A.G. Cattaneo, DBSM, via J-H Dunant 3, 21100 Varese
Pressure ulcers have been an annoying wound for the humans
from very ancient times. Firstly described in the medical
literature in the 16th century, they were probably represented
by the popular art very earlier. Clay models conserved in
Dijon, France, represent feet treated with a sponge on the
heel, a typical site for pressure ulcers; they were left as
"ex voto" near the Seine sources, a holy site for
the ancient Celtic population living in France one or two
Today, despite the great improvement of knowledge and technology,
pressure ulcers continue to represent, as a frequent complication
of major invaliding conditions, not only an additional font
of distress for the patient and a source of frustration for
the caregiver, but even an economical nightmare for the sanitation
Pressure ulcers typically develop in bedridden patients,
in which the main risk factor seems to be the prolonged local
pressure with concomitant poor blood supply, nerve injury,
loss of sensitivity and friction. Other well recognized risk
factors are skin moisture and malnutrition. Compromised trophic
texture, arterial and venous blood supply, sensorial and sympathetic
nerve regulation, immune system responses represent additional
risk factors frequent in older persons. The role of endothelial
dysfunction is possible, but not even proven.
Bedridden patients are more frequent between veterans, when
the inability to actively move can be due to a number of causes.
Major bone fractures (hip fracture being an example), ictal
events, acute illness in frail individuals, loss of consciousness
or simply the weakness accompanying the extreme aging are
among them. The frail oldest person is frequently unable to
properly inspect his body, communicate the distress and maintain
an adequate personal hygiene while incontinent. Malnutrition,
with insufficient intake of essential factors, amino acids,
lipids, vitamins and oligoelements, is also more frequent
than in younger individuals, due to poverty, psychological
or cognitive reasons, neglect or inadequate care.
Pressure sores develop with extreme ease and rapidity, but
the healing process is comparatively long, fastidious and
charged with high frequency of reactivation. These wounds
are quite frequent in all ages, when favouring conditions
develop; in people aged >65 years they affect about 50%
of those requiring geriatric or hospital care. The existence
of supranational observatories devoted to this topic (like
the National Pressure Ulcer Long-Term Care Study in U.S.A.,
or the Pan-European Pressure Ulcer Study) witness for the
great importance of finding a better solution.
From year 2000 three organisms operating in European countries
(the European Pressure Ulcer Advisory Panel, EPUAP, the Royal
College of Nursing, RCN, in UK, and the Deutsches Netzwerk
für Qualitätsentwicklung in der Pflege, DNQP, in
Germany) developed independent guidelines, partially uniformed
after periodical updating. The common aim was the development
of standardized classification system and preventive programs
useful for learning, research, practice and communications.
Similar programs have been developed in USA and other non-European
The classification system of the EPUAP, and similarly that
used in the USA, define 4 grades of lesion, from non blanchable
erythema of intact skin (grade 1) up to skin loss (even partial)
with damage of the fascia and of the supporting structures
(grade 4). The intermediate grades include superficial ulcers,
with damage of epidermis, dermis or both (grade 2) and full
thickness skin loss with damage of subcutaneous tissues but
not involving the fascia (grade 3). Photographic atlas have
been proposed and used.
The preventive programs promoted by the EPUAP, the RCN and
the DNQP show minor differences, and include risk and risk
factors assessment with tested scales, pressure relief obtained
with repositioning and use of pressure reducing devices when
adequate, regular skin inspection and early recognition of
lesions (grade 1), education and training of both the patient
and the care giver (at home and at the hospital).
Recent papers evaluating the fields included in the programs
demonstrate the excellence of a standardized method of classification
combined with a careful educational program in improving prevention
of lesions and recurrences.
Individualized education given to old, at risk subjects added
to structured and frequent contact (by phone) with old patients
discharged after surgery for pressure ulcers significantly
reduced recurrence episodes, or prolonged the disease free
period. Whenever possible, patients should be educated to
inspect their skin and recognize early signs of lesions, and
to correctly care their hygiene and nutritional needs.
Not only the patient should be educated to manage and know
the risk of chronic wounds: better care and prevention have
been obtained by specific education programs addressed to
the medical staff on the epidemiology, pathophysiology and
treatment strategies of pressure ulcers.
It has been demonstrated that reduction of nurse staffing
results deleterious not only for the patient outcome, but
even for the social costs linked to the length of treatment,
frequency of recurrences and complications. However, the most
skilled care was not necessarily linked with the educational
degree of the nurse, basic care givers with long experience
in the field scoring best than those with higher qualifications.
Early diagnosis and recognition of at risk conditions is
mandatory for efficient prevention and cure: to limit the
measures for pressure relief to the subjects presenting grade
1 lesions seems to be a good preventive measure, not enhancing
the risk for advancing of the lesion to more serious stages
and sparing the need for pressure-reducing mattress means
and the efforts in periodically repositioning the patient.
The efficacy of this measure is limited by the frequency of
misdiagnosing moisture lesions from blanchable erythema, a
Unfortunately, the reliability of inter-observer in classifying
chronic skin wounds remained low until recently (Beeckman
et al, 2007, Journal of Advanced Nursing 60: 682-691), and
the high frequency of misdiagnosing moisture lesions from
blanchable erythema greatly limited this simple measure.
Needs for better clarify and disseminate the classification
system, seems to be desirable, due to the complexity of the
Once developed, the pressure ulcers should be treated. The
basics measures for this treatment can be summarized in hygiene,
pressure relief, wound dressing and sterility, pain relief,
surgical debridments and daily curettage when needed. A diffuse
practice, massaging with or without lenitive creams the skin
presenting signs of grade 1 lesion, does not seem to be very
efficient in comparison with pressure relief alone.
The old and the new in all these fields mix together, fomenting
the hope of more efficient cure which remains to be unequivocally
demonstrated. A large number of devices are continuously proposed
to help the healing process and to reduce the progression
and recurrences of the lesion. New mattress are claimed to
have superior quality in pressure relief, wound dressing adsorbed
with new substances (or old, and revisited) or completely
new textiles seems accelerate complete healing, devices proposed
to help the healing process through polarized light, or low
and ultra low pulsed electric current, or even low frequency
ultrasounds can be of great benefit.
While of great interest, all trials testing new therapeutic
methods and devices should be submitted by thorough supervision
by the organism competent for the territory before being divulge
as very efficient.
Take several opposite example, to be clear.
Among old remedies, the resin of the Norway spruce, used in
folk medicine, seemed to retain superior quality in comparison
with dressing with hydro colloid polymers: sterility was more
rapidly and more frequently obtained, and healing occurred
in 92% of patients treated with resin (vs 44% with hydro colloid).
The results were recently obtained in a controlled trial performed
in Finland (Br J Dermatol 158:1055-62, 2008). Analogously,
honey dressing, another traditional mean of cure, performed
better than conventional dressing in a trial performed in
Turkey (J Wound Ostomy Continence Nurs 34:184-190, 2007).
The same can be true when very innovative means of cure are
proposed, like nanotechnologies applied to the silk peptides
crystallization in aqueous environments. The products are
poorly expensive, highly resistant and biocompatible surfaces
for controlled drug release and wounds dressing (J Control
Release 121:190-9, 2007; J Nanosci Nanotechnol. 7:3888-91,
While published in peer-reviewed journals, these results can
be surprising, and however it should be comforting if their
superiority should be stated by unbiased, standardized methodologies.
In conclusion, it should be a good practice if private as
well as national and public organisms devoted to the care
and welfare of older persons will recognize and adopt the
lines suggested by the recognized organism active locally
(the EPUAP in Italy). The policy of promote permanent educational
observatory and trials seems to be the most desirable occurrence.
Improvement in diagnosis and in treatment skills should be
achieved. Very fastidious chronic wounds, those poorly healing
or frequently recurrent should be considered as the spy of
underlying conditions, from local ischemia to neoplasms or
metabolic diseases. Carefully investigation and adequate treatment
follow even in extreme aged persons.
Well established practice should be maintained without hardy
change, if this last has not been seriously proven by local
and multi-centre trials; however the news in the field must
be know by the administrators and critically divulged among
the care givers.
Anna Giulia Cattaneo, DBSM, Università
dell'Insubria, Via J-H Dunant,3 - 2100 Varese
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