Dra Claudia, buenas tardes.

En el actual documento hay tres artículos, el primero titulado “Importance of nutrition in

preventing and treating pressure ulcers” es el que elegí para la realización del club de lectura, sin
embargo, los otros dos artículos me parecieron muy buenos y prácticos respecto a lo básico del
tema, por lo tanto si le parece mejor que presente alguno de esos por mi no habría ningún
problema
evidence & practice / tissue viability
DIETETICS
Importance of nutrition in preventing
and treating pressure ulcers
Taylor C (2017) Importance of nutrition in preventing and treating pressure ulcers. Nursing Older People.
29, 6, 33-38. Date of submission: 10 January 2017; date of acceptance: 24 April 2017. doi: 10.7748/nop.2017.e910
Carolyn Taylor
Specialist dietician, Northern
General Hospital, Sheffield
Teaching Hospitals NHS
Foundation Trust, Sheffield,
England
Correspondence
carolyn.taylor@sth.nhs.uk
Conflict of interest
This work was undertaken by
Carolyn Taylor with funding
from the National Institute for
Health and Care Excellence
(NICE). The views expressed
are those of the author and not
necessarily those of NICE
Peer review
This article has been subject
to external double-blind
peer review and checked
for plagiarism using
automated software
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Abstract
Pressure ulcers are painful, and affect patients’ health, mobility and well-being. They also cost the
NHS between £1.4-2.1 billion a year. Although a large proportion of pressure ulcers are avoidable,
many still occur and, because pressure ulcer incidence is an indicator of care quality, it can put
carers under scrutiny.
The National Institute for Health and Care Excellence states that adequate risk assessment of
pressure ulcer development, including the role of malnutrition, improves care. Adequate nutrition
is vital for the prevention of pressure ulcers and malnutrition can hinder healing when pressure
ulcers have developed. The risk of malnutrition should be assessed with a recognised tool, such
as the Malnutrition Universal Screening Tool, and appropriate treatment plans should be drawn
up for patients identified as being at risk of malnutrition to improve their nutritional state. For
example, the dietary intake of people with poor appetite can be supplemented with nutritious
snacks between meals.
The aims of this article are to help readers understand risk factors for malnutrition and how
dietary intake can be manipulated to improve patients’ nutritional state. It also aims to highlight
how improving nutritional intake helps to prevent pressure ulcers. On completing the article, readers
will be able to consider and review their own practice.
Keywords
diet, nutrition, older people, pressure ulcers, pressure ulcer prevention, tissue viability
Aim and intended learning outcomes pressure ulcers is £1.4-2.1 billion per year
The aim of this article is to help you (Bennett et al 2004), with grade IV pressure
understand how to assess and improve the ulcers costing about £14,108 per patient
nutritional status of patients who are at risk of, (Dealey et al 2012). Increasingly, the incidence
or being treated for, pressure ulcers. of pressure ulcers is seen as an indicator of
After reading this article and completing the the quality of care provision, and healthcare
time out activities you should be able to: providers’ pressure ulcer prevention record can
»» Define what is meant by malnutrition. be scrutinised and assessed.
»» Describe how to assess patients for risk The National Institute for Health and
of malnutrition. Care Excellence (NICE) has published a
»» Outline how malnutrition increases the risk clinical guideline on the prevention and
of pressure ulcer development. management of pressure ulcers (NICE 2014).
»» Describe the causes of malnutrition in The institute has also published a quality
older people. standard (NICE 2015), which highlights how
»» Discuss what changes can be implemented good quality care can result in pressure ulcer
to improve nutritional intake and prevention. The quality standard focuses on
thereby reduce the risk of pressure how prevention of pressure ulcers has the
ulcer development. greatest effect on patients’ health and that this
is best achieved by ensuring risk assessments
Introduction are routinely completed.
While most pressure ulcers are preventable, Poor nutritional intake and poor nutritional
vulnerable people are at risk of pressure state have long been considered risk factors
ulcer development. This not only has health for pressure ulcer development as well as
consequences for patients, but is also expensive causes of delayed healing in existing ulcers
for the NHS. The estimated cost of managing (Posthauer et al 2015). While good quality
volume 29 number 6 / July 2017 / 33
Copyright © 2017 RCN Publishing Company Ltd
evidence & practice / tissue viability
FURTHER RESOURCES
The British Association
for Parenteral and
Enteral Nutrition’s
Malnutrition Universal
Screening Tool can be
accessed at
www.bapen.org.uk/
pdfs/must/must_full.pdf
34 / July 2017 / volume 29 number 6
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evidence to recommend specific nutritional
elements is lacking, the NICE (2014) guideline
highlights the importance of a good overall
nutritional state and the correction of any
deficiencies as the focus for preventing and
healing pressure ulcers. The quality standard
(NICE 2015) states that malnutrition is a risk
factor for pressure ulcers and, if identified,
should trigger a specific pressure ulcer
risk assessment.
TIME OUT 1
Malnutrition and pressure ulcer development
Before reading on, note down the mechanisms you believe
link malnutrition with an increased risk of developing
pressure ulcers. We will review this later.
Malnutrition
Obese and underweight patients can be
considered as having malnutrition because
both states can result from an imbalance
of nutrients. Body mass index (BMI) is the
most commonly used reference point for
measuring body size. BMI is calculated from
a person’s weight and height, where BMI =
weight (kg) ÷ height2 (m2). A BMI of 18.5–
25kg/m2 is considered to be in the healthy
range (NICE 2006). A BMI above 25kg/m2 is
considered to be overweight and one above
30kg/m2 is considered obese. Overweight
results from an energy intake above
requirements and can be the consequence of
a high intake of energy‑dense food. This does
not necessarily mean an overweight person
has a balanced diet, which could be low in
micronutrients such as vitamins and minerals.
Increasing body weight affects mobility
and can hinder attempts to relieve pressure,
thereby increasing the risk of pressure ulcers.
BOX 1 Possible causes of malnutrition
»» Anorexia or loss of appetite due to illness.
»» Nausea and vomiting due to illness or treatment for
illness such as antibiotics.
»» Poor mobility, such as loss of hand dexterity resulting in
inability to eat or embarrassment about making a mess
when eating.
»» Swallowing problems that limit choice of food.
»» Illnesses, such as chronic obstructive pulmonary
disease (COPD), that cause breathing difficulties.
»» Illnesses that increase energy requirements, such as
cancer and COPD, trauma during recovery from surgery,
and spasms associated with neurological conditions.
»» Conditions, such as diarrhoea, pancreatic insufficiency
and inflammatory bowel disease, that prevent
absorption of nutrients. Some medications can also
affect absorption.
(Thomas and Bishop 2007)
Copyright © 2017 RCN Publishing Company Ltd
Increasing body weight also reduces blood
circulation, which reduces healing capacity
if pressure ulcers are present. Obesity is also
associated with an increased risk of type 2
diabetes, which has an adverse effect on
circulation and healing. Efforts should be
made, therefore, to prevent excessive weight
gain in all people (Cai et al 2013).
A BMI less than 18.5kg/m2 is underweight
and associated with insufficient nutritional
intake compared with requirements. Due to the
significant effect of undernutrition on pressure
ulcers and its increased prevalence in older
people, this article focuses on underweight
patients. Inadequate nutritional intake is
referred to as malnutrition for the remainder
of the article.
While definitions of underweight or
overweight are based on BMI, they can be
inaccurate in older people due to the reduced
stature associated with ageing (Omran and
Morley 2000). In addition, BMI does not
correlate with functional ability, which is
due to the associated loss of muscle mass
and strength, or sarcopenia, in the older
population. This means that a higher
BMI in an older person indicates a higher
percentage of body fat than in a younger
adult. An improving BMI may not therefore
indicate improved functional ability and a
concomitant reduced risk of pressure ulcers
(Milne et al 2009).
To understand malnutrition risk, therefore,
a BMI assessment may not be enough. As part
of routine monitoring, risk of malnutrition
should be assessed regularly in all patients
because their health can change and affect
their nutritional states (NICE 2006). Validated
screening tools are recommended to help assess
patients’ risk of malnutrition (NICE 2012)
and the Malnutrition Universal Screening Tool
(MUST) is the most commonly used such tool
in the UK (Elia 2003). It is a quick and simple
five-step tool to assess risk of malnutrition
that uses BMI as one of its parameters, but
also considers unintentional weight loss over
the preceding 3-6 months. This is significant
because, even if someone has a healthy BMI,
rapid weight loss indicates an acute change
in intake compared with requirements.
An unintentional weight loss greater than 5%
of initial weight over this time indicates a high
risk of malnutrition.
The MUST includes a score for people
who have acute illnesses or who have gone,
or are likely to go, without food for more
than five days. These factors put people at a
higher risk of malnutrition. Once the MUST is
complete, strategies can be followed to ensure
nursingolderpeople.com

that those most at risk of malnutrition receive
the care they require.
TIME OUT 2
Malnutrition Universal Screening Tool
Visit the British Association for Parenteral and Enteral
Nutrition (BAPEN) website and familiarise yourself with
the Malnutrition Universal Screening Tool, including
understanding how to estimate BMI when height or weight
cannot be obtained. Consider why it is important to use
such a tool in a methodical way, assessing and reassessing
patients on a regular basis.
Risk in older people
While measures such as MUST are useful they
do not necessarily provide all the answers. For
example, MUST will not identify changes in
muscle strength, which affects function and the
ability to relieve pressure (Flood et al 2014).
Other methods, such as measuring hand-grip
strength, can correlate with improved health
outcomes, but care home residents with
cognitive impairments can find complying with
instructions to complete these methods difficult
(Stow 2015).
Older adults also have reduced skin
elasticity, and are therefore more prone to
pressure ulcers and difficulties with healing
when pressure ulcers develop. However, if
older people have an adequate nutritional
state they will have a better body composition
and therefore better padding over bony
prominences. They are also more likely to
be able to fight infections and illnesses, thus
reducing the overall risk of them developing
pressure ulcers (Dorner et al 2009).
BAPEN (2015) highlights that 35% of care
home residents are at medium or high risk
of malnutrition. It also states that 30% of
residents have a BMI <20kg/m2 compared with
4% of the general population (BAPEN 2015).
Care home residents should have their weight
measured monthly to allow tracking of weight
changes (NICE 2006).
The heightened risk of malnutrition, and
reduced mobility, muscle mass and skin
integrity, put older people at a much higher
risk of pressure ulcer development.
TIME OUT 3
Weight loss
Review with colleagues how often you weigh the patients
you care for and how you monitor changes. Are weight
records located in the same place as your nutritional
assessments? Is there a record of when the weighing scales
were last calibrated?
Weight loss can be insidious. Make brief notes about
a case in which such problems arose and patient review
became especially important.
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Revalidation
Find out more at:
rcni.com/revalidation
Reducing the risk of malnutrition Online archive
It is vital to assess the risk of malnutrition For related
information, visit
and put in place care plans for those identified nursingolderpeople.
at higher risk. While correcting malnutrition com and search using
is recommended for the prevention and the keywords
management of pressure ulcers, it is also
important for all health conditions. Evidence
shows that routine screening and monitoring
of the nutritional state of people in care homes
costs half of that of treating malnutrition
(Meijers et al 2012).
Some patients’ health can change rapidly
before routine screening is completed. Where a
risk of malnutrition is identified, it is important
to consider what caused it and how to solve
it. Several factors can put people at risk of
malnutrition by affecting their intake and
absorption of nutrients, or by increasing their
energy requirements (Box 1).
The consequences of failing to meet
nutritional requirements can cause
further problems (Box 2). In view of these
consequences and the increased risk of
co-morbidity in older people, it is not
surprising that older people are most at risk
of malnutrition, with about 10% of people
over the age of 65 years in the UK affected
by it (European Nutrition for Health Alliance
2006) and approximately 30% of older adults
admitted to hospital identified as being at risk
of malnutrition (Elia 2015).
TIME OUT 4
Risk factors
Older adults are often affected by multiple risk factors. Return
to the patient you profiled in time out 3 and consider whether
he or she was affected by any of the risks listed in Box 1. If so,
outline how one risk seemed to work with others to reduce
the patient’s nutritional state and skin integrity.
iStock
volume 29 number 6 / July 2017 / 35
evidence & practice / tissue viability
Ensuring adequate nutrition
Screening for malnutrition should be carried
out regularly. It is recommended that, in
residential and nursing care, people are
screened on admission and, if a risk is
identified, more often thereafter (NICE 2006).
For those who live at home, it is suggested that
screening is completed by community nurses
during the first face-to-face visits.
In view of the link between malnutrition
and pressure ulcers, screening to identify
malnutrition should be completed if a
risk of pressure ulcer development has
been identified. The risk of malnutrition
changes during periods of illness, when
nutritional intake should be reassessed and
monitored carefully.
If a risk of malnutrition is identified,
actions should be taken promptly. It is
important to consider what factors contribute
to the risk:
»» Do patients need a medication review?
»» Do they have constipation or nausea from
medical treatment or a condition?
»» Have they had any changes in taste?
»» Do they have any difficulties with the
mechanics of eating, such as ill-fitting
dentures or swallowing problems?
»» Do they have difficulties obtaining food?
After considering these questions, it is
important to identify the services that could
help resolve the issues they raise.
Oral intake
Monitoring of oral intake should include
fluid as well as food. Dehydration causes
a loss of skin integrity and can cause
confusion, which can compromise compliance
with pressure area care.
The easiest way to monitor intake among
people in care homes where staff work
different shifts is by recording it for a few
days. A complete food chart covering two
or three consecutive days provides much
richer data than one covering a longer period
BOX 2. Possible consequences
of malnutrition
»» Reduced immune function, which increases the risk
of further illnesses.
»» Reduced muscle strength.
»» Reduced skin integrity, which increases the risk of
pressure ulcer development and reduces the rate at
which skin lesions heal.
»» Depression and anxiety.
»» Difficulties maintaining body temperature.
(Stratton et al 2003)
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incompletely. These food charts should include
information on frequency and portion sizes.
People living at home can be asked for dietary
recall, where they are interviewed about their
dietary intake over specified periods.
When reviewing food charts or dietary recall,
it is important to consider whether patients
are eating sufficient amounts, and whether
there is enough variety in what they are eating
or whether they are choosing foods they find
easier to eat (Thomas and Bishop 2007).
Oral hygiene
Poor oral health can make eating difficult
and painful, causing patients to choose less
nutritious, softer options. An oral hygiene
assessment, as recommended by NICE (2016),
helps to determine if additional support is
required to maintain adequate oral health.
TIME OUT 5
Food charts
Pose three colleagues a challenge by asking them what they
think is relevant to include in a patient’s food chart. Were the
responses from your colleagues consistent?
If entries in the food chart differ significantly, how would
you compare them? What are your local guidelines to ensure
that the recording of dietary intake is consistent?
Addressing poor nutritional intake
If people do not eat enough at mealtimes, it is
important to find alternative ways to meet their
nutritional needs. When someone has a loss
of appetite, large meals can be overwhelming.
One option is to have nutritious snacks
between meals. These can include:
»» Fruit cake or malt loaf.
»» Plain or fruit scones with butter, jam
and cream.
»» Crumpets or muffins with butter and jam.
»» Toast with jam, butter, peanut butter or
yeast extract.
»» Nuts, crisps or dried fruit.
»» Biscuits or cereal bars.
»» Crackers with cheese.
»» Full-fat yoghurts, rice pudding, mousse,
custards or trifles.
»» Cheese and apple cubes.
Other options include fortifying meals to
ensure people increase their nutritional intake
with every mouthful they eat. Meals can be
fortified by (Thomas and Bishop 2007):
»» Using full-fat milk in drinks, breakfast cereals,
soups, puddings and when mashing potatoes.
»» Adding grated cheese to mashed potatoes,
jacket potatoes, soups and vegetables.
»» Adding cream, condensed or evaporated
milk to soups and puddings.
»» Adding fruit purees to puddings.
nursingolderpeople.com

»» Adding additional pulses and beans to soups
and meat dishes.
»» It is also possible to fortify milk by adding
four tablespoons (2oz or 56g) of dried milk
powder to each pint. This can then be used
in drinks and on cereal.
Your local dietetic department may be able to
offer more specific nutritional advice and other
healthcare professionals can help you support
patients. For example, occupational therapists
can assess whether patients require any special
utensils, physiotherapists can assess seating
positions for eating and pressure relief, and
speech and language therapists can help with
swallow assessments to make sure food is of
an appropriate consistency.
Specific nutritional needs
Optimal nutrition is vital for improving
health outcome, but is not the only factor in
preventing pressure ulcers. For some people,
pressure ulcers occur when severe illnesses
lead to prolonged bed rest. For these people,
consideration then needs to be given to how
nutrition may help to improve healing at a
time when they may be struggling with other
health problems.
NICE (2014) highlighted that nutrition is
important due to the role that nutrients have
on collagen formation, the substance the body
produces to heal wounds. It also stated that
correcting any nutritional deficit is vital so
that the body is able to produce the required
collagen. This again highlights the importance
of recognising and monitoring nutritional state.
Those who are at risk of malnutrition will have
fewer resources available to promote healing.
Nutrients
While maintaining a balanced nutritional
intake and correcting all nutritional deficits
are important, protein, iron, zinc and vitamin
C are important in healing pressure ulcers.
This is not included specifically in the NICE
(2014) guideline. A Cochrane review (Langer
and Fink 2014) stated that evidence is lacking
to support routine supplementation with these
nutrients, but has historically been considered
important especially when pressure ulcers
are healing as these nutrients are required for
tissue growth and repair.
Protein forms the basis of the enzymes
that are required for wound healing, cell
multiplication and collagen formation.
Ensuring an adequate protein intake seems
essential (Dorner et al 2009). High-protein
foods include meat, fish, dairy produce, eggs,
pulses, beans and lentils. Meals containing
these elements are recommended when
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Revalidation
Find out more at:
rcni.com/revalidation
someone has a pressure ulcer. If someone
has a poor appetite then fortifying meals
with these foods, as indicated previously, is
recommended.
Iron, due to its presence in haemoglobin,
is required to transport nutrients around the
body (Dorner et al 2009). Iron is found more
readily in red meats and to a lesser extent
in pulses, eggs, fortified cereals and green
vegetables. Eating iron-rich foods with a source
of vitamin C will improve iron absorption
from non-meat sources. Not only does vitamin
C help with iron absorption, it also works with
iron to produce collagen. Vitamin C is also
important for immune function and deficiency
can result in an inability to fight infections.
Adequate dosages should be obtainable from
dietary sources such as fruit and vegetables.
However, it is a water-soluble vitamin so it
is not stored in the body and requires a daily
intake. It is also easily destroyed by heat, water
and light so cooking will reduce its content
in food. This becomes a particular problem
when patients choose soft, overcooked options.
Alternatives, including having fruit juice
with each meal, may need to be considered.
Megadoses have not been shown to improve
healing (Dorner et al 2009).
Zinc is another element that is required for
collagen formation and synthesis of protein.
It is bound to albumin, which is a protein.
Albumin levels in the blood can indicate the
amount of protein available.
If pressure ulcers have high exudate levels
then blood levels of albumin could be low and
there will also be low levels of zinc, which will
inhibit further the ability to produce collagen
and therefore heal the pressure ulcer. Zinc
is found in a variety of foods, most readily
in red meats and poultry but also in pulses,
wholegrains and fortified breakfast cereals.
Overzealous supplementation with zinc,
however, should be discouraged as it can lead
to copper deficiency. As copper is also required
for collagen formation, deficiency will affect
healing rates (Dorner et al 2009).
TIME OUT 6
Nutrition
Once again return to your case study from time out 3 and
review the patient’s dietary intake. Was the patient having
sufficient nutrients to help with pressure ulcer healing?
Which additional nutritional parameters could have been
implemented to ensure a more balanced, nutritious intake?
What further issues may have affected the provision of
these elements? Perhaps consider the financial implications
of additional food to those providing the meals. Do these
costs outweigh the benefit or reduce other costs such
as those for dressings?
volume 29 number 6 / July 2017 / 37
evidence & practice / tissue viability

Write for us Conclusion TIME OUT 7

For information about Patients’ nutritional state affects the prevention
writing for RCNi
journals, contact and management of pressure ulcers. While
writeforus@rcni.com providing additional food items may be
costly, it outweighs the cost for the patient
For author guidelines, and the NHS by reducing the risk of pressure
go to rcni.com/ ulcers and improving recovery. Identifying
writeforus
those who will benefit most from dietary
interventions is appropriate.
Adequate nutritional state will also have
additional benefits for other health conditions.
While care home residents will not have
individually cooked meals, it is important to
assess each person individually to meet their
needs and food preferences. Having a variety
of options, particularly snacks between meals,
will help achieve this. Knowing who is at risk,
what is causing the risk and how the risk can
be reduced is vital.
Reflection
Now that you have completed the article, you might like to
write a reflective account as part of your revalidation. Go to
journals.rcni.com/r/nop-reflective-account to find out more.
Implications for practice
»» Nutritional state affects the management
and prevention of pressure ulcers
»» Older adults are at greater risk of malnutrition
»» By assessing patients’ risk of malnutrition,
strategies can be put in place to help meet
their nutritional requirements
»» Preventing and treating malnutrition in older
adults will be beneficial for a number of
conditions, not only pressure ulcers
»» Eating nourishing foods little and often can
improve nutritional intake for those with a
poor appetite

References

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of pressure ulcers in the UK. Age and Ageing.
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Care Homes in the UK. BAPEN, Redditch.
Cai S, Rahman M, Intrator O (2013) Obesity and
pressure ulcers among nursing home residents.
Medical Care. 51, 6, 478-486.
Dealey C, Posnett J, Walker A (2012) The cost of
pressure ulcers in the United Kingdom. Journal of
Wound Care. 21, 6, 261-266.
Dorner B, Posthauer M, Thomas D (2009) The
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uploads/2012/03/Nutrition-White-Paper-Website-
Version.pdf (Last accessed: 23 May 2017.)
Elia M (2003) The ‘MUST’ Report. Nutritional
Screening of Adults: A Multidisciplinary
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and Enteral Nutrition, Redditch.
Elia M (2015) The Cost of Malnutrition in
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Nutritional Interventions: A Report on the Cost
of Disease-Related Malnutrition in England
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the NICE Clinical Guidelines/Quality Standard
on Nutritional Support in Adults. www.
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(Last accessed: 6 June 2017.)
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Malnutrition among Older People in the
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Flood A, Chung A, Parker H et al (2014) The use
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and energy supplementation in elderly people
at risk from malnutrition. Cochrane Database of
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(2006) Nutrition Support for Adults: Oral Nutrition
Support, Enteral Tube Feeding and Parenteral
Nutrition. Clinical Guideline 32. www.nice.org.uk/
guidance/cg32 (Last accessed: 23 May 2017.)
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(2012) Nutrition Support in Adults. Quality
Standard 24. www.nice.org.uk/guidance/qs24
(Last accessed: 23 May 2017.)
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(2014) Pressure Ulcers: Prevention and
Management. Clinical Guideline 179. www.nice.org.
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Excellence (2015) Pressure Ulcers. Quality
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(Last accessed: 23 May 2017.)
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(Last accessed: 23 May 2017.)
Omran M, Morley J (2000) Assessment of protein
energy malnutrition in older persons, part 1:
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38 / July 2017 / volume 29 number 6 nursingolderpeople.com

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evidence & practice / self-assessment questionnaire

Importance of nutrition in preventing

and treating pressure ulcers
TEST YOUR KNOWLEDGE BY COMPLETING SELF-ASSESSMENT QUESTIONNAIRE 5

 1. A body mass index of <18.5kg/m2 is:  7. Ways to fortify meals include: How to complete
 a) Underweight c  a) Providing low-fat yoghurt c this assessment
 b) Healthy c  b) Adding grated cheese to mashed potatoes c This self-assessment
questionnaire will help you test
 c) Overweight c  c) Adding skimmed milk to soups c
your knowledge. It comprises
 d) Obese c  d) Providing low-carbohydrate breakfast cereals c ten multiple choice questions
broadly linked to the previous
 2. Obesity raises the risk of pressure ulcer  8. Which of the following statements is true? article. There is one correct
development because it:  a) An adequate protein intake is not essential answer to each question.
 a) Affects mobility c for wound healing c You can read the article before
answering the questions or
 b) Can hinder attempts to relieve pressure c  b) Protein, iron, zinc and vitamin C are important nutrients attempt the questions first, then
 c) Reduces blood circulation c for wound healing c read the article and see if you
 c) Iron is found readily in citrus fruits c would answer them differently.
 d) All the above c
When you have completed
 d) Vitamin C is stored in the body c
the questionnaire, cut out
 3. According to the Malnutrition Universal Screening
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 Pressure ulcers: Prevention
and management
Joshua S. Mervis, MD, and Tania J. Phillips, MD
Boston, Massachusetts

Learning objectives
After completing this learning activity, participants should be able to identify and the discuss the role of various pressure ulcer prevention strategies, including use of specialized
support surfaces, repositioning, nutrition, dressings, topical agents; compare and contrast the different types of support surfaces; and recall the various aspects of pressure ulcer
management and discuss the evidence for specific interventions in the realms of wound care fundamentals, nonsurgical therapy, and surgical therapy.

Disclosures
Editors
The editors involved with this CME activity and all content validation/peer reviewers of the journal-based CME activity have reported no relevant financial relationships with
commercial interest(s).

Authors
The authors involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s).

Planners
The planners involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). The editorial and education staff involved
with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s).

Prevention has been a primary goal of pressure ulcer research. Despite such efforts, pressure ulcers remain
common in hospitals and in the community. Moreover, pressure ulcers often become chronic wounds that
are difficult to treat and that tend to recur after healing. Especially given these challenges, dermatologists
should have the knowledge and skills to implement pressure ulcer prevention strategies and to effectively
treat pressure ulcers in their patients. This continuing medical education article focuses on pressure ulcer
prevention and management, with an emphasis on the evidence for commonly accepted practices. ( J Am
Acad Dermatol 2019;81:893-902.)

Key words: chronic wounds; debridement; dressings; management; nutrition; pressure injury; pressure
sore; pressure ulcer; prevention; repositioning; support surface; surgery; therapy; treatment; wound care;
wound healing; wounds.

I ncreased national attention has been given to

pressure ulcers, yet they remain a significant
source of morbidity and mortality and continue
to pose a significant burden for patients and the
Abbreviations used:
AP:
CLP:
NPWT:
alternating pressure
constant low-pressure
negative pressure wound therapy
health care system.1 While pressure ulcers are often a
consequence of other medical conditions or

From the Department of Dermatology, Boston University School Scanning this QR code will direct you to the
of Medicine. CME quiz in the American Academy of
Funding sources: None. Dermatology’s (AAD) online learning center
Conflicts of interest: None disclosed. where after taking the quiz and successfully
Accepted for publication December 12, 2018. passing it, you may claim 1 AMA PRA
Reprints not available from the authors. Category 1 credit. NOTE: You must have an
Correspondence to: Joshua S. Mervis, MD, Department of AAD account and be signed in on your
Dermatology, Boston University School of Medicine, 609 device in order to be directed to the CME
Albany St, Boston, MA 02118. E-mail: jmervis@bu.edu. quiz. If you do not have an AAD account, you
0190-9622/$36.00 will need to create one. To create an AAD
Ó 2019 by the American Academy of Dermatology, Inc. account: go to the AAD’s website: www.aad.
https://doi.org/10.1016/j.jaad.2018.12.068 org.
Date of release: October 2019
Expiration date: October 2022

893
894 Mervis and Phillips
generally poor health, the vast majority of pressure
ulcers are avoidable.2 The prevention of pressure
ulcers is therefore the goal, which is even more
critical given the challenges and the high cost of
treatment. Cornerstones of effective prevention
strategies include the use of appropriate support
surfaces, frequent repositioning, proper nutrition,
and moisture management. The implementation of
prevention strategies often necessitates higher
upfront costs, yet evidence has shown this approach
to be cost-reducing compared with standard care
alternatives.3-5 If an ulcer has already developed,
appropriate wound care, nonoperative treatment,
and surgical management as needed should be used
in addition to all preventative care measures.
PREVENTION STRATEGIES
Repositioning
Key points
d Pressure redistribution is the cornerstone of
pressure ulcer prevention
d Frequent repositioning, low angle of bed
incline, and optimal patient positioning can
reduce the incidence of pressure ulcers
Repositioning to avoid long periods of locally
sustained pressure is as an essential element of
pressure ulcer prevention. Expert opinion has tradi-
tionally advised repositioning every 2 hours, but
recent guidelines from the National Pressure Ulcer
Advisory Panel have omitted this recommendation
because of a lack of evidence.6 In a randomized
study looking at repositioning every 2 hours versus
3 hours on a standard hospital mattress, a nonsignif-
icant 7% decrease in pressure ulcer incidence was
observed in the 2-hour repositioning group.7 A post
hoc analysis of these same data revealed that among
stage 2 to 4 pressure ulcers, 14% in the 2-hour group
versus 24% in the 3-hour group developed pressure
ulcers.8 When these same investigators compared
4-hour versus 6-hour repositioning on a viscoelastic
foam mattress, a 14% decrease in pressure ulcer
incidence was observed with more frequent reposi-
tioning.7 In a large 2014 study that looked at the
incidence of grade 2 or higher pressure ulcers in
patients in the intensive care unit on mechanical
ventilation using alternating pressure mattresses,
2-hour repositioning did not significantly decrease
pressure ulcers compared with 4-hour reposition-
ing.9 Moreover, a recent cost-effectiveness analysis
concluded that given the available clinical data,
alternating 2- and 4-hour repositioning compared
with continuous 4-hour repositioning may be
marginally more effective clinically but is not an
effective use of resources.10
J AM ACAD DERMATOL
OCTOBER 2019
Angle of incline and specific position are also
relevant risk factors. The head of the bed should be
kept at as low an angle of elevation as possible
because shear and frictional forces increase with
greater degree of incline. In addition, the 308 lateral
tilt position, in which the patient is propped up
laterally by pillows wedged under the buttocks and
legs, has been proposed as advantageous to supine
or 908 lateral positioning. The 308 tilt avoids direct
support surface interface pressure with most bony
prominences. A large randomized trial found that 308
lateral positioning plus 3-hour repositioning,
compared with 908 lateral positioning plus 6-hour
repositioning, significantly reduced pressure ulcer
incidence by [70% after 28 days.11
Support surfaces
Key points
d Specialized support surfaces, including mat-
tresses and overlays, are designed to reduce
pressure and minimize shear
d Constant low-pressure and alternating
pressure supports reduce the incidence of
pressure ulcers compared with standard
mattresses
In addition to reducing the duration of pressure
via frequent repositioning, minimizing pressure
magnitude is essential. A variety of support surfaces,
including specialized beds, mattresses, mattress
overlays, and cushions, are available that aim to
reduce pressure and minimize shear. Moreover,
these support surfaces may be classified as constant
low-pressure (CLP) devices, which conform to body
shape, or alternating pressure (AP) devices, which
mechanically vary pressure.
CLP supports. Though high-quality trials are
lacking, studies have generally shown that CLP
devices are preferable to standard foam hospital
mattresses.12 High-specification foam,13,14 bead-
filled,15 and water-filled16 mattresses have all been
found to decrease the incidence and severity of
pressure ulcers in high-risk patients when compared
with standard foam hospital mattresses. A recent
meta-analysis of 5 trials comparing alternative foam
mattresses with the hospital standard showed that
the alternative foams were superior in reducing
pressure ulcer incidence.12 Notably, however, the
‘‘standard’’ mattresses in all these studies are typically
poorly defined and variable by location and time.
Among the various alternative foam mattresses,
head-to-head comparisons have failed to show any
significant differences.12,14,17 High-specification
foam mattresses with air overlays have not shown
any benefit over the foam mattress alone.12,18
J AM ACAD DERMATOL
VOLUME 81, NUMBER 4
Likewise, the limited available data on head-to-head
comparisons of other CLP support surfaces,
including air mattresses, air and fluid overlays, and
heel pressure relief devices, has not shown evidence
favoring one material over any other.19-24 There is
some evidence that low-air-loss beds, which are air-
filled mattresses that help control skin temperature
and moisture via steady air flow over the skin,
decrease the incidence of pressure ulcers compared
with a standard hospital bed or static air overlay.12,25
Medical sheepskins, first reported for pressure relief
in the 1950s,26 have shown evidence of benefit
compared with standard care, significantly reducing
pressure ulcer incidence in both hospitalized and
patients who are in nursing homes.27,28
Wheelchair cushions, which are commonly rec-
ommended for and used by permanently immobile
individuals, are available in many materials. While
cushions have been shown to lower interface pres-
sure,29 studies of their efficacy in reducing pressure
ulcer incidence are inconclusive and are limited by a
lack of standardized comparisons.30,31
AP supports. AP mattresses and overlays
contain numerous air-filled compartments that
inflate and deflate in a coordinated fashion to
continuously vary pressure across body sites.
Studies of AP devices are few and heterogeneous,
with most studies omitting details regarding air cell
specifications and cycling times.12 Limited evidence
does suggest, however, that compared with a
hospital’s standard mattress, AP surfaces reduce
the incidence of pressure ulcers.16 Studies
comparing different AP devices have not revealed
any evidence of differences,32-35 except for 1 study
showing that a double-layer overlay may be more
effective than single-layer devices.36 A large ran-
domized controlled trial comparing an AP mattress
with an AP overlay found no difference in incidence
of stage 2 or higher pressure ulcers.35 The AP
mattress, however, delayed mean time to ulceration
by nearly 11 days and was found to have an 80%
probability of reducing costs related to shorter
hospital stays.5
CLP versus AP supports. Currently, there is
insufficient evidence to say if or when AP versus CLP
support surfaces are preferred. Studies that have
attempted to shed light on this matter have generally
shown no differences between groups, and a recent
meta-analysis found no evidence to suggest
otherwise.12
Nutrition
Key points
d Nutritional deficiencies may promote skin
breakdown
Mervis and Phillips 895
d Malnutrition is best diagnosed with tools
that incorporate a patient history and phys-
ical examination
Protein, calorie, vitamin, and mineral deficiencies
are all logically implicated as elements contributing
to skin breakdown. The importance of nutritional
assessment to the prevention of pressure ulcers is
apparent, as reflected by its inclusion in various
society guidelines and risk factor assessment tools.37
Many studies have found that malnutrition, weight
loss, or eating problems are associated with pressure
ulcer development.38-41 Nonetheless, evidence from
randomized controlled trials in support of specific
interventions that prevent pressure ulcer develop-
ment is currently lacking.42
Traditional markers of malnutrition, such as albu-
min and prealbumin, are negative acute-phase re-
actants that may go down in the setting of
inflammation and that are also impacted by other
factors, including liver function, kidney function,
and hydration status.43 The Academy of Nutrition
and Dietetics and the American Society for Parenteral
and Enteral Nutrition no longer recommends the use
of serum proteins for diagnosing malnutrition.
Assessment methods that incorporate historical and
physical examination elements, such as the Academy
of Nutrition and Dietetics and the American Society
for Parenteral and Enteral Nutrition guidelines or
subjective global assessment, are now favored43
(Table I).
Dressings
Key points
d Prophylactic dressings can reduce the effects
of friction and shear
d Dressings can also protect intact skin from
maceration
Dressings, including films, hydrocolloids, and
foams, have been used prophylactically to prevent
skin damage. These dressings may minimize the
effects of friction or shear on at-risk body sur-
faces.44 Nakagami et al45 studied a modified hy-
drocolloid dressing for prevention of pressure
ulcers over the trochanters. The dressing was
randomized to either the right or left trochanter,
with the opposite side receiving no dressing. While
no pressure ulcers were reported over the 3-week
study, ‘‘persistent erythema’’ was reduced from
29.7% (n 5 11) on the control side to 5.5%
(n 5 2) on the dressing side. Another randomized
study of 366 patients in an intensive care unit
found that a soft silicone foam dressing applied
over the sacrum lowered the incidence of pressure
896 Mervis and Phillips J AM ACAD DERMATOL
OCTOBER 2019

Table I. Principal elements of nutritional assessment included in the American Society for Parenteral and
Enteral Nutrition guidelines and subjective global assessment
History Physical examination
Nutrient intake* Solids Subcutaneous fat* Under the eyes
Liquids Between the fingers
Supplements Chest, ribs, and iliac crest
Weight change* Percent change in Muscle wasting* Temples
last 6 months Clavicle
Percent change in Shoulder
last 2 weeks Scapula
Quadriceps
Symptoms affecting Dysphagia, nausea, Edema/ascites* Extent of lower extremity or sacral edema
oral intake or diarrhea Ascites on examination or imaging
Functional* Ambulation
capacity Activities of daily living
Grip strength

*According to the American Society for Parenteral and Enteral Nutrition guidelines, deficiencies or positive findings in $2 of 6 of these
categories are suggestive of malnutrition.

ulcers (0.7%) compared with the no-dressing con-
trol group (5.9%).46 Likewise, Santamaria et al47
found that soft silicone foam dressings reduced the
incidence of sacral and heel pressure ulcers in 440
patients in an intensive care unit. The dressing
intervention was ultimately cost-reducing
compared with the control group, which had a
higher incidence of pressure ulcers.48 Dressings
may also protect healthy skin from maceration
related to incontinence, which can predispose the
skin to superficial ulceration.49
The management of pressure ulcers (Fig 1) consists
of all the elements of pressure ulcer prevention,
including the use of pressure-reducing support sur-
faces, repositioning, and adequate nutrition. Of note,
however, no interventions in any of these categories
have been demonstrated in high-quality studies to
improve healing.6,42,54,55 Additional treatment-
specific interventions targeted at optimizing wound
healing include off-loading, basic wound care funda-
mentals, and various other nonsurgical and surgical
management options (Table II).

Topical agents Pressure off-loading

Key point Key point
d Fatty acid creams may reduce the incidence d Continuous off-loading of pressure from the

of pressure ulcers site of ulceration is essential to healing

Various creams, lotions, and ointments have been
used as part of pressure ulcer prevention strategies,
with the proposed mechanisms of action being a
reduction in frictional forces and the promotion and
maintenance of healthy skin.50 Fatty acid creams
have some limited evidence of efficacy, reducing
pressure ulcer incidence in 2 randomized
studies.51,52 Other topicals containing various
‘‘active’’ ingredients, such as silicone, dimethyl
sulfoxide, zinc, and others, have been tried44 with
little or even detrimental53 effect.
MANAGEMENT
Key point
d Principal elements of pressure ulcer preven-
tion, including repositioning, the use of
specialized support surfaces, and adequate
nutrition, are also applicable to pressure
ulcer management
Off-loading of pressure from the ulcer reverses
the primary underlying etiology and is the most
essential component of treatment. Pressure reduc-
tion is aided by the use of pressure-reducing support
surfaces and frequent repositioning. Caution should
be taken not only to relieve pressure from the site of
ulceration but also to avoid causation of new
pressure ulcers at other sites because of a singular
focus on off-loading a particular site.
WOUND CARE FUNDAMENTALS
Cleansing and debridement
Key points
d Saline or tap water are appropriate for
wound cleansing
d Sharp debridement efficiently removes
necrotic tissue and slough, reduces the bac-
terial burden, and helps eliminate pheno-
typically altered cells that impair healing
J AM ACAD DERMATOL
VOLUME 81, NUMBER 4
Fig 1. Flow chart for the management of pressure ulcers. NPUAP, National Pressure Ulcer
Advisory Panel; NPWT, negative pressure wound therapy.
Cleansing wounds is generally thought to be an
important element of wound care because it helps
remove dead tissue, bacteria, and foreign bodies
from the wound. No specific cleansing fluid or
technique has proven best,56 but saline or tap water
are considered appropriate.57 Wilcox et al58 investi-
gated the importance of debridement in wound
healing and found that more frequent sharp debride-
ment was associated with a faster time to complete
wound healing in a sample of [300,000 wounds,
16.2% of which were pressure ulcers. Debridement
removes necrotic tissue and slough, reduces bacte-
rial burden and biofilm, and removes phenotypically
altered fibroblasts and keratinocytes that are charac-
teristic of nonhealing wounds.59,60 In performing all
these actions, debridement aims to convert a chronic
wound environment to one more similar to the acute
wound milieu, thus setting the wound on a healing
trajectory.
Infection
Key points
d Wound cultures are not indicated unless
infection is suspected
d Stage 4 pressure ulcers are highly suscepti-
ble to osteomyelitis
Signs of infection, such as increased pain, warmth,
erythema, drainage, or systemic symptoms, should
be regularly assessed. Cytotoxic agents like
hydrogen peroxide and povidone-iodine should be
Mervis and Phillips 897
avoided. Wounds with a heavy bioburden may
benefit from cadexomer iodine, a slow-release paste,
that is the only topical antibiotic with evidence for
improving time to complete healing in chronic
wounds.61 When infection is suspected, oral antibi-
otics should be initiated and later refined as neces-
sary based on culture results or the lack of a clinical
response.62 Routine wound culture should not be
performed in cases where infection is not suspected.
Deep wounds and those with exposed bone are
susceptible to osteomyelitis, which is best detected
on magnetic resonance imaging or bone biopsy63
and that necessitates intravenous antibiotic therapy.
Dressing selection
Key points
d Dressings that promote a moist wound heal-
ing environment should be selected
d Antibacterial dressings containing silver or
honey lack evidence for long-term use
Dressings should be selected that promulgate a
moist wound healing environment, with the goal of
finding a balance between exudate absorption and
moisture retention64 (Table III). Excess fluid over the
wound may lead to maceration, irritation, and the
breakdown of surrounding healthy skin.
Antibacterial dressings containing silver or medical
honey are often used for bioburden control but lack
evidence for long-term use.61 Recent systematic
reviews have found no evidence for any particular
898 Mervis and Phillips J AM ACAD DERMATOL
OCTOBER 2019

Table II. Treatment of pressure ulcers

Level of
Treatment evidence* Reference(s)
Cellular and tissue-based products III Brem et al,76 Beers et al,77 Johnson et al,78 and Levy
et al79
Debridement (sharp) III Wilcox et al58
Dressing selection for moist wound healing IB Westby et al66
environment
Negative pressure wound therapy IB Gupta and Ichioka,72 Mou€
es et al,74 and Dwivedi
75
et al
Nutritional supplementation (if evidence of IV Langer and Fink42 and Gould et al57
malnutrition)
Platelet-derived growth factor III Harrison-Balestra et al67
Platelet-rich plasma III Scevola et al68
Repositioning IV Moore and Cowman55
Specialized support surfaces IB McInnes et al54
Surgical management
Primary surgical closure IV
Skin flap III Thiessen et al86 and Kuo et al89
Wound cleansers IB Moore and Cowman56

*Level IA evidence includes evidence from metaanalysis of randomized controlled trials; level IB evidence includes evidence from $1
randomized controlled trial; level IIA evidence includes evidence from $1 controlled study without randomization; level IIB evidence
includes evidence from $1 other type of experimental study; level III evidence includes evidence from nonexperimental descriptive studies,
such as comparative studies, correlation studies, and case-control studies; and level IV evidence includes evidence from expert committee
reports or opinions or clinical experience of respected authorities.

dressing type associated with more rapid heal- Negative pressure wound therapy
ing,65,66 which highlights the importance of tailoring Key points
dressing choice to the individual wound at a given d Negative pressure wound therapy may accel-

point in time. erate healing time in stage 3 or 4 pressure

ulcers
NONSURGICAL THERAPIES d Negative pressure wound therapy can help

Topical agents optimize the wound bed before surgical

Key point
d Topicals agents that contain growth factors
may be considered for pressure ulcers that
do not respond to other treatments
Topical agents have the theoretical advantage of
improving the healing of pressure ulcers that do not
respond to initial conservative care while potentially
mitigating the need for surgical repair. Platelet-
derived growth factor has been approved by the
US Food and Drug Administration for the treatment
of diabetic foot ulcers and has been reported to be
effective and well-tolerated in the management of
pressure ulcers.67 Other experimental topical agents
include platelet-rich plasma,68,69 activated donor
macrophages,70 and phenytoin,71 but the evidence
for and availability of these treatments is limited.
The Wound Healing Society recommends the
consideration of topical growth factors, such as
closure
Negative pressure wound therapy (NPWT) may be
advantageous for stage 3 or 4 pressure ulcers. NPWT
has several potential benefits, including improved
exudate management, increased wound perfusion,
stimulation of granulation tissue formation, and
reduced bacterial load.72,73 NPWT can help optimize
the wound bed for surgical closure or stimulate
healing in stalled wounds that are not amenable to
surgery. While high-quality data from large prospec-
tive trials are lacking, small randomized controlled
trials and retrospective analyses have found signifi-
cant reductions in wound size with the use of NPWT
compared with standard of care dressings.57,72,74,75
Cellular and tissue-based products
Key point
d A variety of cellular and acellular matrices

platelet-derived growth factor or platelet-rich have been reported to improve healing of

plasma, for pressure ulcers that fail to respond to pressure ulcers, but evidence from clinical
other treatments.57 trials is lacking
J AM ACAD DERMATOL Mervis and Phillips 899
VOLUME 81, NUMBER 4

Table III. Dressing categories and their advantages or disadvantages

Dressing Use Advantages Disadvantages
Hydrogel Dry wounds with or Promotes autolytic debridement; Can cause maceration of surrounding
without eschar adds moisture to a dry wound bed healthy skin
Film Minimally exudative Transparency allows wound to be Does not absorb or allow drainage of
wounds seen fluid; adhesive coating may disturb
reepithelialization upon removal
Hydrocolloid Mildly exudative Gelling property when exposed to Minimally absorptive; can cause
wounds exudate promotes moist wound maceration under the dressing
healing; waterproof and can stay in
place for days
Foam Moderately exudative Absorbent and moisture retentive; Can dry out wound bed if low
wounds available with adhesive borders; exudate volume
can use as a secondary dressing for
highly exudative wounds
Alginates and Highly exudative Very absorbent May dry out and adhere to wound
hydrofiber wounds bed, causing pain and trauma upon
removal

Cellular and tissue-based products are cellular SURGICAL MANAGEMENT

and acellular matrices that are used to treat chronic
wounds. Evidence for the use of these products
specifically for pressure ulcers is limited, but suc-
cessful healing of stage 3 and 4 pressure ulcers has
been reported with a human bilayered skin substi-
tute,76 acellular porcine-derived small intestinal sub-
mucosa,77 and placental membrane products,78
among others.
Of note, pressure ulcers often result in deep,
undermined, or tunneling wounds that are not
suitable for the application of cellular and tissue-
based products, which are typically produced as flat
sheets. A flowable acellular matrix comprised of
micronized human cadaveric dermis (Cymetra;
LifeCell Corp, Branchburg, NJ) is available that
easily passes through an 18-gauge needle and can
be injected onto the wound.79 The flowable dermal
matrix fills sinus tracts and crevices and provides a
collagen scaffold that supports fibroblast migration
and dermal regeneration. This matrix has been
reported to support the healing of chronic wounds,
including both deep and tunneling pressure
ulcers.79,80
Hyperbaric oxygen
Key point
d No evidence exists for the use of hyperbaric
oxygen in the treatment of pressure ulcers
Though hyperbaric oxygen may improve the
healing of certain wounds, such as diabetic foot
ulcers with osteomyelitis, no benefits of hyperbaric
oxygen have been shown for pressure ulcers.57
Key point
d Skin flaps with or without muscle transfer
are the principal surgical method of wound
closure for pressure ulcers
Several surgical techniques have been used to
close pressure ulcers, though data from randomized
trials are lacking.81 The primary closure of relatively
small nonhealing stage 2 or 3 pressure ulcers may be
attempted when immediate closure is desired. While
this relatively simple procedure can be performed in
the clinic setting, wound dehiscence is a common
complication.
For more extensive stage 3 or 4 pressure ulcers,
surgical management with a skin flap is indicated
when wounds show little chance of healing with
more conservative management. Intraoperative bone
biopsy specimens should be obtained for culture and
sensitivity when osteomyelitis is suspected.82 The
removal of underlying bony prominences is recom-
mended to help relieve pressure points.57,83 Lower
local recurrence rates with ostectomy were suggested
by 1 small study.84 Care must be taken, however, not
to remove bone in excess, because doing so may
expose critical deep structures or produce new
unnatural weight-bearing skin surfaces.57
Skin grafts are generally not used for pressure
ulcers because they do not typically provide enough
strength or bulk to cover the wound.85 A variety of
skin flap techniques have been successfully used for
pressure ulcer closure.85 Though muscle has been
presumed to be a critical element of successful skin
flaps for pressure ulcers, evidence now suggests that
900 Mervis and Phillips
muscle transfer is not necessary.86 In retrospective
analyses, there do not appear to be any significant
differences between musculocutaneous, fasciocuta-
neous, and perforator-based flaps with respect to
postoperative complications or recurrence rates.86-89
Therefore, patient and wound characteristics should
be the most important factors in determining the
choice of flap technique.90
In conclusion, pressure ulcers continue to be a
significant burden for patients and society, with the
need ongoing for more effective prevention and
treatment strategies. High-quality studies comparing
many of the available interventions are still needed.
Regardless of the specific intervention, however,
pressure ulcers undoubtedly require a multifaceted
approach that optimizes pressure relief, nutrition
status, and proper wound care, as well as nonsur-
gical and surgical treatments as needed.
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50. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a
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53. Houwing R, van der Zwet W, van Asbeck S, Halfens R, Willem
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54. McInnes E, Jammali-Blasi A, Cullum N, Bell-Syer S, Dumville J.
Support surfaces for treating pressure injury: a Cochrane
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55. Moore ZE, Cowman S. Repositioning for treating pressure
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56. Moore ZE, Cowman S. Wound cleansing for pressure ulcers.
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58. Wilcox JR, Carter MJ, Covington S. Frequency of debridements
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59. Lebrun E, Kirsner RS. Frequent debridement for healing of
chronic wounds. JAMA Dermatol. 2013;149:1059.
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61. O’Meara S, Al-Kurdi D, Ologun Y, Ovington LG, Martyn-St
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64. Powers JG, Morton LM, Phillips TJ. Dressings for chronic
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65. Walker RM, Gillespie BM, Thalib L, Higgins NS, Whitty JA. Foam
dressings for treating pressure ulcers. Cochrane Database Syst
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66. Westby MJ, Dumville JC, Soares MO, Stubbs N, Norman G.
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68. Scevola S, Nicoletti G, Brenta F, Isernia P, Maestri M, Faga A.
Allogenic platelet gel in the treatment of pressure sores: a
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69. Martinez-Zapata MJ, Martı-Carvajal AJ, Sola I, et al. Autologous
platelet-rich plasma for treating chronic wounds. Cochrane
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70. Zuloff-Shani A, Adunsky A, Even-Zahav A, et al. Hard to heal
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71. Hao XY, Li HL, Su H, et al. Topical phenytoin for treating
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72. Gupta S, Ichioka S. Optimal use of negative pressure wound
therapy in treating pressure ulcers. Int Wound J. 2012;9(suppl
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73. Niezgoda JA, Mendez-Eastman S. The effective management
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74. Mou€ es CM, Vos MC, van den Bemd GJ, Stijnen T, Hovius SE.
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75. Dwivedi MK, Srivastava RN, Bhagat AK, et al. Pressure ulcer
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treating pressure ulcers. Cochrane Database Syst Rev. 2016;12:
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83. Solis LR, Liggins A, Uwiera RR, et al. Distribution of internal
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84. Gusenoff JA, Redett RJ, Nahabedian MY. Outcomes for surgical
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85. Cushing CA, Phillips LG. Evidence-based medicine: pressure
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86. Thiessen FE, Andrades P, Blondeel PN, et al. Flap surgery for
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87. Sameem M, Au M, Wood T, Farrokhyar F, Mahoney J. A
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88. Chen YC, Huang EY, Lin PY. Comparison of gluteal perforator
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2014;67:377-382.
89. Kuo PJ, Chew KY, Kuo YR, Lin PY. Comparison of outcomes of
pressure sore reconstructions among perforator flaps,
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locutaneous flaps. Microsurgery. 2014;34:547-553.
90. Keys KA, Daniali LN, Warner KJ, Mathes DW. Multivariate
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Plast Reconstr Surg. 2010;125:1725-1734.
 CONTINUING MEDICAL EDUCATION

Pressure ulcers: Pathophysiology,

epidemiology, risk factors,
and presentation
Joshua S. Mervis, MD, and Tania J. Phillips, MD
Boston, Massachusetts

Learning objectives
After completing this learning activity, participants should be able to describe the burden that pressure ulcers pose to the individual and society; explain the pathophysiology of
pressure ulcers, including the roles of pressure, shear, and friction; identify at-risk populations and discuss the elements of risk assessment and utility of risk assessment tools; and
classify pressure ulcers according to the updated NPUAP staging system.

Disclosures
Editors
The editors involved with this CME activity and all content validation/peer reviewers of the journal-based CME activity have reported no relevant financial relationships with
commercial interest(s).

Authors
The authors involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s).

Planners
The planners involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). The editorial and education staff involved
with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s).

Though preventable in most cases, pressure ulcers continue to pose a major burden to the individual and
society, affecting #3 million adults annually in the United States alone. Despite increased national attention
over the past 20 years, the prevalence of pressure ulcers has largely remained unchanged, while the
associated costs of care continue to increase. Dermatologists can play a significant role in pressure ulcer
prevention by becoming aware of at-risk populations and implementing suitable preventive strategies.
Moreover, dermatologists should be able to recognize early changes that occur before skin breakdown and
to properly identify and stage pressure ulcers to prevent delay of appropriate care. The aim of the first
article in this continuing medical education series is to discuss the pathophysiology, risk factors,
epidemiology, social and economic burdens, and clinical presentation of pressure ulcers. ( J Am Acad
Dermatol 2019;81:881-90.)

Key words: chronic wounds; epidemiology; pathophysiology; presentation; prevention; pressure injury;
pressure sore; pressure ulcer; risk factors; staging; wound healing; wounds.

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of Medicine. CME quiz in the American Academy of
Funding sources: None. Dermatology’s (AAD) online learning center
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Expiration date: October 2022

881
882 Mervis and Phillips
Abbreviations used:
ICU: intensive care unit
NPUAP: National Pressure Ulcer Advisory Panel
Once thought to be an unavoidable consequence
of paraplegia or infirmity, tissue damage caused by
sustained pressure has long been known to exist.
The renowned British surgeon Sir James Paget
assessed this form of injury in 1873, noting: ‘‘The
sloughing and mortification or death of a part pro-
duced by pressure.Sloughing follows these in the
skin and subcutaneous tissue and fat. These latter die
before the skin as sloughing proceeds faster in them,
so when the skin comes away, the place formerly
occupied by these tissues is empty.’’1 This descrip-
tion is remarkably accurate given what we know
today. Nonetheless, it was only with the start of
World War I and the parallel modernization of
nursing that people widely began to appreciate
that pressure ulcers could be prevented and treated.2
Often referred to as pressure ulcers in the mod-
ern vernacular, many terms have been used to
describe pressure-induced wounds, including de-
cubitus ulcer, pressure sore, and bedsore. Notably,
decubitusd‘‘to lie down’’ in Latinddoes not accu-
rately describe these ulcers because they may occur
in any position of prolonged pressure. In addition,
in 2016, the National Pressure Ulcer Advisory Panel
(NPUAP) released new terminology guidelines,
redubbing the preferred name as ‘‘pressure injury’’
to better reflect all forms of tissue damage caused by
pressure, including the stage before skin break-
down.3 We will use ‘‘pressure ulcer’’ in this
continuing medical education article because it is
still the most widely used and accepted
terminology.
The NPUAP defines a pressure ulcer as ‘‘localized
damage to the skin and underlying soft tissue usually
over a bony prominence or related to a medical or
other device.as a result of intense and/or pro-
longed pressure or pressure in combination with
shear.’’3 The most common locations in adults are
over the bony prominences of the sacral and hip
regions, though the lower extremities are affected in
#25% of cases.4,5 While less often considered,
neonatal and pediatric patients also suffer from
pressure ulcers, which are most common over the
occiput in these populations.6
Moreover, although pressure ulcers have been
given substantial consideration within hospitals
and long-term care facilities in recent decades,
they remain a significant problem. In the United
States alone, pressure ulcers affect #3 million
J AM ACAD DERMATOL
OCTOBER 2019
adults annually and result in a diminished quality
of life, high costs for the individual and health care
system, and significantly increased morbidity and
mortality. This purpose of the first article in this
continuing medical education series is to discuss
the pathophysiology, risk factors, epidemiology,
social and economic burdens, and clinical presen-
tation of pressure ulcers. The second article in this
series will focus on prevention and treatment
strategies.
PATHOPHYSIOLOGY
Key points
d Sustained pressure over a bony prominence
ultimately leads to tissue ischemia and
necrosis
d Combination of shear and friction while
lying at an incline may affect underlying
capillary beds and contribute to local tissue
hypoxia
d Excess moisture can lead to maceration and
contribute to skin breakdown
In individuals with normal sensation, mobility,
and mental status, prolonged pressure elicits a
feedback response that prompts a change in body
position; however, when the feedback response is
absent or impaired, sustained pressure ultimately
leads to tissue ischemia, injury, and necrosis.
Pressure ulcers typically begin when the individual’s
body weight exerts a downward force on the skin
and subcutaneous tissue that lie between a bony
prominence and an external surface, such as a
mattress or wheelchair cushion. Sustained pressure
from medical devices may also cause pressure
injuries. It is generally thought that force that results
in an external pressure more than the arterial
capillary filling pressure, around 32 mm Hg, and
more than the venous capillary outflow pressure,
around 8 to 12 mm Hg, inhibits blood flow and
results in local tissue hypoxia.7 While some have
questioned these particular threshold pressures, the
centrality of ischemia and sustained pressure to the
etiology of pressure ulcers is widely accepted.8
Sustained external pressures above a threshold
causes prolonged ischemia and sets the tissue
down a path toward necrosis. Reperfusion injury,
which occurs because of the return of blood supply
after a period of ischemia, has been posited as an
additional source of tissue damage leading to
pressure ulcers.9,10 Reperfusion of ischemic tissue
may cause increased formation of reactive oxygen
species and trigger an inflammatory response. In
rats, multiple ischemiaereperfusion cycles have
J AM ACAD DERMATOL
VOLUME 81, NUMBER 4
been shown to cause more tissue damage than
continuous ischemia alone.11
The highest pressures often occur at the interface
of bone and muscle, causing necrosis at this depth
while leaving the skin relatively spared.12,13
Likewise, the effects of hypoxia and risk of tissue
damage are initially greatest in muscle, followed
by subcutaneous tissue and then skin, likely
reflecting their respective metabolic requirements.14
Therefore, at the point when skin ulceration is
observed, extensive deep tissue injury is likely to
have already occurred.
In addition, as reflected in the newest NPUAP
guidelines,3 shear and friction, as when lying at an
incline, may affect local capillary beds and are
thought to contribute to tissue hypoxia.15 When
lying at an angle, the downward force of gravity is
countered by friction, which prevents the person
from sliding down in the bed. Though the skin may
not move down the bed, internal structures like
muscle and bone that are not in contact with an
external surface are displaced downward because of
gravity. These shearing forces can disrupt blood flow
as vessels caught between the skin and bone are
distorted or compressed.16,17
Finally, excess moisture from either perspiration
or incontinence can macerate the skin, making it
more susceptible to breakdown with friction and
repositioning.18,19
EPIDEMIOLOGY
Key points
d Pressure ulcers are a significant problem
worldwide and affect #3 million people in
the United States
d The overall prevalence of pressure ulcers in
hospitalized patients has been estimated to
range from 5% to 15% but may be signifi-
cantly higher in intensive care units and
certain long-term care settings
Pressure ulcers are a significant problem world-
wide.5,20-22 Recent epidemiologic data regarding
pressure ulcers in the United States are somewhat
limited, but the incidence has been estimated at
around 1 to 3 million per year.23-25 Among hospi-
talized patients, the reported prevalence rates vary
significantly, affecting 5% to 15% of patients over-
all5,26 but affecting consistently higher percentages
of patients in intensive care units (ICUs).27 The
1999 National Pressure Ulcer Prevalence Survey,
which included [350 acute care facilities and
42,000 patients, found that the overall prevalence
of pressure ulcers was 14.8%, with 7.1% of ulcers
occurring during a hospital stay.28 Pressure ulcers
Mervis and Phillips 883
were seen in 21.5% of patients in ICUs, and the
elderly were more at risk, with the highest preva-
lence at 29% among patients 71 to 80 years of age.28
The National Pressure Ulcer Prevalence Survey was
repeated 5 times between 1999 and 2005.5 By 2005,
data from 651 facilities with 85,838 patients,
including acute care (533 facilities, 74,401 patients),
long-term acute care (38 facilities, 1983 patients),
and long-term care (52 facilities, 6242 patients),
had been compiled. Between 1999 and 2005, the
prevalence of all pressure ulcers was constant, at
around 15% overall and 25% in ICUs.5 Pressure
ulcers were most prevalent in long-term acute care
facilities (23-27%), while acute care and long-term
care facility prevalence rates ranged from 13% to
15%. Hospital-acquired pressure ulcers were
consistent around 7.5% overall and similar across
facility type.5 Another study of Medicare benefi-
ciaries hospitalized between 2006 and 2007 found
that 4.5% of patients developed a pressure ulcer
during their hospital stays.29 Moreover, Keelaghan
et al30 found that among newly hospitalized pa-
tients, #26.2% of those admitted from nursing
homes compared with 4.8% of those admitted
from other living situations were found to have
pressure ulcers.
Patients with neurologic impairments have a
lifetime risk of developing a pressure ulcer that
ranges from 25% to 85%.31 Up to middle age,
pressure ulcers are more prevalent in men because
of the increased number of men with traumatic
spinal cord injuries; however, among the elderly,
prevalence between sexes is nearly equal, which
likely reflects longer life expectancy in women.5
Some data suggest that darker-skinned patients have
a higher risk of pressure ulcer development,32 which
may in part be explained by increased difficulty in
recognizing nonblanching erythema before skin
breakdown.33
Up to roughly 25% of patients in neonatal and
pediatric ICUs may develop pressure ulcers, while
incidence rates among noncritical hospitalized chil-
dren have been reported to range from 0.3% to 6%.6
AT-RISK POPULATIONS
Key points
d Anyone, including children and neonates, is
susceptible to pressure ulcers in the setting
of sustained pressure
d The greatest risk for pressure ulcers is in
people with impaired mobility or sensation
who are generally bed- or wheelchair-bound
d Natural skin changes with aging are an addi-
tional risk factor in elderly patients
884 Mervis and Phillips
Fig 1. Braden scale for the risk assessment of pressure ulcers.
Anyone experiencing sustained pressures over
the skin that are strong enough to cause underly-
ing tissue ischemia is susceptible to pressure
ulcers. Typically, this precondition of sustained
pressure occurs in people with impaired mobility
or sensation, possibly because of spinal cord
injury, other neurologic impairment, sedation,
peri- or postoperative immobilization, hospitaliza-
tion, and frailty, among other reasons. Poor nutri-
tion with a subsequent loss of muscle bulk and
body mass, commonly seen in both immobilized
and elderly populations, accentuates bony prom-
inences and may increase risk of ulceration, either
directly because of pressure effects or because of
malnutrition. The elderly also have additional risk
factors inherent to natural skin aging, including
dermal and epidermal thinning, decreased
epidermal turnover, and loss of dermal papillae
resulting in flattening of the dermoepidermal
junction.34 Consequently, aging skin has less
resistance to shear forces and a reduced contig-
uous surface area between the dermis and
epidermis through which nutrient and oxygen
transport can occur.34 Among neonatal and
pediatric populations, pressure ulcers are more
likely to be related to medical equipment.35
Other medical conditions that have been
associated with pressure ulcers include cognitive
impairment, deep venous thrombosis, impaired
microcirculation, congestive heart failure, lower
extremity edema, diabetes, and rheumatoid
arthritis.36
J AM ACAD DERMATOL
OCTOBER 2019
ECONOMIC IMPACT
Key points
d Medicare and Medicaid have not paid for
hospital-acquired pressure ulcers since 2008,
costing hospitals [$11 billion annually
d Models have shown that implementing pre-
ventive strategies ultimately lowers costs
A recent analysis of a Medicare data set found that
after arterial ulcers, pressure ulcers are the costliest
chronic wounds.37 Since 2008, Medicare and
Medicaid have not paid for hospital-acquired pres-
sure ulcers, putting the onus on hospitals to focus on
prevention. Hospital-acquired pressure ulcers alone
cost [$11 billion annually.23 The average cost of a
hospital stay for patients with pressure ulcers is
$72,000 compared with $32,000 for those without
pressure ulcers.38 A study from the United Kingdom
found that average individual cost of pressure ulcer
treatment ranged from $1500 for stage 1 to $18,000
for stage 4 ulcers.39
Multiple cost-effectiveness analyses have found
that the cost of prevention strategies is less than
the cost of treatment.23,40,41 One model has shown
that implementation of effective prevention
methods could lower costs ($7300 vs $10,100
in standard care approach) and increase
quality-adjusted life years (11.2 vs 9.3).23 The
implementation of prevention strategies, however,
may be challenging, given the increased up-front
costs and necessary changes to established
protocols and workflow.
J AM ACAD DERMATOL
VOLUME 81, NUMBER 4
Fig 2. Common sites of pressure ulcers.
PSYCHOSOCIAL IMPACT
Key point
d Pressure ulcers have significant physical,
social, and psychological impacts that can
significantly affect quality of life
Apart from the serious medical complications
that can arise, living with a pressure ulcer can have
physical, social, and psychological impacts that
significantly affect quality of life.42-44 Undergoing
treatment, be it in the hospital, clinic, or home,
often necessitates reduced physical activity and
time away from one’s daily routine and usual social
activities. Bauer et al38 found that hospitalized
patients with pressure ulcers had a median length
of stay of 7 days versus 3 days for those without
pressure ulcers. Decreased independence, social
isolation, pain, fear, and anxiety have all been
reported to be common to the experience of living
with a pressure ulcer.44-46
Mervis and Phillips 885
RISK ASSESSMENT
Key points
d Risk-assessment tools can help identify at-
risk patients, but evidence for their efficacy
in lower pressure ulcer incidence is lacking
d Clinical judgment may be as valuable as the
commonly used risk-assessment tools
currently available
At-risk patients require a thorough assessment
that incorporates a detailed medical history, skin
examination, and evaluation of patient support
systems. Risk assessment instruments have been
developed to identify individuals who are at greatest
risk and to reduce the incidence of pressure ulcers,
with the idea being that at-risk individuals may then
benefit from more rigorous interventions.47
Agreement on the predictive risk factors is lacking,
however,48 which has led to the proliferation of
various tools that include diverse variables of
886 Mervis and Phillips
Table I. National Pressure Ulcer Advisory Panel staging system*
Pressure injury stage Description
1 Nonblanchable erythema
of intact skin
2 Partial-thickness skin loss
with exposed dermis
3 Full-thickness skin loss
4 Full-thickness skin and
tissue loss
Unstageable Obscured full-thickness
pressure injury skin and tissue loss
Deep tissue Persistent nonblanchable
pressure injury deep red, maroon, or
purple discoloration
*Data from Edsberg et al.3
interest. The Braden (Fig 1), Norton, and
Waterlow scales are the most commonly used risk
assessment tools for lowering the incidence of
pressure ulcers.49-52 Studies of the effectiveness of
risk assessment instruments have yielded mixed
results.53 In general, these scales have all shown
low sensitivity and specificity in identifying at-risk
patients.54 Likewise, there is no current evidence that
these tools are superior to clinical judgment in
lowering pressure ulcer incidence,47 though few
high-quality studies have been carried out. A ran-
domized comparison of nurses using the Braden
scale (n 5 74), unstructured risk assessment
(n 5 106), or training plus unstructured risk
assessment (n 5 76) found no statistical difference
in pressure ulcer incidence among hospitalized
patients.55 A single-blinded randomized controlled
trial comparing the Waterlow scale (n 5 411), the
Ramstadius screening tool (n 5 420), and nurses’
clinical judgment (n 5 420) revealed no difference in
pressure ulcer incidence in hospitalized patients.56
Moreover, studies have not stratified by care setting
or patient subgroups.54 The ability to develop one
risk assessment instrument that has validity across all
care settings and patient populations is unlikely,
particularly given that predisposing risk factors may
vary by clinical setting.47,57
CLINICAL PRESENTATION
Key points
d Common locations for pressure ulcers
include over the sacrum, ischial tuberosity,
greater trochanter, heel, and lateral
malleolus
J AM ACAD DERMATOL
OCTOBER 2019
Other notes
Blanchable erythema or sensory changes may precede
development of stage 1 injury; purple or maroon discoloration
indicates deep tissue pressure injury
Adipose or deeper tissues are not exposed; often caused by
adverse microclimate and shear
Adipose tissue is visible in the ulcer bed, which may have
undermining and tunneling; fascia, muscle, tendon, ligament,
cartilage, or bone is not exposed
Fascia, muscle, tendon, ligament, cartilage, or bone is exposed;
undermining, tunneling, and epibole may be present
Extent of tissue damage within the ulcer is obscured by slough or
eschar and cannot be determined; removal of slough or eschar
reveals a stage 3 or 4 pressure injury
May be seen with intact or nonintact skin
d All pressure ulcers should be staged accord-
ing to the most recent NPUAP staging system
d Undermining and tunneling should always
be assessed along with standard wound
measurements
Approximately 70% of pressure ulcers occur over
the sacrum, ischial tuberosity, or greater trochanter,
while 15% to 25% occur on the lower extremities,
typically the heel or lateral malleolus (Fig 2).4,5
Though these locations are the most classic,
pressure ulcers can occur at any site of prolonged
pressure, including the elbow, ear, nose, chest, and
back.
Staging
Several pressure ulcer classification scales have
been used,58-60 but the NPUAP staging system, first
devised in 1989 and most recently revised in 2016,3
has been widely adopted. The newest system defines
6 classifications (Table I; Figs 3 and 4). Pressure
ulcers should be staged after cleaning the wound
bed to ensure optimal visualization of the anatomy. If
obscured by adherent slough or eschar, the pressure
ulcer is classified as ‘‘unstageable.’’
In addition to the 6 defined stages, 2 types of
pressure injury are newly defined by the NPUAP.3
‘‘Medical device-related pressure injury’’ refers to
prolonged pressure from diagnostic or therapeutic
devices and should be staged no differently than
other pressure ulcers. ‘‘Mucosal membrane pressure
injury’’ is caused by the presence of a medical device
over a mucous membrane and cannot be staged.
Of note, pressure ulcers should be staged
according to their maximum historical depth.
J AM ACAD DERMATOL Mervis and Phillips 887
VOLUME 81, NUMBER 4

Fig 3. Pressure ulcer stage diagrams. A, Stage 1. B, Stage 2. C, Stage 3. D, Stage 4. E,

Unstageable pressure injury. F, Deep tissue pressure injury. Used with permission of the
National Pressure Ulcer Advisory Panel.

Accordingly, a pressure ulcer that is initially stage 3 to as a stage 3 or lesser ulcer. The NPUAP has
but progresses to stage 4 over the course of advised against such ‘‘reverse staging’’61 because
treatment is now classified as stage 4; however, reepithelialization may precede the healing of
as this ulcer heals, it should not again be referred deeper tissue.62
888 Mervis and Phillips J AM ACAD DERMATOL
OCTOBER 2019

Fig 4. Pressure ulcers. A, Stage 1 over the metatarsophalangeal joint. B, Stage 2 on the heel. C,
Stage 3 on the sacrum. D, Stage 4 on the sacrum. E, An unstageable pressure injury on the
lateral malleolus. F, Deep tissue pressure injury on the lower leg. Photographs courtesy of
Robert S. Kirsner, MD, and Luis J. Borda, MD.

Other features deeper pressure ulcers and impede the migration of

Undermining, or extension of tissue damage
under the edges of intact skin such that the ulcer
area is larger at the base than skin surface, is often
seen in stage 3 and 4 pressure ulcers. These wounds
may also show tunneling, or sinus tracks that extend
into and through subcutaneous tissue, typically
beyond the edges of intact skin. The depth and
location of undermining and tunneling can be
assessed using a cotton-tipped applicator and should
be regularly recorded along with standard wound
measurements. Epibole, which refers to rolled
wound borders caused by the downward extension
of epithelium over the ulcer edges, may occur in
keratinocytes from the wound margins.
In conclusion, pressure ulcers are a common
problem that continue to pose a major social and
economic burden. Sustained pressure over bony
prominences leads to ischemia of the underlying
tissue and skin. Pressure ulcers occur in people who
are immobilized or lack sensation, most often seen in
association with spinal cord injury, other neurologic
dysfunction, or hospitalization. The newest NPUAP
guidelines now define 6 classes of pressure injury
that better reflect the clinical presentations of tissue
ischemia and necrosis that may occur in the absence
of skin breakdown. Prevention and treatment of
J AM ACAD DERMATOL
VOLUME 81, NUMBER 4
pressure ulcers is the focus of the second article in
this continuing medical education series.
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