. For large or deep wounds, surgical coverage is required to prevent recurrence, which occurs in 13 to 61 percent of patients [28-31]. Whether to proceed with surgery ultimately depends upon patient preference, treatment goals, risk of recurrence, and quality-of-life considerations. (See "Surgical management of pressure-induced skin and soft tissue injuries", section on 'Indications for surgery'.)

Unstageable — Unstageable pressure-induced injury is one in which the base of the wound cannot be assessed due to overlying nonviable tissue. These wounds require debridement to remove slough or eschar down to viable tissue and they are then treated based upon the observed stage. As described above for Stage III, IV and deep pressure induced injuries, imaging studies may help assess the extent and depth of the wound. Large area unstageable wounds may require surgical debridement in the operating room to completely assess their extent. (See "Surgical management of pressure-induced skin and soft tissue injuries", section on 'Indications for surgery'.)

If the patient's condition does not allow debridement, the wound can be managed by leaving stable eschar (ie, dry, adherent, intact without erythema or fluctuance) intact. To prevent infection, nondebrided eschars should be kept dry.

PRESSURE REDISTRIBUTION AND SUPPORTIVE INTERVENTIONS — Pressure redistribution and supportive interventions similar to those implemented with prevention strategies are used to reduce ongoing tissue trauma (see "Prevention of pressure-induced skin and soft tissue injury"), and include the following [2,32-34]:

●Maintain head of bed at/or below 30 degrees or at the lowest degree of elevation consistent with the patient's medical condition to prevent shear-related injury.

●Reposition and turn immobilized patients.

●Position patients with special attention to anatomy, postural alignment, distribution of weight, and support of feet.

●Use positioning, transferring, and turning techniques to minimize skin injury due to friction and shear forces. Use lifting devices when repositioning as applicable.

●Use positioning devices to redistribute pressure over bony prominences.

●Use heel protection devices to offload heel pressures. Heel boots are used when the site of injury is noted at the leg, ankle, or foot. Pillows may be considered a heel protection device.

●Use support surfaces (bed and chair) to redistribute pressure as indicated by patient's condition. Patients with Stage III or IV injuries qualify for a Group II mattress and hospital bed. For patients who use wheelchairs, specialty seat cushions with back support are prescribed.

●Use a skin protectant/barrier for patients with frequent urine or fecal incontinence or patients with both urinary and fecal incontinence.

●Use skin moisturizer to prevent dryness.

●Avoid massage over reddened bony prominences.

●For nutritionally compromised patients, implement a plan of nutrition support and/or supplementation that meets a patient's needs and is consistent with overall goals of therapy.

●Educate patient about the causes and risk factors for pressure injury development and ways to minimize risk.

FOLLOW-UP ASSESSMENT AND MONITORING — Wound follow-up is performed weekly for the best results. When reassessing the wound, determine whether management modifications are needed as the wound heals or deteriorates. Implement measures to eliminate or control pain as indicated by the patient's condition. Educate the patient/family on pressure injury management strategies as applicable. Monitor pressure injury(s) on admission to health care setting, at minimum weekly, and with any signs of skin/wound deterioration. Monitor for factors that impede healing status. Monitor for healing. Assess for potential complications associated with pressure injuries.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic wound management" and "Society guideline links: Pressure-induced skin and soft tissue injury".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Pressure sores (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Pressure-induced skin and soft tissue injury – Local care is according to the stage of the pressure-induced injury and the specific characteristics of the wound, which determine the need for debridement, topical antimicrobial therapy, dressings, and for more extensive wounds, the need for surgery. (See 'Wound staging and documentation' above.)

●Wound documentation – The pressure-induced wound should be characterized according to the National Pressure Injury Advisory Panel (NPIAP) pressure injury staging system (figure 1 and picture 1 and table 1). Wound documentation should be performed during each office visit, including characteristics of the wound bed (size, tissue type, drainage, bioburden) and condition of periwound skin. It is also important to identify and document risk factors contributing to pressure-induced skin and soft tissue injury, which may hinder the progress of wound healing. Nutritional screening (eg, malnutrition screening tool) should be performed on all patients. (See 'Wound staging and documentation' above.)

Hospitals are mandated to record pressure-induced injuries that occur when a patient is in the hospital. Pressure injuries are documented as avoidable or unavoidable. These are defined as follows:

•Avoidable pressure injury – Avoidable pressure injury is one that develops and the healthcare provider did not: evaluate the clinical condition or pressure injury risk factors; define and implement intervention consistent with patient needs, goals of care, and recognize standards of practice; or monitor and evaluate the outcome of intervention.

•Unavoidable pressure injury – Unavoidable pressure injuries are those that develop despite all appropriate measures being taken. Unavoidable pressure injuries include those associated with comorbid conditions such as peripheral vascular disease, septic shock, and use of vasopressors.

●Patient care setting – The care setting under which pressure-induced injury is managed varies. For outpatient care, telehealth platforms can be used for the initial evaluation and remote wound management can be conducted in the outpatient setting. As needed, homecare services should be ordered to provide assistance for dressings and wound supplies should be prescribed in advance. For pressure-induced skin and soft tissue injuries that cannot be managed via telehealth, in-office management is necessary. (See 'Care setting' above.)

Inpatient surgical management is indicated for:

•Persistent nonhealing wounds despite optimal outpatient management

•Significant necrosis or osteomyelitis

•Wounds associated with systemic infection

•Deterioration in the patient's functional status

•Higher stage wounds (III, IV and deeper) requiring surgical wound coverage

●Local wound management – Local care follows the basic principles of wound management (table 2 and table 3) and are implemented to optimize healing, recognizing that complete healing may be unrealistic in some patients. Local care is selected based on the characteristics of the wound bed (size, tissue type, drainage, bioburden), condition of periwound skin, and patient's general health status. (See 'Specific wound management' above.)

In general, with each wound care session:

•Cleanse or irrigate the wound and periwound skin at each dressing change.

•Determine whether debridement is necessary based on the presence of nonviable tissue and the extent that is required. Document the type of debridement used. If surgical debridement is used, the extent and depth should be documented.

•Healing of pressure-induced injuries is promoted by dressings that maintain a moist wound environment while keeping the surrounding intact skin dry. In general:

-Wounds with excessive drainage need more absorptive dressings. Dressings with absorptive qualities include foams and alginates.

-Wounds that are desiccated need moisture added. Choices for a dry wound include hydrocolloids and hydrogels, saline-moistened gauze, and transparent films.

•Pack dead space and undermined tunnels with 0.9% saline gauze or with medicated gauze.

•Unless a wound has clinical signs of infection, avoid antimicrobial therapy.

•Follow-up weekly to evaluate wound progress.

•Provide pressure redistribution and supportive interventions like those implemented as preventive strategies to reduce ongoing tissue trauma. (See 'Pressure redistribution and supportive interventions' above.)