Dermatology

Decubitus Ulcer (Chronic ulcer of skin, pressure ulcer, bedsore, pressure sore, tissue necrosis, decubiti, decubitus, trophic ulcer, decubitus ominosus/chronicus, cuticular necrosis, skin ulcer)

Are You Confident of the Diagnosis?

  • Characteristic findings on physical examination

The diagnosis is made by observation (Figure 1, Figure 2, Figure 3).  An ulcer reflects a break in the skin that can even extend to the underlying bone.

Figure 1.

Non-blanchable erythema and decubitus dermatitis

Figure 2.

Superficial ulcer

Figure 3.

Deep ulcer with necrotic debris attached

  • Expected results of diagnostic studies

An ulcer requires no overt diagnostic studies; however, for suspected osteomyelitis, an X-ray and magnetic resonance imaging (MRI) are indicated.  For accompanying infection, bacterial cultures and sensitivities are needed. 

  • Diagnosis confirmation

Differential diagnosis:

--Diabetic neuropathic ulcer - diabetic patient with peripheral neuropathy, typically on the foot.

--Arterial ulcer - arterial blockage causing tissue necrosis located on ankle or foot.

--Venous insufficiency ulcer - impaired venous return causing venous stasis dermatitis/ulcers, typically found on pretibial area or above medial malleolus.

--Cellulitis - skin infection may mimic an early decubitus ulcer (intact skin with nonblanchable redness)

--Pyoderma gangrenosum - early stage with redness and induration or slight ulceration on the edge may be indistinguishable

The diagnosis is a clinical one, not requiring laboratory studies or histopathologic confirmation. In reality, the decubitus ulcer is a diagnosis of exclusion after the conditions listed under differential diagnosis are excluded.

Who is at Risk for Developing this Disease?

Epidemiology:  The elderly; neurologic patients with such diseases as multiple sclerosis or amyotrophic lateral sclerosis;  patients sustaining trauma that includes spinal cord injury; and  patients subjected to lengthy operations. No gender difference exists.

Scales:  A number of scales are used by nursing personnel, including the Norton and Braden scales, to aid in predicting which patient may develop a skin breakdown (Table 1, Table 2). Each of the scales has its deficits and is not 100% accurate.

Table 1.

Scales for predicting development of decubitus ulcers
The Norton Scale*
Physical Condition Mental Condition Activity Mobility Incontinent
(4)Good (3)Fair (2)Poor (1)Very Bad (4)Alert (3)Apathetic (2)Confused (1)Stupor (4)Ambulant (3)Walk w assistance (2)Chairbound (1)Stupor (4)Full (3)Slightly limited (2)Very limited (1)Immobile (4)Not (3)Occasional(2)Usually/Urine (1)Urine and Feces
 
 
 
The Braden Scale*
Sensory Perception (1)completely limited (2) very limited (responds only to painful stimuli/can't feel pain over half of body (3)slightly limited (responds to verbal commands/can't feel pain in one or two extremities) (4)no impairment
Moisture (1)constantly moist (2)moist often but not always (3)occasionaly moist (4) rarely moist
Activity (1)confined to bed (2)confined to chair (3)walks occasionally (4)walks frequently
Mobility (1)completely immobile (2)very limited (occasional changes in position) (3)slightly limited (frequent/slight changes in position) (4)no limitation
Nutrition (1)very poor (never eats a complete meal) (2)probably inadequate (eats less than half of balanced meal) (3)adequate (eats over half of balanced meals) (4)excellent
Friction and Shear (1)problem (requires assistance in moving) (2)potential problem (minimal assistance in moving) (3)no apparent problem  

Table 2.

Grading and Staging of decubitus ulcers  
Grading
Blanchable erythema
Non-blanchable erythema
Decubitus dermatitis including bullae
Superficial ulcer
Deep ulcer
Eschar/gangrene
Staging*
Stage  Description
Stage I Nonblanchable erythema of intact skin
Stage II Full-thickness loss of skin involving epidermis/dermis
Stage III Full-thickness loss of skin including subcutaneous tissue that may extend down to underlying fascia
Stage IV Full-thickness loss of skin including subcutaneous tissue, muscle, bone, or supporting structures (eg, tendons or joint capsule) 

What is the Cause of the Disease?

  • Etiology

  • Pathophysiology

Pressure over bony prominences, shearing force, destruction of skin, and compromised blood flow.  Contributing factors include malnutrition, infection, and underlying disease.

Systemic Implications and Complications

--Incontinence - fecal or urinary

--Immobility

--Malnutrition

--Tissue Ischemia - hypotension, dehydration, vasomotor failure, vasoconstriction secondary to shock, heart failure, medications

--Neurologic disease - dementia, delirium, spinal cord injury, neuropathy

Treatment Options

Table 3.

Table 3.

Treatment options for decubitus ulcers
Medical Options Surgical* Physical Modalities
Topical  Wound infection - topical antibiotics only if infection is presentDecubitus dermatitis - topical corticosteroidsDressing - alginates, foams, hydrofibers; saline moistened gauze, transparent films, hydrocolloids, hydrogels DebridementScalpel or scissorsWet-to-dry dressingsEnzymaticAutolytic with an occlusive dressingBiosurgery (maggots)   Systemic  Wound infection - systemic antimicrobials, only if infection is presentAppropriate nutritional intake (enteral/parenteral nutrition, if needed)  Skin graftsSkin flapsMusculocutaneous flapsFree flaps   *Only for selected patients who have wound healing capability. Dynamic support surfaces: air-fluidized mattress, low air loss bed, alternating pressure mattressStatic support surfaces: Foam support surfaces and Overlays (foam, air, water)Repositioning* * Although nursing personnel often recommend turning every 2 hours, there is no evidence that specified internvals for turning are useful.

Optimal Therapeutic Approach for this Disease

  • Is infection present? Determined by classic signs, such as redness, pain, purulent discharge. If present, discharge treat infection.

  • If necrotic tissue is present, debridement is often needed to promote healing by removing the barrier to reepithelialization

    • Begin with nonselective methods (surgical debridement, mechanical abrasion, wet-to-dry dressings, forceful irrigation)

    • Progress to selective methods as necrotic tissue is removed (partial surgical, autolytic, enzymatic, chemical, biosurgical debridement)

  • Occlusive dressings (hydrocolloid) providing moist environment and accelerating healing.

  • Pressure relief

    • Repositioning schedule - no evidence supports specific timing, but public opinion deems a 2-hour turning schedule in the United States and 3 or more hour intervals in the UK.

    • Specialty beds - alternating pressure air mattress, air-fluidized beds.

  • Proper nutrition - no solid evidence supporting use of supplements, but proper caloric intake is important to promote healing.  While zinc-depleted patients may have poor wound healing, there is no evidence to show adding oral zinc prevents or heals ulcers. Similarly, ascorbic acid neither prevents nor promotes wound healing in these patients.  

Patient Management

Treated but not necessarily prevented.  The patient's underlying condition(s) are the significant factor(s).  Some patients no longer have the ability to heal a wound.

Unusual Clinical Scenarios to Consider in Patient Management

Decubitus ulcers may take some time to appear.  Sometimes, they are suddenly recognized. This does not mean that they developed overnight; rather, there may be the volcano effect, whereby the destructive process finally reaches the surface and can now be visualized.

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