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Clinical Guidelines |

Treatment of Pressure Ulcers: A Clinical Practice Guideline From the American College of PhysiciansTreatment of Pressure Ulcers FREE

Amir Qaseem, MD, PhD, MHA; Linda L. Humphrey, MD, MPH; Mary Ann Forciea, MD; Melissa Starkey, PhD; Thomas D. Denberg, MD, PhD, for the Clinical Guidelines Committee of the American College of Physicians*
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* This paper, written by Amir Qaseem, MD, PhD, MHA; Linda L. Humphrey, MD, MPH; Mary Ann Forciea, MD; Melissa Starkey, PhD; and Thomas D. Denberg, MD, PhD, was developed for the Clinical Guidelines Committee of the American College of Physicians. Individuals who served on the Clinical Guidelines Committee from initiation of the project until its approval were Thomas D. Denberg, MD, PhD (Chair); Michael J. Barry, MD; Molly Cooke, MD; Paul Dallas, MD; Nick Fitterman, MD; Mary Ann Forciea, MD; Russell P. Harris, MD, MPH; Linda L. Humphrey, MD, MPH; Tanveer P. Mir, MD; Holger J. Schünemann, MD, PhD; J. Sanford Schwartz, MD; Paul Shekelle, MD, PhD; and Timothy Wilt, MD, MPH. Approved by the ACP Board of Regents on 26 July 2014.


From the American College of Physicians and University of Pennsylvania Health System, Philadelphia, Pennsylvania; Oregon Health & Science University, Portland, Oregon; and Carilion Clinic, Roanoke, Virginia.

Note: Clinical practice guidelines are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.

Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations.

Acknowledgment: The authors thank M.E. Beth Smith, DO, for updating the literature from the evidence review for the development of this guideline.

Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.

Disclosures: Dr. Barry reports grants and salaries from the Informed Medical Decisions Foundation and Healthwise outside the submitted work. Dr. Cooke reports support for travel to meetings for the study or other purposes from the American College of Physicians; board membership with the National Board of Medical Examiners; a consultancy for the University of Texas; employment with the University of California, San Francisco; and travel, accommodation, or meeting expenses from the American Board of Internal Medicine and the Accreditation Council for Graduate Medical Education outside the submitted work. Dr. Dallas reports support for travel to meetings for the study or other purposes from the American College of Physicians and stock ownership in Pfizer, Ortho Pharmaceutical, Sanofi-Aventis, GlaxoSmithKline, and Merck. Dr. Schwartz reports services from the National Heart, Lung, and Blood Institute during the conduct of the study; personal fees from Allergan, Bayer, Blue Cross Blue Shield Association, General Electric, UBC, and Genentech outside the submitted work; and a grant from Pfizer outside the submitted work. Dr. Shekelle reports personal fees from the ECRI Institute during the conduct of the study and royalties from UpToDate. Authors not named here have disclosed no conflicts of interest. Authors followed the policy regarding conflicts of interest described at www.annals.org/article.aspx?articleid=745942. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1568. A record of conflicts of interest is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm.

Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, aqaseem@acponline.org.

Current Author Addresses: Drs. Qaseem and Starkey: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.

Dr. Humphrey: Oregon Health & Science University, 3710 SW U.S. Veterans Hospital, Portland, OR 97201.

Dr. Forciea: University of Pennsylvania Health System, 3615 Chestnut Street, Philadelphia, PA 19104.

Dr. Denberg: Carilion Clinic, PO Box 13727, Roanoke, VA 24036.

Author Contributions: Conception and design: A. Qaseem.

Analysis and interpretation of the data: A. Qaseem, L.L. Humphrey, M.A. Forciea, M. Starkey, T.D. Denberg.

Drafting of the article: A. Qaseem, M.A. Forciea, M. Starkey, T.D. Denberg.

Critical revision of the article for important intellectual content: A. Qaseem, L.L. Humphrey, M.A. Forciea, M. Starkey, T.D. Denberg.

Final approval of the article: A. Qaseem, L.L. Humphrey, M.A. Forciea, T.D. Denberg.

Statistical expertise: A. Qaseem.

Administrative, technical, or logistic support: A. Qaseem, M. Starkey, T.D. Denberg.

Collection and assembly of data: A. Qaseem, M. Starkey.


Ann Intern Med. 2015;162(5):370-379. doi:10.7326/M14-1568
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Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations based on the comparative effectiveness of treatments of pressure ulcers.

Methods: This guideline is based on published literature on this topic that was identified by using MEDLINE, EMBASE, CINAHL, EBM Reviews, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, and the Health Technology Assessment database through February 2014. Searches were limited to English-language publications. The outcomes evaluated for this guideline include complete wound healing, wound size (surface area, volume, and depth) reduction, pain, prevention of sepsis, prevention of osteomyelitis, recurrence rate, and harms of treatment (including but not limited to pain, dermatologic complications, bleeding, and infection). This guideline grades the quality of evidence and strength of recommendations by using ACP's clinical practice guidelines grading system. The target audience for this guideline includes all clinicians, and the target patient population is patients with pressure ulcers.

Recommendation 1: ACP recommends that clinicians use protein or amino acid supplementation in patients with pressure ulcers to reduce wound size. (Grade: weak recommendation, low-quality evidence)

Recommendation 2: ACP recommends that clinicians use hydrocolloid or foam dressings in patients with pressure ulcers to reduce wound size. (Grade: weak recommendation, low-quality evidence)

Recommendation 3: ACP recommends that clinicians use electrical stimulation as adjunctive therapy in patients with pressure ulcers to accelerate wound healing. (Grade: weak recommendation, moderate-quality evidence)


Pressure ulcers affect 3 million adults in the United States across health care settings. They have a major impact on health status, quality of life, and health care costs. Treatment of pressure ulcers is critical to promote healing and minimize the risk for complications. Treatment interventions include management of conditions that give rise to pressure ulcers (support surfaces and nutritional support), protection and promotion of wound healing (wound dressings; topical applications; and various adjunctive therapies that are used in addition to standard pressure ulcer care, such as vacuum-assisted closure, ultrasound therapy, electrical stimulation, and hyperbaric oxygen therapy), and surgical repair of the wound (1) (Table 1). Treatment of pressure ulcers often requires a multidisciplinary approach involving nurses, physicians, and other members of a care team.

Table Jump PlaceholderTable 1. Selected Pressure Ulcer Treatment Interventions 

The purpose of this American College of Physicians (ACP) guideline is to present the available evidence on the comparative effectiveness of treatments for pressure ulcers. The target audience for this guideline includes all clinicians, including physicians, nurses, dietitians, and physical therapists. The target patient population comprises adults with pressure ulcers. For recommendations on the risk assessment and prevention of pressure ulcers, please refer to the accompanying ACP guideline (2).

This guideline is based on a systematic evidence review (3), an updated evidence review (Supplement), and an evidence report sponsored by the Agency for Healthcare Research and Quality (AHRQ) (1) that addressed the following key questions:

1. In adults with pressure ulcers, what is the comparative effectiveness of treatment strategies for improved health outcomes, including but not limited to complete wound healing, healing time, reduced wound surface area, pain, and prevention of serious complications of infection? Does the comparative effectiveness of treatment strategies differ on the basis of features (anatomical site or severity) of the pressure ulcers, patient characteristics, and health care settings?

2. What are the harms of treatments for pressure ulcers? Do the harms differ on the basis of features (anatomical site or severity) of the pressure ulcers, patient characteristics, and health care settings?

We searched MEDLINE, EMBASE, CINAHL, EBM Reviews, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, and the Health Technology Assessment database through February 2014 for studies in English. The primary outcomes of interest for this guideline include complete wound healing and wound size (surface area, volume, and depth) reduction. Additional outcomes include pain, prevention of sepsis, prevention of osteomyelitis, recurrence rate, and harms of treatment (including but not limited to pain, dermatologic complications, bleeding, and infection). Although most studies reported statistical significance of various outcomes, the guideline panel assessed clinically significant changes when evaluating the evidence.

Further details about the methods and inclusion and exclusion criteria applied in the evidence review are available in the full AHRQ report (1) and the Supplement. This guideline rates the quality of evidence and strength of recommendations by using ACP's guideline grading system (Table 2). Details of the ACP guideline development process can be found in ACP's methods paper (4).

Table Jump PlaceholderTable 2. The American College of Physicians' Guideline Grading System 

Most studies reported on only 1 outcome each (such as reduction of pressure ulcer size, improved wound healing, or rate of wound healing). Complete wound healing was reported in few studies; intermediate outcomes, such as reduction of wound size and rate of wound healing, were used to assess efficacy of the interventions. Some improvements were seen only in patients with large ulcers (>7 cm). Table 1 provides descriptions of the various treatment strategies, and Table 3 summarizes the evidence. Moderate-quality evidence showed that air-fluidized beds reduced pressure ulcer size compared with other surfaces (610), but pressure ulcer outcomes did not differ in comparisons of other support surfaces (low- to moderate-quality evidence) (1114, 2125). Moderate-quality evidence showed that protein-containing supplements improved wound healing (2740), although vitamin C supplementation did not (low-quality evidence) (26). Low-quality evidence showed that hydrocolloid dressings reduced ulcer size compared with gauze dressings (4251) and that platelet-derived growth factor (PDGF) improved wound healing (6973). Findings were mixed or did not differ for hydrocolloid compared with foam dressings (moderate-quality evidence) (5259), radiant heat (moderate-quality evidence) (6063), topical collagen (low-quality evidence) (42, 6668), and oxandrolone (41). Low-quality evidence showed that dextranomer paste was inferior to other wound dressings for reducing ulcer area (6465). Moderate-quality evidence showed that electrical stimulation accelerated wound healing as an adjunctive therapy (7483), and low-quality evidence showed no difference or mixed findings for the other adjunctive therapies assessed, including electromagnetic therapy (8487), therapeutic ultrasound (8890), negative-pressure wound therapy (9193), light therapy (9496), and laser therapy (100103).

Table Jump PlaceholderTable 3. Evidence for Pressure Ulcer Treatment Strategies 

Low-quality evidence from 3 fair-quality retrospective studies showed that patients with sacral pressure ulcers had a lower recurrence rate after surgery than those with ischial pressure ulcers (104106).

Low-quality evidence from 1 fair-quality study showed that patients with spinal cord injury had a higher rate of recurrent pressure ulcers after surgical flap closure than other patients with pressure ulcers (104).

Low-quality evidence from 1 good-quality and 3 fair-quality studies showed that electrical stimulation was similarly effective in patients with spinal cord injuries compared with other patients (74, 78, 8081).

Low-quality evidence from 1 good-quality and 8 fair-quality studies showed that electrical stimulation produced similar results in a hospital and a rehabilitation center (7483).

Reporting of harms was sparse, and comparison among trials was difficult because of heterogeneity of treatments or populations.

Support Surfaces

Evidence was insufficient to conclude about harms for various support surfaces because few studies reported adverse events and those that reported them mostly found no statistically significant difference compared with controls.

Nutrition

Evidence was insufficient to conclude about harms for nutritional supplementation because adverse event reporting was poor for these studies.

Medications

More patients had elevated liver enzyme levels (32.4% vs. 2.9%; P < 0.001) with oxandrolone than with placebo, but there was no difference in withdrawals due to adverse events (19% vs. 18%) (41).

Local Wound Applications

Skin irritation, inflammation, and tissue damage and maceration were the most commonly reported harms for various dressings and topical therapies (moderate-quality evidence). Evidence was insufficient to determine whether specific dressings or topical therapies resulted in less harm than others. Evidence was also insufficient to conclude about harms for biological agents because few harms were reported and the studies lacked precision.

Surgery

The most commonly reported harm from surgery was dehiscence. Reoperation due to recurrence or flap (tissue placed over the open wound) failure ranged from 12% to 24% among patients treated with surgery (low-quality evidence) (105, 107). Low-quality evidence from 1 intervention series showed a 21% complication rate for all skin flap surgeries and showed that tensor fascia lata flaps were associated with higher complication rates (49%), whereas rotation flaps were associated with the lowest complication rates (12%) compared with other surgical flap procedures (108).

Adjunctive Therapies

The most common adverse effect reported with electrical stimulation was skin irritation (low-quality evidence) (75, 79, 81). No substantial adverse effects were reported for light therapy (9495, 9798) or laser therapy (100103) (low-quality evidence).

Dehiscence was more common if bone was removed during the surgery (low-quality evidence) (105), and patients with ischial ulcers had higher complication rates than those with sacral or trochanteric ulcers (low-quality evidence) (107, 109).

Low-quality evidence showed that frail elderly patients had more adverse events associated with electrical stimulation than younger patients (75, 79, 81).

Treatment of pressure ulcers involves multiple methods intended to alleviate the conditions contributing to ulcer development (support surfaces, repositioning, and nutritional support), protection of the wound from contamination and creation of a clean wound environment, promotion of tissue healing (local wound applications, debridement, and wound cleansing), adjunctive therapies, and consideration for surgical repair. Evidence showed that many interventions were similar to controls for alleviation of pressure ulcers. Air-fluidized beds were superior to other support surfaces (primarily standard hospital beds) for reducing pressure ulcer size. Alternating-air beds and low–air-loss mattresses did not differ substantially from other surfaces for reducing wound size. Overall, few harms were reported for support surfaces.

Nutritional supplementation with protein or amino acids improved the rate of wound healing.

Hydrocolloid dressings were superior to gauze dressings for reducing wound size and were equivalent to foam dressings for complete wound healing. Although radiant heat dressings accelerated wound healing, there was no evidence that they improved complete wound healing compared with other dressings. Dextranomer paste was inferior to other dressings for reducing wound size. Platelet-derived growth factor improved ulcer healing compared with placebo for more severe ulcers, and evidence was insufficient to determine the effect of other biological agents. The most commonly reported harms for local wound applications included skin irritation, inflammation, and tissue damage and maceration.

Adjunctive therapies, including electromagnetic therapy, negative-pressure wound therapy, therapeutic ultrasound, and laser therapy, were similar to controls for ulcer alleviation. Electrical stimulation accelerated wound healing compared with control, but there was no evidence that it was superior for complete wound healing. The most common adverse effect for this treatment was skin irritation, and frail elderly patients were more susceptible to adverse events associated with electrical stimulation. Light therapy resulted in reduced ulcer size compared with control and was not associated with any substantial adverse events; however, it was equivalent to sham treatment for complete wound healing.

Although surgery is considered an option for advanced-stage pressure ulcers, evidence was insufficient to determine the superiority of one surgical technique over another for wound closure. Dehiscence, a commonly reported adverse event, was more common when bone was removed and in patients with ischial ulcers.

Recommendation 1: ACP recommends that clinicians use protein or amino acid supplementation in patients with pressure ulcers to reduce wound size. (Grade: weak recommendation, low-quality evidence)

Evidence showed that nutritional supplementation with protein or amino acids reduced pressure ulcer wound size, but evidence for the optimal dose or form of protein was insufficient. Protein supplementation was assessed in conjunction with standard therapies, such as dressings or support surfaces. Also, the trials generally included patients with nutritional deficiencies, and the evidence may not be generalizable to all patients with pressure ulcers because they may not benefit from nutritional supplementation. Evidence also did not show any benefit of vitamin C supplementation compared with placebo. Data are insufficient to comment on complete wound healing. The relationship between reduction in wound size or rate of healing and eventual complete healing has not been well-defined.

Recommendation 2: ACP recommends that clinicians use hydrocolloid or foam dressings in patients with pressure ulcers to reduce wound size. (Grade: weak recommendation, low-quality evidence)

Low-quality evidence showed that hydrocolloid dressings are better than gauze dressings for reducing wound size. In addition, moderate-quality evidence showed that hydrocolloid dressings resulted in complete wound healing similar to that of foam dressings (hydrocellular or polyurethane). Evidence was insufficient to determine whether specific dressings resulted in fewer harms than others. Data are insufficient to comment on complete wound healing. The relationship between reduction in wound size or rate of healing and eventual complete healing has not been well-defined.

Recommendation 3: ACP recommends that clinicians use electrical stimulation as adjunctive therapy in patients with pressure ulcers to accelerate wound healing. (Grade: weak recommendation, moderate-quality evidence)

Moderate-quality evidence supports the use of electrical stimulation in addition to standard treatment because it has been shown to accelerate the healing rate of stage 2 to 4 ulcers. Data are insufficient to comment on complete wound healing. The relationship between reduction in wound size or rate of healing and eventual complete healing has not been well-defined.

The Figure summarizes the recommendations and clinical considerations.

Grahic Jump Location
Figure.

Summary of the American College of Physicians guideline on treatment of pressure ulcers.

PDGF = platelet-derived growth factor.

Grahic Jump Location

Evidence was insufficient to determine the effectiveness or comparative effectiveness of alternating-air chair cushions, 3-dimensional polyester overlays versus gel overlays, zinc supplementation, l-carnosine supplementation, comparisons of different wound dressings other than those addressed earlier, debriding enzymes compared with dressings or other topical therapies, topical application of phenytoin to promote healing, maggot therapy, biological agents other than PDGF (fibroblast, nerve, and macrophage suspension), surgical techniques, or hydrotherapy (wound cleansing using whirlpool or pulsed lavage) for treatment of pressure ulcers (1) (Supplement). Evidence was also insufficient to balance the benefits and harms of various support surfaces to treat pressure ulcers. Many studies assessed reduction in wound size or rate of healing rather than complete wound healing, and more evidence is needed on intermediate outcomes as predictors of complete healing, the most important outcome. Although hyperbaric oxygen therapy is often used to treat pressure ulcers in hospitals, we found insufficient evidence to assess its safety and efficacy.

ACP does not recommend the use of various advanced support surfaces, including alternating-air and low–air-loss beds, because the quality of evidence for these surfaces was limited and the harms were poorly reported and could be significant given the immobility of the patient. Furthermore, due to their expense, the use of advanced support surfaces adds unnecessary costs to health care systems. In addition, although low-quality evidence showed that dressings containing PDGF promoted healing, ACP supports the use of other dressings, such as hydrocolloid and foam dressings, which are effective at promoting healing and cost less than PDGF dressings.

Saha S, Smith ME, Totten A, Fu R, Wasson N, Rahman B, et al. Pressure Ulcer Treatment Strategies: Comparative Effectiveness. Comparative effectiveness review no. 90. (Prepared by Oregon Evidence-based Practice Center under contract no. 290-2007-10057-I.) AHRQ publication no. 13-EHC003-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2013.
 
Qaseem A, Mir TP, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015; 162:359-69.
CrossRef
 
Smith ME, Totten A, Hickam DH, Fu R, Wasson N, Rahman B, et al. Pressure ulcer treatment strategies: a systematic comparative effectiveness review. Ann Intern Med. 2013; 159:39-50.
CrossRef
 
Qaseem A, Snow V, Owens DK, Shekelle P, Clinical Guidelines Committee of the American College of Physicians. The development of clinical practice guidelines and guidance statements of the American College of Physicians: summary of methods. Ann Intern Med. 2010; 153:194-9.
CrossRef
 
McGaughey H, Dhamija S, Oliver L, Porter-Armstrong A, McDonough S. Pulsed electromagnetic energy in management of chronic wounds: a systematic review. Phys Ther Rev. 2009; 14:132-46.
CrossRef
 
Allman RM, Walker JM, Hart MK, Laprade CA, Noel LB, Smith CR. Air-fluidized beds or conventional therapy for pressure sores. A randomized trial. Ann Intern Med. 1987; 107:641-8.
CrossRef
 
Jackson BS, Chagares R, Nee N, Freeman K. The effects of a therapeutic bed on pressure ulcers: an experimental study. J Enterostomal Ther. 1988; 15:220-6.
PubMed
 
Munro BH, Brown L, Heitman BB. Pressure ulcers: one bed or another? Geriatr Nurs. 1989; 10:190-2.
PubMed
CrossRef
 
Ochs RF, Horn SD, van Rijswijk L, Pietsch C, Smout RJ. Comparison of air-fluidized therapy with other support surfaces used to treat pressure ulcers in nursing home residents. Ostomy Wound Manage. 2005; 51:38-68.
PubMed
 
Strauss MJ, Gong J, Gary BD, Kalsbeek WD, Spear S. The cost of home air-fluidized therapy for pressure sores. A randomized controlled trial. J Fam Pract. 1991; 33:52-9.
PubMed
 
Clark M, Donald IP. Proceedings of the 7th European Conference on Advances in Wound Management, Harrogate, United Kingdom, 18–20 November 1998. London: Macmillan Magazines; 1999; 122-5.
 
Malbrain M, Hendriks B, Wijnands P, Denie D, Jans A, Vanpellicom J, et al. A pilot randomised controlled trial comparing reactive air and active alternating pressure mattresses in the prevention and treatment of pressure ulcers among medical ICU patients. J Tissue Viability. 2010; 19:7-15.
PubMed
CrossRef
 
Russell L, Reynolds TM, Towns A, Worth W, Greenman A, Turner R. Randomized comparison trial of the RIK and the Nimbus 3 mattresses. Br J Nurs. 2003; 12:254.
PubMed
CrossRef
 
Valente SA, Greenough WB, DeMarco SL, Andersen RE. More expensive surfaces are not always better. Kuwait Med J. 2012; 44:40-5.
 
Devine B. Alternating pressure air mattresses in the management of established pressure sores. J Tissue Viability. 1995; 5:94-8.
CrossRef
 
Evans D, Land L, Geary A. A clinical evaluation of the Nimbus 3 alternating pressure mattress replacement system. J Wound Care. 2000; 9:181-6.
PubMed
CrossRef
 
Land L, Evans D, Geary A, Taylor C. A clinical evaluation of an alternating-pressure mattress replacement system in hospital and residential care settings. J Tissue Viability. 2000; 10:6-11.
PubMed
CrossRef
 
Nixon J, Cranny G, Iglesias C, Nelson EA, Hawkins K, Phillips A, et al. Randomised, controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers: PRESSURE (pressure relieving support surfaces) trial. BMJ. 2006; 332:1413.
PubMed
CrossRef
 
Russell L, Reynolds T, Carr J, Evans A, Holmes M. A comparison of healing rates on two pressure-relieving systems. Br J Nurs. 2000; 9:2270-80.
PubMed
CrossRef
 
Russell L, Reynolds TM, Carr J, Evans A, Holmes M. Randomised controlled trial of two pressure-relieving systems. J Wound Care. 2000; 9:52-5.
PubMed
CrossRef
 
Caley L, Jones S, Freer J, Miller S. Randomized prospective trial: treatment outcomes and cost-effectiveness of two types of low-air-loss therapy. Proceedings of the 9th Annual Clinical Symposium on Pressure Ulcer and Wound Management, Nashville, TN. October 1994; 1-2.
 
Day A, Leonard F. Seeking quality care for patients with pressure ulcers. Decubitus. 1993; 6:32-43.
PubMed
 
Ferrell BA, Osterweil D, Christenson P. A randomized trial of low-air-loss beds for treatment of pressure ulcers. JAMA. 1993; 269:494-7.
PubMed
CrossRef
 
Mulder G, Taro N, Seeley J, Andrews K. A study of pressure ulcer response to low air loss beds vs. conventional treatment. The Journal of Geriatric Dermatology. 1994; 2:87-91.
 
Warner DJ. A clinical comparison of two pressure-reducing surfaces in the management of pressure ulcers. Decubitus. 1992; 5:52-5.
PubMed
 
ter Riet G, Kessels AG, Knipschild PG. Randomized clinical trial of ascorbic acid in the treatment of pressure ulcers. J Clin Epidemiol. 1995; 48:1453-60.
PubMed
CrossRef
 
Barnes P Jr, Sauter TE, Zaheri S. Subnormal prealbumin levels and wound healing. Tex Med. 2007; 103:65-8.
PubMed
 
Benati G, Delvecchio S, Cilla D, Pedone V. Impact on pressure ulcer healing of an arginine-enriched nutritional solution in patients with severe cognitive impairment. Arch Gerontol Geriatr Suppl. 2001; 7:43-7.
PubMed
CrossRef
 
Breslow RA, Hallfrisch J, Guy DG, Crawley B, Goldberg AP. The importance of dietary protein in healing pressure ulcers. J Am Geriatr Soc. 1993; 41:357-62.
PubMed
 
Brewer S, Desneves K, Pearce L, Mills K, Dunn L, Brown D, et al. Effect of an arginine-containing nutritional supplement on pressure ulcer healing in community spinal patients. J Wound Care. 2010; 19:311-6.
PubMed
CrossRef
 
Cereda E, Gini A, Pedrolli C, Vanotti A. Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomized controlled trial. J Am Geriatr Soc. 2009; 57:1395-402.
PubMed
CrossRef
 
Chernoff R. The effect of a high protein formula (Replete) on decubitus ulcer healing in long term tube fed institutionalized patients. J Am Diet Assoc. 1990; 90:A130.
 
Desneves KJ, Todorovic BE, Cassar A, Crowe TC. Treatment with supplementary arginine, vitamin C and zinc in patients with pressure ulcers: a randomised controlled trial. Clin Nutr. 2005; 24:979-87.
PubMed
CrossRef
 
Lee SK, Posthauer ME, Dorner B, Redovian V, Maloney MJ. Pressure ulcer healing with a concentrated, fortified, collagen protein hydrolysate supplement: a randomized controlled trial. Adv Skin Wound Care. 2006; 19:92-6.
PubMed
CrossRef
 
Leigh B, Desneves K, Rafferty J, Pearce L, King S, Woodward MC, et al. The effect of different doses of an arginine-containing supplement on the healing of pressure ulcers. J Wound Care. 2012; 21:150-6.
PubMed
CrossRef
 
Meaume S, Kerihuel JC, Constans T, Teot L, Lerebours E, Kern J, et al. Efficacy and safety of ornithine alpha-ketoglutarate in heel pressure ulcers in elderly patients: results of a randomized controlled trial. J Nutr Health Aging. 2009; 13:623-30.
PubMed
CrossRef
 
Myers SA, Takiguchi S, Slavish S, Rose CL. Consistent wound care and nutritional support in treatment. Decubitus. 1990; 3:16-28.
PubMed
 
Ohura T, Nakajo T, Okada S, Omura K, Adachi K. Evaluation of effects of nutrition intervention on healing of pressure ulcers and nutritional states (randomized controlled trial). Wound Repair Regen. 2011; 19:330-6.
PubMed
CrossRef
 
Van Anholt RD, Sobotka L, Meijer EP, Schols JM. An arginine- and micronutrient-enriched nutritional supplement accelerates pressure ulcer healing and reduces wound care in non-malnourished patients. European Wound Management Association Journal. 2010; 10:45.
 
Yamamoto T, Fujioka M, Kitamura R, Yakabe A, Kimura H, Katagiri Y, et al, European Pressure Ulcer Advisory Panel. Evaluation of nutrition in the healing of pressure ulcers: are the EPUAP nutritional guidelines sufficient to heal wounds? Wounds. 2009; 21:153-7.
 
Bauman WA, Spungen AM, Collins JF, Raisch DW, Ho C, Deitrick GA, et al. The effect of oxandrolone on the healing of chronic pressure ulcers in persons with spinal cord injury: a randomized trial. Ann Intern Med. 2013; 158:718-26.
CrossRef
 
Neill K, Conforti C, Kedas A, Burris JF. Pressure sore response to a new hydrocolloid dressing. Wounds. 1989; 1:173-85.
 
Hollisaz MT, Khedmat H, Yari F. A randomized clinical trial comparing hydrocolloid, phenytoin and simple dressings for the treatment of pressure ulcers [ISRCTN33429693]. BMC Dermatol. 2004; 4:18.
PubMed
CrossRef
 
Chang KW, Alsagoff S, Ong KT, Sim PH. Pressure ulcers—randomised controlled trial comparing hydrocolloid and saline gauze dressings. Med J Malaysia. 1998; 53:428-31.
PubMed
 
Kim YC, Shin JC, Park CI, Oh SH, Choi SM, Kim YS. Efficacy of hydrocolloid occlusive dressing technique in decubitus ulcer treatment: a comparative study. Yonsei Med J. 1996; 37:181-5.
PubMed
CrossRef
 
Mulder GD, Altman M, Seeley JE, Tintle T. Prospective randomized study of the efficacy of hydrogel, hydrocolloid, and saline solution-moistened dressings on the management of pressure ulcers. Wound Repair Regen. 1993; 1:213-8.
PubMed
CrossRef
 
Colwell JC, Foreman MD, Trotter JP. A comparison of the efficacy and cost-effectiveness of two methods of managing pressure ulcers. Decubitus. 1993; 6:28-36.
PubMed
 
Xakellis GC, Chrischilles EA. Hydrocolloid versus saline-gauze dressings in treating pressure ulcers: a cost-effectiveness analysis. Arch Phys Med Rehabil. 1992; 73:463-9.
PubMed
 
Winter A, Hewitt H. Testing a hydrocolloid. Nurs Times. 1990; 86:59-62.
PubMed
 
Alm A, Hornmark AM, Fall PA, Linder L, Bergstrand B, Ehrnebo M, et al. Care of pressure sores: a controlled study of the use of a hydrocolloid dressing compared with wet saline gauze compresses. Acta Derm Venereol Suppl (Stockh). 1989; 149:1-10.
PubMed
 
Gorse GJ, Messner RL. Improved pressure sore healing with hydrocolloid dressings. Arch Dermatol. 1987; 123:766-71.
PubMed
CrossRef
 
Bale S, Hagelstein S, Banks V, Harding KG. Costs of dressings in the community. J Wound Care. 1998; 7:327-30.
PubMed
 
Bale S, Squires D, Varnon T, Walker A, Benbow M, Harding KG. A comparison of two dressings in pressure sore management. J Wound Care. 1997; 6:463-6.
PubMed
 
Banks V, Bale S, Harding K. The use of two dressings for moderately exuding pressure sores. J Wound Care. 1994; 3:132-4.
 
Banks V, Bale SE, Harding KG. Comparing two dressings for exuding pressure sores in community patients. J Wound Care. 1994; 3:175-8.
 
Brod M, McHenry E, Plasse TF, Fedorczyk D, Trout JR. A randomized comparison of poly-hema and hydrocolloid dressings for treatment of pressure sores [Letter]. Arch Dermatol. 1990; 126:969-70.
PubMed
CrossRef
 
Hondé C, Derks C, Tudor D. Local treatment of pressure sores in the elderly: amino acid copolymer membrane versus hydrocolloid dressing. J Am Geriatr Soc. 1994; 42:1180-3.
PubMed
 
Seeley J, Jensen JL, Hutcherson J. A randomized clinical study comparing a hydrocellular dressing to a hydrocolloid dressing in the management of pressure ulcers. Ostomy Wound Manage. 1999; 45:39-44.
PubMed
 
Thomas S, Banks V, Bale S, Fear-Price M, Hagelstein S, Harding KG, et al. A comparison of two dressings in the management of chronic wounds. J Wound Care. 1997; 6:383-6.
PubMed
 
Kloth LC, Berman JE, Nett M, Papanek PE, Dumit-Minkel S. A randomized controlled clinical trial to evaluate the effects of noncontact normothermic wound therapy on chronic full-thickness pressure ulcers. Adv Skin Wound Care. 2002; 15:270-6.
PubMed
CrossRef
 
Price P, Bale S, Crook H, Harding KG. The effect of a radiant heat dressing on pressure ulcers. J Wound Care. 2000; 9:201-5.
PubMed
CrossRef
 
Thomas DR, Diebold MR, Eggemeyer LM. A controlled, randomized, comparative study of a radiant heat bandage on the healing of stage 3-4 pressure ulcers: a pilot study. J Am Med Dir Assoc. 2005; 6:46-9.
PubMed
CrossRef
 
Whitney JD, Salvadalena G, Higa L, Mich M. Treatment of pressure ulcers with noncontact normothermic wound therapy: healing and warming effects. J Wound Ostomy Continence Nurs. 2001; 28:244-52.
PubMed
 
Colin D, Kurring PA, Yvon C. Managing sloughy pressure sores. J Wound Care. 1996; 5:444-6.
PubMed
 
Sayag J, Meaume S, Bohbot S. Healing properties of calcium alginate dressings. J Wound Care. 1996; 5:357-62.
PubMed
 
Graumlich JF, Blough LS, McLaughlin RG, Milbrandt JC, Calderon CL, Agha SA, et al. Healing pressure ulcers with collagen or hydrocolloid: a randomized, controlled trial. J Am Geriatr Soc. 2003; 51:147-54.
PubMed
CrossRef
 
Zerón HM, KrötzschGómez FE, Muñoz RE. Pressure ulcers: a pilot study for treatment with collagen polyvinylpyrrolidone. Int J Dermatol. 2007; 46:314-7.
PubMed
CrossRef
 
Piatkowski A, Ulrich D, Seidel D, Abel M, Pallua N, Andriessen A. Randomised, controlled pilot to compare collagen and foam in stagnating pressure ulcers. J Wound Care. 2012; 21:505-11.
PubMed
CrossRef
 
Mustoe TA, Cutler NR, Allman RM, Goode PS, Deuel TF, Prause JA, et al. A phase II study to evaluate recombinant platelet-derived growth factor-BB in the treatment of stage 3 and 4 pressure ulcers. Arch Surg. 1994; 129:213-9.
PubMed
CrossRef
 
Rees RS, Robson MC, Smiell JM, Perry BH. Becaplermin gel in the treatment of pressure ulcers: a phase II randomized, double-blind, placebo-controlled study. Wound Repair Regen. 1999; 7:141-7.
PubMed
CrossRef
 
Robson MC, Phillips LG, Thomason A, Altrock BW, Pence PC, Heggers JP, et al. Recombinant human platelet-derived growth factor-BB for the treatment of chronic pressure ulcers. Ann Plast Surg. 1992; 29:193-201.
PubMed
CrossRef
 
Robson MC, Phillips LG, Thomason A, Robson LE, Pierce GF. Platelet-derived growth factor BB for the treatment of chronic pressure ulcers. Lancet. 1992; 339:23-5.
PubMed
CrossRef
 
Scevola S, Nicoletti G, Brenta F, Isernia P, Maestri M, Faga A. Allogenic platelet gel in the treatment of pressure sores: a pilot study. Int Wound J. 2010; 7:184-90.
PubMed
CrossRef
 
Adegoke BO, Badmos KA. Acceleration of pressure ulcer healing in spinal cord injured patients using interrupted direct current. Afr J Med Med Sci. 2001; 30:195-7.
PubMed
 
Adunsky A, Ohry A, DDCT Group. Decubitus direct current treatment (DDCT) of pressure ulcers: results of a randomized double-blinded placebo controlled study. Arch Gerontol Geriatr. 2005; 41:261-9.
PubMed
CrossRef
 
Ahmad ET. High voltage pulsed galvanic stimulation: effect of treatment durations on healing of chronic pressure ulcers. Indian Journal of Physiotherapy & Occupational Therapy. 2008; 2:1-5.
 
Ahmad ET. High-voltage pulsed galvanic stimulation: effect of treatment duration on healing of chronic pressure ulcers. Ann Burns Fire Disasters. 2008; 21:124-8.
PubMed
 
Baker LL, Rubayi S, Villar F, Demuth SK. Effect of electrical stimulation waveform on healing of ulcers in human beings with spinal cord injury. Wound Repair Regen. 1996; 4:21-8.
PubMed
CrossRef
 
Gentzkow GD, Pollack VP, Kloth LC, Stubbs HA. Improved healing of pressure ulcers using Dermapulse, a new electrical stimulation device. Wounds. 1991; 3:158-70.
 
Griffin JW, Tooms RE, Mendius RA, Clifft JK, Vander Zwaag R, el-Zeky F. Efficacy of high voltage pulsed current for healing of pressure ulcers in patients with spinal cord injury. Phys Ther. 1991; 71:433-42.
PubMed
 
Houghton PE, Campbell KE, Fraser CH, Harris C, Keast DH, Potter PJ, et al. Electrical stimulation therapy increases rate of healing of pressure ulcers in community-dwelling people with spinal cord injury. Arch Phys Med Rehabil. 2010; 91:669-78.
PubMed
CrossRef
 
Kloth LC, Feedar JA. Acceleration of wound healing with high voltage, monophasic, pulsed current. Phys Ther. 1988; 68:503-8.
PubMed
 
Wood JM, Evans PE 3rd, Schallreuter KU, Jacobson WE, Sufit R, Newman J, et al. A multicenter study on the use of pulsed low-intensity direct current for healing chronic stage II and stage III decubitus ulcers. Arch Dermatol. 1993; 129:999-1009.
PubMed
CrossRef
 
Comorosan S, Vasilco R, Arghiropol M, Paslaru L, Jieanu V, Stelea S. The effect of diapulse therapy on the healing of decubitus ulcer. Rom J Physiol. 1993; 30:41-5.
PubMed
 
Gupta A, Taly AB, Srivastava A, Kumar S, Thyloth M. Efficacy of pulsed electromagnetic field therapy in healing of pressure ulcers: a randomized control trial. Neurol India. 2009; 57:622-6.
PubMed
CrossRef
 
Ozdemir F, Kasapoglu M, Oymak F, Murat S. Efficiency of magnetic field treatment on pressure sores in bedridden patients. Balkan Med J. 2011; 28:274-8.
 
Salzberg CA, Cooper-Vastola SA, Perez FJ, Viehbeck MG, Byrne DW. The effects of non-thermal pulsed electromagnetic energy (DIAPULSE) on wound healing of pressure ulcers in spinal cord-injured patients: a randomized, double-blind study. Wounds. 1995; 7:11-6.
 
McDiarmid T, Burns PN, Lewith GT, Machin D. Ultrasound and the treatment of pressure sores. Physiotherapy. 1985; 71:66-70.
 
ter Riet G, Kessels AG, Knipschild P. Randomised clinical trial of ultrasound treatment for pressure ulcers. BMJ. 1995; 310:1040-1.
PubMed
CrossRef
 
ter Riet G, Kessels AG, Knipschild P. A randomized clinical trial of ultrasound in the treatment of pressure ulcers. Phys Ther. 1996; 76:1301-11.
PubMed
 
Ford CN, Reinhard ER, Yeh D, Syrek D, De Las Morenas A, Bergman SB, et al. Interim analysis of a prospective, randomized trial of vacuum-assisted closure versus the healthpoint system in the management of pressure ulcers. Ann Plast Surg. 2002; 49:55-61.
PubMed
CrossRef
 
Ho CH, Powell HL, Collins JF, Bauman WA, Spungen AM. Poor nutrition is a relative contraindication to negative pressure wound therapy for pressure ulcers: preliminary observations in patients with spinal cord injury. Adv Skin Wound Care. 2010; 23:508-16.
PubMed
CrossRef
 
Wanner MB, Schwarzl F, Strub B, Zaech GA, Pierer G. Vacuum-assisted wound closure for cheaper and more comfortable healing of pressure sores: a prospective study. Scand J Plast Reconstr Surg Hand Surg. 2003; 37:28-33.
PubMed
CrossRef
 
Dehlin O, Elmståhl S, Gottrup F. Monochromatic phototherapy in elderly patients: a new way of treating chronic pressure ulcers? Aging Clin Exp Res. 2003; 15:259-63.
PubMed
CrossRef
 
Dehlin O, Elmståhl S, Gottrup F. Monochromatic phototherapy: effective treatment for grade II chronic pressure ulcers in elderly patients. Aging Clin Exp Res. 2007; 19:478-83.
PubMed
CrossRef
 
Nussbaum EL, Flett H, Hitzig SL, McGillivray C, Leber D, Morris H, et al. Ultraviolet-C irradiation in the management of pressure ulcers in people with spinal cord injury: a randomized, placebo-controlled trial. Arch Phys Med Rehabil. 2013; 94: (4) 650-9.
PubMed
CrossRef
 
Durovic A, Maric D, Brdareski Z, Jevtic M, Durdevic S. The effects of polarized light therapy in pressure ulcer healing. Vojnosanit Pregl. 2008; 65:906-12.
PubMed
CrossRef
 
Schubert V. Effects of phototherapy on pressure ulcer healing in elderly patients after a falling trauma. A prospective, randomized, controlled study. Photodermatol Photoimmunol Photomed. 2001; 17:32-8.
PubMed
CrossRef
 
Iordanou P, Baltopoulos G, Giannakopoulou M, Bellou P, Ktenas E. Effect of polarized light in the healing process of pressure ulcers. Int J Nurs Pract. 2002; 8:49-55.
PubMed
CrossRef
 
Lucas C, Coenen CHM, DeHaan RJ. The effect of low level laser therapy (LLLT) on stage III decubitus ulcers (pressure sores); a prospective randomised single blind, multicentre pilot study. Lasers Med Sci. 2000; 15:94-100.
CrossRef
 
Lucas C, van Gemert MJ, de Haan RJ. Efficacy of low-level laser therapy in the management of stage III decubitus ulcers: a prospective, observer-blinded multicentre randomised clinical trial. Lasers Med Sci. 2003; 18:72-7.
PubMed
CrossRef
 
Nussbaum EL, Biemann I, Mustard B. Comparison of ultrasound/ultraviolet-C and laser for treatment of pressure ulcers in patients with spinal cord injury. Phys Ther. 1994; 74:812-23.
PubMed
 
Taly AB, SivaramanNair KP, Murali T, John A. Efficacy of multiwavelength light therapy in the treatment of pressure ulcers in subjects with disorders of the spinal cord: a randomized double-blind controlled trial. Arch Phys Med Rehabil. 2004; 85:1657-61.
PubMed
CrossRef
 
Kierney PC, Engrav LH, Isik FF, Esselman PC, Cardenas DD, Rand RP. Results of 268 pressure sores in 158 patients managed jointly by plastic surgery and rehabilitation medicine. Plast Reconstr Surg. 1998; 102:765-72.
PubMed
CrossRef
 
Schryvers OI, Stranc MF, Nance PW. Surgical treatment of pressure ulcers: 20-year experience. Arch Phys Med Rehabil. 2000; 81:1556-62.
PubMed
CrossRef
 
Yamamoto Y, Tsutsumida A, Murazumi M, Sugihara T. Long-term outcome of pressure sores treated with flap coverage. Plast Reconstr Surg. 1997; 100:1212-7.
PubMed
CrossRef
 
Foster RD, Anthony JP, Mathes SJ, Hoffman WY, Young D, Eshima I. Flap selection as a determinant of success in pressure sore coverage. Arch Surg. 1997; 132:868-73.
PubMed
CrossRef
 
Biglari B, Büchler A, Reitzel T, Swing T, Gerner HJ, Ferbert T, et al. A retrospective study on flap complications after pressure ulcer surgery in spinal cord-injured patients. Spinal Cord. 2014; 52:80-3.
PubMed
CrossRef
 
Foster RD, Anthony JP, Mathes SJ, Hoffman WY. Ischial pressure sore coverage: a rationale for flap selection. Br J Plast Surg. 1997; 50:374-9.
PubMed
CrossRef
 
National Pressure Ulcer Advisory Panel. NPUAP Pressure Ulcer Stages/Categories. Washington, DC: National Pressure Ulcer Advisory Panel; 2014. Accessed at www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories on 26 July 2013.
 

Figures

Grahic Jump Location
Figure.

Summary of the American College of Physicians guideline on treatment of pressure ulcers.

PDGF = platelet-derived growth factor.

Grahic Jump Location

Tables

Table Jump PlaceholderTable 1. Selected Pressure Ulcer Treatment Interventions 
Table Jump PlaceholderTable 2. The American College of Physicians' Guideline Grading System 
Table Jump PlaceholderTable 3. Evidence for Pressure Ulcer Treatment Strategies 

References

Saha S, Smith ME, Totten A, Fu R, Wasson N, Rahman B, et al. Pressure Ulcer Treatment Strategies: Comparative Effectiveness. Comparative effectiveness review no. 90. (Prepared by Oregon Evidence-based Practice Center under contract no. 290-2007-10057-I.) AHRQ publication no. 13-EHC003-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2013.
 
Qaseem A, Mir TP, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015; 162:359-69.
CrossRef
 
Smith ME, Totten A, Hickam DH, Fu R, Wasson N, Rahman B, et al. Pressure ulcer treatment strategies: a systematic comparative effectiveness review. Ann Intern Med. 2013; 159:39-50.
CrossRef
 
Qaseem A, Snow V, Owens DK, Shekelle P, Clinical Guidelines Committee of the American College of Physicians. The development of clinical practice guidelines and guidance statements of the American College of Physicians: summary of methods. Ann Intern Med. 2010; 153:194-9.
CrossRef
 
McGaughey H, Dhamija S, Oliver L, Porter-Armstrong A, McDonough S. Pulsed electromagnetic energy in management of chronic wounds: a systematic review. Phys Ther Rev. 2009; 14:132-46.
CrossRef
 
Allman RM, Walker JM, Hart MK, Laprade CA, Noel LB, Smith CR. Air-fluidized beds or conventional therapy for pressure sores. A randomized trial. Ann Intern Med. 1987; 107:641-8.
CrossRef
 
Jackson BS, Chagares R, Nee N, Freeman K. The effects of a therapeutic bed on pressure ulcers: an experimental study. J Enterostomal Ther. 1988; 15:220-6.
PubMed
 
Munro BH, Brown L, Heitman BB. Pressure ulcers: one bed or another? Geriatr Nurs. 1989; 10:190-2.
PubMed
CrossRef
 
Ochs RF, Horn SD, van Rijswijk L, Pietsch C, Smout RJ. Comparison of air-fluidized therapy with other support surfaces used to treat pressure ulcers in nursing home residents. Ostomy Wound Manage. 2005; 51:38-68.
PubMed
 
Strauss MJ, Gong J, Gary BD, Kalsbeek WD, Spear S. The cost of home air-fluidized therapy for pressure sores. A randomized controlled trial. J Fam Pract. 1991; 33:52-9.
PubMed
 
Clark M, Donald IP. Proceedings of the 7th European Conference on Advances in Wound Management, Harrogate, United Kingdom, 18–20 November 1998. London: Macmillan Magazines; 1999; 122-5.
 
Malbrain M, Hendriks B, Wijnands P, Denie D, Jans A, Vanpellicom J, et al. A pilot randomised controlled trial comparing reactive air and active alternating pressure mattresses in the prevention and treatment of pressure ulcers among medical ICU patients. J Tissue Viability. 2010; 19:7-15.
PubMed
CrossRef
 
Russell L, Reynolds TM, Towns A, Worth W, Greenman A, Turner R. Randomized comparison trial of the RIK and the Nimbus 3 mattresses. Br J Nurs. 2003; 12:254.
PubMed
CrossRef
 
Valente SA, Greenough WB, DeMarco SL, Andersen RE. More expensive surfaces are not always better. Kuwait Med J. 2012; 44:40-5.
 
Devine B. Alternating pressure air mattresses in the management of established pressure sores. J Tissue Viability. 1995; 5:94-8.
CrossRef
 
Evans D, Land L, Geary A. A clinical evaluation of the Nimbus 3 alternating pressure mattress replacement system. J Wound Care. 2000; 9:181-6.
PubMed
CrossRef
 
Land L, Evans D, Geary A, Taylor C. A clinical evaluation of an alternating-pressure mattress replacement system in hospital and residential care settings. J Tissue Viability. 2000; 10:6-11.
PubMed
CrossRef
 
Nixon J, Cranny G, Iglesias C, Nelson EA, Hawkins K, Phillips A, et al. Randomised, controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers: PRESSURE (pressure relieving support surfaces) trial. BMJ. 2006; 332:1413.
PubMed
CrossRef
 
Russell L, Reynolds T, Carr J, Evans A, Holmes M. A comparison of healing rates on two pressure-relieving systems. Br J Nurs. 2000; 9:2270-80.
PubMed
CrossRef
 
Russell L, Reynolds TM, Carr J, Evans A, Holmes M. Randomised controlled trial of two pressure-relieving systems. J Wound Care. 2000; 9:52-5.
PubMed
CrossRef
 
Caley L, Jones S, Freer J, Miller S. Randomized prospective trial: treatment outcomes and cost-effectiveness of two types of low-air-loss therapy. Proceedings of the 9th Annual Clinical Symposium on Pressure Ulcer and Wound Management, Nashville, TN. October 1994; 1-2.
 
Day A, Leonard F. Seeking quality care for patients with pressure ulcers. Decubitus. 1993; 6:32-43.
PubMed
 
Ferrell BA, Osterweil D, Christenson P. A randomized trial of low-air-loss beds for treatment of pressure ulcers. JAMA. 1993; 269:494-7.
PubMed
CrossRef
 
Mulder G, Taro N, Seeley J, Andrews K. A study of pressure ulcer response to low air loss beds vs. conventional treatment. The Journal of Geriatric Dermatology. 1994; 2:87-91.
 
Warner DJ. A clinical comparison of two pressure-reducing surfaces in the management of pressure ulcers. Decubitus. 1992; 5:52-5.
PubMed
 
ter Riet G, Kessels AG, Knipschild PG. Randomized clinical trial of ascorbic acid in the treatment of pressure ulcers. J Clin Epidemiol. 1995; 48:1453-60.
PubMed
CrossRef
 
Barnes P Jr, Sauter TE, Zaheri S. Subnormal prealbumin levels and wound healing. Tex Med. 2007; 103:65-8.
PubMed
 
Benati G, Delvecchio S, Cilla D, Pedone V. Impact on pressure ulcer healing of an arginine-enriched nutritional solution in patients with severe cognitive impairment. Arch Gerontol Geriatr Suppl. 2001; 7:43-7.
PubMed
CrossRef
 
Breslow RA, Hallfrisch J, Guy DG, Crawley B, Goldberg AP. The importance of dietary protein in healing pressure ulcers. J Am Geriatr Soc. 1993; 41:357-62.
PubMed
 
Brewer S, Desneves K, Pearce L, Mills K, Dunn L, Brown D, et al. Effect of an arginine-containing nutritional supplement on pressure ulcer healing in community spinal patients. J Wound Care. 2010; 19:311-6.
PubMed
CrossRef
 
Cereda E, Gini A, Pedrolli C, Vanotti A. Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomized controlled trial. J Am Geriatr Soc. 2009; 57:1395-402.
PubMed
CrossRef
 
Chernoff R. The effect of a high protein formula (Replete) on decubitus ulcer healing in long term tube fed institutionalized patients. J Am Diet Assoc. 1990; 90:A130.
 
Desneves KJ, Todorovic BE, Cassar A, Crowe TC. Treatment with supplementary arginine, vitamin C and zinc in patients with pressure ulcers: a randomised controlled trial. Clin Nutr. 2005; 24:979-87.
PubMed
CrossRef
 
Lee SK, Posthauer ME, Dorner B, Redovian V, Maloney MJ. Pressure ulcer healing with a concentrated, fortified, collagen protein hydrolysate supplement: a randomized controlled trial. Adv Skin Wound Care. 2006; 19:92-6.
PubMed
CrossRef
 
Leigh B, Desneves K, Rafferty J, Pearce L, King S, Woodward MC, et al. The effect of different doses of an arginine-containing supplement on the healing of pressure ulcers. J Wound Care. 2012; 21:150-6.
PubMed
CrossRef
 
Meaume S, Kerihuel JC, Constans T, Teot L, Lerebours E, Kern J, et al. Efficacy and safety of ornithine alpha-ketoglutarate in heel pressure ulcers in elderly patients: results of a randomized controlled trial. J Nutr Health Aging. 2009; 13:623-30.
PubMed
CrossRef
 
Myers SA, Takiguchi S, Slavish S, Rose CL. Consistent wound care and nutritional support in treatment. Decubitus. 1990; 3:16-28.
PubMed
 
Ohura T, Nakajo T, Okada S, Omura K, Adachi K. Evaluation of effects of nutrition intervention on healing of pressure ulcers and nutritional states (randomized controlled trial). Wound Repair Regen. 2011; 19:330-6.
PubMed
CrossRef
 
Van Anholt RD, Sobotka L, Meijer EP, Schols JM. An arginine- and micronutrient-enriched nutritional supplement accelerates pressure ulcer healing and reduces wound care in non-malnourished patients. European Wound Management Association Journal. 2010; 10:45.
 
Yamamoto T, Fujioka M, Kitamura R, Yakabe A, Kimura H, Katagiri Y, et al, European Pressure Ulcer Advisory Panel. Evaluation of nutrition in the healing of pressure ulcers: are the EPUAP nutritional guidelines sufficient to heal wounds? Wounds. 2009; 21:153-7.
 
Bauman WA, Spungen AM, Collins JF, Raisch DW, Ho C, Deitrick GA, et al. The effect of oxandrolone on the healing of chronic pressure ulcers in persons with spinal cord injury: a randomized trial. Ann Intern Med. 2013; 158:718-26.
CrossRef
 
Neill K, Conforti C, Kedas A, Burris JF. Pressure sore response to a new hydrocolloid dressing. Wounds. 1989; 1:173-85.
 
Hollisaz MT, Khedmat H, Yari F. A randomized clinical trial comparing hydrocolloid, phenytoin and simple dressings for the treatment of pressure ulcers [ISRCTN33429693]. BMC Dermatol. 2004; 4:18.
PubMed
CrossRef
 
Chang KW, Alsagoff S, Ong KT, Sim PH. Pressure ulcers—randomised controlled trial comparing hydrocolloid and saline gauze dressings. Med J Malaysia. 1998; 53:428-31.
PubMed
 
Kim YC, Shin JC, Park CI, Oh SH, Choi SM, Kim YS. Efficacy of hydrocolloid occlusive dressing technique in decubitus ulcer treatment: a comparative study. Yonsei Med J. 1996; 37:181-5.
PubMed
CrossRef
 
Mulder GD, Altman M, Seeley JE, Tintle T. Prospective randomized study of the efficacy of hydrogel, hydrocolloid, and saline solution-moistened dressings on the management of pressure ulcers. Wound Repair Regen. 1993; 1:213-8.
PubMed
CrossRef
 
Colwell JC, Foreman MD, Trotter JP. A comparison of the efficacy and cost-effectiveness of two methods of managing pressure ulcers. Decubitus. 1993; 6:28-36.
PubMed
 
Xakellis GC, Chrischilles EA. Hydrocolloid versus saline-gauze dressings in treating pressure ulcers: a cost-effectiveness analysis. Arch Phys Med Rehabil. 1992; 73:463-9.
PubMed
 
Winter A, Hewitt H. Testing a hydrocolloid. Nurs Times. 1990; 86:59-62.
PubMed
 
Alm A, Hornmark AM, Fall PA, Linder L, Bergstrand B, Ehrnebo M, et al. Care of pressure sores: a controlled study of the use of a hydrocolloid dressing compared with wet saline gauze compresses. Acta Derm Venereol Suppl (Stockh). 1989; 149:1-10.
PubMed
 
Gorse GJ, Messner RL. Improved pressure sore healing with hydrocolloid dressings. Arch Dermatol. 1987; 123:766-71.
PubMed
CrossRef
 
Bale S, Hagelstein S, Banks V, Harding KG. Costs of dressings in the community. J Wound Care. 1998; 7:327-30.
PubMed
 
Bale S, Squires D, Varnon T, Walker A, Benbow M, Harding KG. A comparison of two dressings in pressure sore management. J Wound Care. 1997; 6:463-6.
PubMed
 
Banks V, Bale S, Harding K. The use of two dressings for moderately exuding pressure sores. J Wound Care. 1994; 3:132-4.
 
Banks V, Bale SE, Harding KG. Comparing two dressings for exuding pressure sores in community patients. J Wound Care. 1994; 3:175-8.
 
Brod M, McHenry E, Plasse TF, Fedorczyk D, Trout JR. A randomized comparison of poly-hema and hydrocolloid dressings for treatment of pressure sores [Letter]. Arch Dermatol. 1990; 126:969-70.
PubMed
CrossRef
 
Hondé C, Derks C, Tudor D. Local treatment of pressure sores in the elderly: amino acid copolymer membrane versus hydrocolloid dressing. J Am Geriatr Soc. 1994; 42:1180-3.
PubMed
 
Seeley J, Jensen JL, Hutcherson J. A randomized clinical study comparing a hydrocellular dressing to a hydrocolloid dressing in the management of pressure ulcers. Ostomy Wound Manage. 1999; 45:39-44.
PubMed
 
Thomas S, Banks V, Bale S, Fear-Price M, Hagelstein S, Harding KG, et al. A comparison of two dressings in the management of chronic wounds. J Wound Care. 1997; 6:383-6.
PubMed
 
Kloth LC, Berman JE, Nett M, Papanek PE, Dumit-Minkel S. A randomized controlled clinical trial to evaluate the effects of noncontact normothermic wound therapy on chronic full-thickness pressure ulcers. Adv Skin Wound Care. 2002; 15:270-6.
PubMed
CrossRef
 
Price P, Bale S, Crook H, Harding KG. The effect of a radiant heat dressing on pressure ulcers. J Wound Care. 2000; 9:201-5.
PubMed
CrossRef
 
Thomas DR, Diebold MR, Eggemeyer LM. A controlled, randomized, comparative study of a radiant heat bandage on the healing of stage 3-4 pressure ulcers: a pilot study. J Am Med Dir Assoc. 2005; 6:46-9.
PubMed
CrossRef
 
Whitney JD, Salvadalena G, Higa L, Mich M. Treatment of pressure ulcers with noncontact normothermic wound therapy: healing and warming effects. J Wound Ostomy Continence Nurs. 2001; 28:244-52.
PubMed
 
Colin D, Kurring PA, Yvon C. Managing sloughy pressure sores. J Wound Care. 1996; 5:444-6.
PubMed
 
Sayag J, Meaume S, Bohbot S. Healing properties of calcium alginate dressings. J Wound Care. 1996; 5:357-62.
PubMed
 
Graumlich JF, Blough LS, McLaughlin RG, Milbrandt JC, Calderon CL, Agha SA, et al. Healing pressure ulcers with collagen or hydrocolloid: a randomized, controlled trial. J Am Geriatr Soc. 2003; 51:147-54.
PubMed
CrossRef
 
Zerón HM, KrötzschGómez FE, Muñoz RE. Pressure ulcers: a pilot study for treatment with collagen polyvinylpyrrolidone. Int J Dermatol. 2007; 46:314-7.
PubMed
CrossRef
 
Piatkowski A, Ulrich D, Seidel D, Abel M, Pallua N, Andriessen A. Randomised, controlled pilot to compare collagen and foam in stagnating pressure ulcers. J Wound Care. 2012; 21:505-11.
PubMed
CrossRef
 
Mustoe TA, Cutler NR, Allman RM, Goode PS, Deuel TF, Prause JA, et al. A phase II study to evaluate recombinant platelet-derived growth factor-BB in the treatment of stage 3 and 4 pressure ulcers. Arch Surg. 1994; 129:213-9.
PubMed
CrossRef
 
Rees RS, Robson MC, Smiell JM, Perry BH. Becaplermin gel in the treatment of pressure ulcers: a phase II randomized, double-blind, placebo-controlled study. Wound Repair Regen. 1999; 7:141-7.
PubMed
CrossRef
 
Robson MC, Phillips LG, Thomason A, Altrock BW, Pence PC, Heggers JP, et al. Recombinant human platelet-derived growth factor-BB for the treatment of chronic pressure ulcers. Ann Plast Surg. 1992; 29:193-201.
PubMed
CrossRef
 
Robson MC, Phillips LG, Thomason A, Robson LE, Pierce GF. Platelet-derived growth factor BB for the treatment of chronic pressure ulcers. Lancet. 1992; 339:23-5.
PubMed
CrossRef
 
Scevola S, Nicoletti G, Brenta F, Isernia P, Maestri M, Faga A. Allogenic platelet gel in the treatment of pressure sores: a pilot study. Int Wound J. 2010; 7:184-90.
PubMed
CrossRef
 
Adegoke BO, Badmos KA. Acceleration of pressure ulcer healing in spinal cord injured patients using interrupted direct current. Afr J Med Med Sci. 2001; 30:195-7.
PubMed
 
Adunsky A, Ohry A, DDCT Group. Decubitus direct current treatment (DDCT) of pressure ulcers: results of a randomized double-blinded placebo controlled study. Arch Gerontol Geriatr. 2005; 41:261-9.
PubMed
CrossRef
 
Ahmad ET. High voltage pulsed galvanic stimulation: effect of treatment durations on healing of chronic pressure ulcers. Indian Journal of Physiotherapy & Occupational Therapy. 2008; 2:1-5.
 
Ahmad ET. High-voltage pulsed galvanic stimulation: effect of treatment duration on healing of chronic pressure ulcers. Ann Burns Fire Disasters. 2008; 21:124-8.
PubMed
 
Baker LL, Rubayi S, Villar F, Demuth SK. Effect of electrical stimulation waveform on healing of ulcers in human beings with spinal cord injury. Wound Repair Regen. 1996; 4:21-8.
PubMed
CrossRef
 
Gentzkow GD, Pollack VP, Kloth LC, Stubbs HA. Improved healing of pressure ulcers using Dermapulse, a new electrical stimulation device. Wounds. 1991; 3:158-70.
 
Griffin JW, Tooms RE, Mendius RA, Clifft JK, Vander Zwaag R, el-Zeky F. Efficacy of high voltage pulsed current for healing of pressure ulcers in patients with spinal cord injury. Phys Ther. 1991; 71:433-42.
PubMed
 
Houghton PE, Campbell KE, Fraser CH, Harris C, Keast DH, Potter PJ, et al. Electrical stimulation therapy increases rate of healing of pressure ulcers in community-dwelling people with spinal cord injury. Arch Phys Med Rehabil. 2010; 91:669-78.
PubMed
CrossRef
 
Kloth LC, Feedar JA. Acceleration of wound healing with high voltage, monophasic, pulsed current. Phys Ther. 1988; 68:503-8.
PubMed
 
Wood JM, Evans PE 3rd, Schallreuter KU, Jacobson WE, Sufit R, Newman J, et al. A multicenter study on the use of pulsed low-intensity direct current for healing chronic stage II and stage III decubitus ulcers. Arch Dermatol. 1993; 129:999-1009.
PubMed
CrossRef
 
Comorosan S, Vasilco R, Arghiropol M, Paslaru L, Jieanu V, Stelea S. The effect of diapulse therapy on the healing of decubitus ulcer. Rom J Physiol. 1993; 30:41-5.
PubMed
 
Gupta A, Taly AB, Srivastava A, Kumar S, Thyloth M. Efficacy of pulsed electromagnetic field therapy in healing of pressure ulcers: a randomized control trial. Neurol India. 2009; 57:622-6.
PubMed
CrossRef
 
Ozdemir F, Kasapoglu M, Oymak F, Murat S. Efficiency of magnetic field treatment on pressure sores in bedridden patients. Balkan Med J. 2011; 28:274-8.
 
Salzberg CA, Cooper-Vastola SA, Perez FJ, Viehbeck MG, Byrne DW. The effects of non-thermal pulsed electromagnetic energy (DIAPULSE) on wound healing of pressure ulcers in spinal cord-injured patients: a randomized, double-blind study. Wounds. 1995; 7:11-6.
 
McDiarmid T, Burns PN, Lewith GT, Machin D. Ultrasound and the treatment of pressure sores. Physiotherapy. 1985; 71:66-70.
 
ter Riet G, Kessels AG, Knipschild P. Randomised clinical trial of ultrasound treatment for pressure ulcers. BMJ. 1995; 310:1040-1.
PubMed
CrossRef
 
ter Riet G, Kessels AG, Knipschild P. A randomized clinical trial of ultrasound in the treatment of pressure ulcers. Phys Ther. 1996; 76:1301-11.
PubMed
 
Ford CN, Reinhard ER, Yeh D, Syrek D, De Las Morenas A, Bergman SB, et al. Interim analysis of a prospective, randomized trial of vacuum-assisted closure versus the healthpoint system in the management of pressure ulcers. Ann Plast Surg. 2002; 49:55-61.
PubMed
CrossRef
 
Ho CH, Powell HL, Collins JF, Bauman WA, Spungen AM. Poor nutrition is a relative contraindication to negative pressure wound therapy for pressure ulcers: preliminary observations in patients with spinal cord injury. Adv Skin Wound Care. 2010; 23:508-16.
PubMed
CrossRef
 
Wanner MB, Schwarzl F, Strub B, Zaech GA, Pierer G. Vacuum-assisted wound closure for cheaper and more comfortable healing of pressure sores: a prospective study. Scand J Plast Reconstr Surg Hand Surg. 2003; 37:28-33.
PubMed
CrossRef
 
Dehlin O, Elmståhl S, Gottrup F. Monochromatic phototherapy in elderly patients: a new way of treating chronic pressure ulcers? Aging Clin Exp Res. 2003; 15:259-63.
PubMed
CrossRef
 
Dehlin O, Elmståhl S, Gottrup F. Monochromatic phototherapy: effective treatment for grade II chronic pressure ulcers in elderly patients. Aging Clin Exp Res. 2007; 19:478-83.
PubMed
CrossRef
 
Nussbaum EL, Flett H, Hitzig SL, McGillivray C, Leber D, Morris H, et al. Ultraviolet-C irradiation in the management of pressure ulcers in people with spinal cord injury: a randomized, placebo-controlled trial. Arch Phys Med Rehabil. 2013; 94: (4) 650-9.
PubMed
CrossRef
 
Durovic A, Maric D, Brdareski Z, Jevtic M, Durdevic S. The effects of polarized light therapy in pressure ulcer healing. Vojnosanit Pregl. 2008; 65:906-12.
PubMed
CrossRef
 
Schubert V. Effects of phototherapy on pressure ulcer healing in elderly patients after a falling trauma. A prospective, randomized, controlled study. Photodermatol Photoimmunol Photomed. 2001; 17:32-8.
PubMed
CrossRef
 
Iordanou P, Baltopoulos G, Giannakopoulou M, Bellou P, Ktenas E. Effect of polarized light in the healing process of pressure ulcers. Int J Nurs Pract. 2002; 8:49-55.
PubMed
CrossRef
 
Lucas C, Coenen CHM, DeHaan RJ. The effect of low level laser therapy (LLLT) on stage III decubitus ulcers (pressure sores); a prospective randomised single blind, multicentre pilot study. Lasers Med Sci. 2000; 15:94-100.
CrossRef
 
Lucas C, van Gemert MJ, de Haan RJ. Efficacy of low-level laser therapy in the management of stage III decubitus ulcers: a prospective, observer-blinded multicentre randomised clinical trial. Lasers Med Sci. 2003; 18:72-7.
PubMed
CrossRef
 
Nussbaum EL, Biemann I, Mustard B. Comparison of ultrasound/ultraviolet-C and laser for treatment of pressure ulcers in patients with spinal cord injury. Phys Ther. 1994; 74:812-23.
PubMed
 
Taly AB, SivaramanNair KP, Murali T, John A. Efficacy of multiwavelength light therapy in the treatment of pressure ulcers in subjects with disorders of the spinal cord: a randomized double-blind controlled trial. Arch Phys Med Rehabil. 2004; 85:1657-61.
PubMed
CrossRef
 
Kierney PC, Engrav LH, Isik FF, Esselman PC, Cardenas DD, Rand RP. Results of 268 pressure sores in 158 patients managed jointly by plastic surgery and rehabilitation medicine. Plast Reconstr Surg. 1998; 102:765-72.
PubMed
CrossRef
 
Schryvers OI, Stranc MF, Nance PW. Surgical treatment of pressure ulcers: 20-year experience. Arch Phys Med Rehabil. 2000; 81:1556-62.
PubMed
CrossRef
 
Yamamoto Y, Tsutsumida A, Murazumi M, Sugihara T. Long-term outcome of pressure sores treated with flap coverage. Plast Reconstr Surg. 1997; 100:1212-7.
PubMed
CrossRef
 
Foster RD, Anthony JP, Mathes SJ, Hoffman WY, Young D, Eshima I. Flap selection as a determinant of success in pressure sore coverage. Arch Surg. 1997; 132:868-73.
PubMed
CrossRef
 
Biglari B, Büchler A, Reitzel T, Swing T, Gerner HJ, Ferbert T, et al. A retrospective study on flap complications after pressure ulcer surgery in spinal cord-injured patients. Spinal Cord. 2014; 52:80-3.
PubMed
CrossRef
 
Foster RD, Anthony JP, Mathes SJ, Hoffman WY. Ischial pressure sore coverage: a rationale for flap selection. Br J Plast Surg. 1997; 50:374-9.
PubMed
CrossRef
 
National Pressure Ulcer Advisory Panel. NPUAP Pressure Ulcer Stages/Categories. Washington, DC: National Pressure Ulcer Advisory Panel; 2014. Accessed at www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories on 26 July 2013.
 

Letters

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Comments

Submit a Comment/Letter
Comment
Posted on March 18, 2015
Thomas E. Finucane, MD
Johns hopkins School of Medicine
Conflict of Interest: None Declared
Recommendation 1 of the American College of Physicians Practice Guideline on Treatment of Pressure Ulcers is “that clinicians use protein or amino acid supplementation in patients with pressure ulcers to reduce wound size”. They note that “Evidence for the optimal dose or form of protein was insufficient.”1

Of the 14 cited studies, 5 focus on arginine supplementation, and one each on a proprietary formulation, a collagen protein hydrolysate, and ornithine alpha-keto glutarate, presumably the recommended amino acid supplementations. Of the 5 studies of arginine, Reference 28 (N=16, 3 groups, duration 2 weeks)2 provides no statistics. Reference 30 (N = 35)2 uses historical controls. Reference 33 (N=16, 3 groups, duration 3 weeks)4 finds worse outcomes with protein supplementation unless it is enriched with arginine. Reference 35 (N=23, duration 3 weeks)5 compares 2 doses of arginine and concludes that they are equally effective. Reference 396 and the title of the journal in which it was published were not found in PubMed or Google Scholar.

Also noted is that reduction in wound size is of uncertain clinical significance.

The Recommendation, supporting a protean and undefined intervention to achieve an outcome of uncertain importance based on evidence categorized as “moderate quality”, supports and lends credence to a multibillion dollar industry that is based largely on credulity. Is this really Choosing Wisely?

Thomas E. Finucane


1. Qaseem A, Humphrey L, Forciea MA et al. Treatment of pressure ulcers: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015;162(5):370-379. doi:10.7326/M14-1568.

2. Benati G, Delvecchio S, Cilla D et al. Impact on pressure ulcer healing of an arginine-enriched nutritional solution in patients with severe cognitive impairment. Arch Gerontol Geriatr Suppl. 2001;7:43-7.

3. Brewer S, Desneves K, Pearce L et al. Effect of an arginine-containing nutritional supplement on pressure ulcer healing in community spinal patients. J Wound Care. 2010 Jul;19(7):311-6.

4. Desneves KJ1, Todorovic BE, Cassar A et al. Treatment with supplementary arginine, vitamin C and zinc in patients with pressure ulcers: a randomised controlled trial. Clin Nutr. 2005 Dec;24(6):979-87. Epub 2005 Nov 15.

5. Meaume S, Kerihuel JC, Constans T et al. Efficacy and safety of ornithine alpha-ketoglutarate in heel pressure ulcers in elderly patients: results of a randomized controlled trial. J Nutr Health Aging. 2009 Aug;13(7):623-30.

6. van Anholt RD, Sobotka L, Meijer EP et al. An arginine-and micronutrient-enriched nutritional supplement accelerates pressure ulcer healing and reduces wound care intensity in non-malnourished patients. European Wound Management Association Journal 2010; 10:45.
Comment
Posted on March 20, 2015
Emanuele Cereda MD, PhD
Servizio di Dietetica Nutrizione Clinica
Conflict of Interest: None Declared
Pressure ulcers (PUs) are a tough problem to manage and a horrible one for patients, having a negative impact on mortality, morbidity, quality of life, and health care costs. Different treatment strategies could be and should be integrated to achieve healing [1]. However, recent evidence-based guidelines by the American College of Physicians (ACP) [2] have highlighted that most interventions are supported by low-quality evidence and could be recommended according to experts’ opinion. This synthesis of literature is consistent with the one recently released (September 2014) by the National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA) [3].
In respect to nutritional care, they recommended the use of protein or amino acid supplementation to reduce wound size. However, as often happens, guidelines cover a defined review time and evidence from most recent trials is lost. Specifically, a high-quality trial (the Oligoelement Sore Trial [OEST]) [4] published in a recent issue of Annals of Internal Medicine has demonstrated that malnourished PU patients receiving a high-calorie, high-protein nutritional support (approximately 30-30 kcal/kg/day and 1.5 grams of protein/kg/day) achieve improved healing when a mix of micronutrients (arginine, zinc, and antioxidants) involved in tissue regeneration [5] is additionally provided.
Despite covering a similar review time, compared to ACP’ guidelines, those released by NPUAP, EPUAP and PPPIA [3] include also a moderate-strength recommendation on the use arginine and micronutrients-enriched nutritional support. On account of the results of the OEST study [4], the expectation now is that this is going to become a high-strength recommendation.
Although this trial does not provide any specific indication on the amount of calorie and proteins to be supplied, it clearly emphasizes the importance of nutritional care and of delivering a more tailored nutritional support which should include but not be limited to high amounts of calories and proteins (suggested intake, 30-30 kcal/kg/day and 1.5 grams of protein/kg/day) [3,7]. This applies at least to patients malnourished or at nutritional risk, an aspect pointed out many times in NPUAP-EPUAP-PPPIA guidelines [3]. This type of patients are more likely to be compromised, depleted and unable to meet energy needs [6]. On the other hand, it is worth mentioning that most PU patients are at nutritional risk [4,7]. Therefore, it is reasonable to state that PU care without attention for nutrition is incomplete PU care. Nutritional screening and support should systematically considered in the management of every PU patients.


References

1. Smith ME, Totten A, Hickam DH, Fu R, Wasson N, Rahman B, Motu'apuaka M, Saha S. Pressure ulcer treatment strategies: a systematic comparative effectiveness review. Ann Intern Med 2013;159:39-50.

2. Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the american college of physicians. Ann Intern Med 2015;162:370-9.

3. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Perth, Australia; 2014.

4. Cereda E, Klersy C, Serioli M, Crespi A, D'Andrea F; OligoElement Sore Trial Study Group. A nutritional formula enriched with arginine, zinc, and antioxidants for the healing of pressure ulcers: a randomized trial. Ann Intern Med 2015;162:167-74.

5. Schols JMGA, Heyman H, Meijer EP. Nutritional support in the treatment and prevention of pressure ulcers: an overview of studies with an arginine enriched oral nutritional supplement. J Tissue Viability 2009;18:72-79.

6. Cereda E, Klersy C, Rondanelli M, Caccialanza R. Energy balance in patients with pressure ulcers: a systematic review and meta-analysis of observational studies. J Am Diet Assoc 2011;111:1868-1876

7. Posthauer ME, Banks M, Dorner B, Schols JM. The role of nutrition for pressure ulcer management: national pressure ulcer advisory panel, European pressure ulcer advisory panel, and pan pacific pressure injury alliance white paper. Adv Skin Wound Care 2015;28:175-188.
Dressing Choice
Posted on March 29, 2015
Scott Matthew Bolhack, MD, MBA, CWS, CMD, FACP, FAAP
TLC HealthCare Wound Specialists
Conflict of Interest: None Declared
The authors state in Recommendation 2:
Recommendation 2: ACP recommends that clinicians use hydrocolloid or foam dressings in patients with pressure ulcers to reduce wound size. (Grade: weak recommendation, low-quality evidence).

This has got to be the most peculiar recommendation that I have seen. Without reference to the stage of the wound, the level of exudate, the location of the pressure ulcer, making recommendations about any dressing is challenging enough. But reviewers, how are you going to place hydrocolloid or foam on a deep tissue, heavily exudating ulceration?
In Reply
Posted on April 2, 2015
Jill Monfre PhD RN CWOCN, Justin Endo MD
Dr. Endo: Assistant Professor, Department of Dermatology, University of Wisconsin; Dr. Monfre: Clinical Nurse Specialist, University of Wisconsin Hospital and Clinics
Conflict of Interest: None Declared
We appreciate Qaseem et al. creating the Clinical Practice Guidelines for the Treatment of Pressure Ulcers (PrU), based on best available evidence. (1) However, we would like to comment on their literature search methodology, caveats about nutrition supplementations, and their omission of the use of donut cushions.
Many research advances about PrU treatment have recently occurred. Searching the literature from the inception of databases may overshadow the more significant and recent studies. We agree that all literature should be reviewed, but significant and recent research should take precedence over those published decades ago.
Qaseem et al. found no difference (albeit low quality evidence) with vitamin C supplementation but recommended protein supplementation. (1) In addition to Cereda’s comment about their recent trial about supplementation, we would also like to point out a systemic review by Choo et al. (2) The majority of reviewed articles found that protein supplements alone did not promote pressure ulcer healing. However, protein supplements enriched with arginine, zinc, vitamin C, or other antioxidants showed significant wound healing. Therefore, we agree with Cereda’s comment that protein or vitamin supplementation alone may be necessary but not sufficient to heal PrU.
Finally, we are disappointed that Qaseem et al. omitted donut cushions. (1) The National Pressure Ulcer Advisory Panel (NPUAP) has repeatedly recommended against donut cushions, because they increase tissue pressure at the wound edge, thereby decreasing circulation and increasing edema. (3) However, many physicians and patients are unaware of the harm. A survey found that over half of critical care physicians thought that donut cushions are recommended. (4) Anecdotally, we continue seeing providers of various levels of experience from medical and surgical specialties make this mistake, and it is likely due to a lack of education during residency. (4) Also, patients can readily purchase these cushions (just search on any internet engine to see the number of vendors and customer reviews). Are we as providers routinely and specifically asking patients what they are using? It is essential to address explicitly the harm of donut cushions.
We are pleased that ACP is trying to improve physician awareness, and we agree that further PrU research is needed to inform practice. We urge the readership to review the comprehensive 2014 Prevention and Treatment of Pressure Ulcers Clinical Practice Guideline that was collaboratively published by the NPUAP, European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA). (5)

REFERENCES
1. Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD. Treatment of Pressure Ulcers: A Clinical Practice Guideline From the American College of PhysiciansTreatment of Pressure Ulcers. Annals of Internal Medicine. 2015;162(5):370-9.
2. Choo TS, Hayter M, Watson R. The effectiveness of nutritional intervention(s) and the treatment of pressure ulcers--a systematic literature review. Int J Nurs Pract. 2013;19 Suppl 1:19-27.
3. National Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention Points. 2007.
4. Cox J, Roche S, Gandhi N. Critical care physicians: attitudes, beliefs, and knowledge about pressure ulcers. Adv Skin Wound Care. 2013;26(4):168-76.
5. European Pressure Ulcer Advisory Panel NPUAP, Pan Pacific Pressure Injury Alliance, 2014;Pages. Accessed at Cambridge Media at http://www.npuap.org/wp-content/uploads/2014/08/Updated-10-16-14-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf.

Cost versus Benefit of Air-Fluidized Beds
Posted on April 17, 2015
David L. Keller, MD
independent internist
Conflict of Interest: None Declared
Table 3 states that air-fluidized beds have moderate quality evidence of reducing pressure ulcer size, compared with other surfaces, leading to an improved overall treatment effect. In trying to understand why air-fluidized beds were not included in the recommended treatments for pressure ulcers, I noted that the section on "High Value Care" states that "the use of advanced support surfaces adds unnecessary costs to the health care systems". However, the evidence demonstrating improvement due to electrical stimulation was of similar quality ("moderate") as air-fluidized beds. Electrical stimulation was included in the recommended treatments for pressure ulcers. Is electrical stimulation really less expensive than an air-fluidized bed, after accounting for the professional fees charged by the clinician providing that service? How many communities have such a clinician? The cost of air-fluidized beds, like any other commodity, is flexible and based on the volume of orders received. A recommendation by ACP for air-fluidized beds would increase the number of orders and decrease the cost of such beds, due to economies of scale. Economic considerations should not bias clinical recommendations. We are physicians, not economists.
The International Pressure Ulcer Guideline Development Group
Posted on April 21, 2015
Janet E. Cuddigan, PhD, RN, CWCN, FAAN, Jan Kottner, PhD, Emily Haesler, BN
University of Nebraska Medical Center, Charité-Universitätsmedizin Berlin, Canberra, Australia
Conflict of Interest: None Declared
The International Pressure Ulcer Guideline Development Group (GDG) congratulates the American College of Physicians (ACP) on the recent publication of their pressure ulcer prevention (1) and treatment (2) guidelines. The ACP guidelines make an important contribution to the field by fulfilling their purpose of presenting available evidence on the comparative effectiveness of risk assessment, prevention and treatment of pressure ulcers.
The international GDG released a comprehensive evidence-based guideline on pressure ulcer prevention and treatment in 2014 (3), updating the 2009 NPUAP/EPUAP guideline (4). The ACP and GDG both used rigorous methodologies to examine direct evidence on pressure ulcer prevention and treatment. The ACP recommendations are consistent with those of the GDG.
The GDG identified limitations in direct evidence, yet were driven by their purpose to provide evidence-based guidance for clinicians who are faced with very real pressure ulcer prevention and treatment decisions. Rather than “remain silent” on important aspects of pressure ulcer care not addressed by pressure ulcer research, the GDG developed a methodology for evaluating indirect evidence (e.g., healthy humans in biomechanical studies, bench research from animal and cell culture models and studies of chronic wounds).
Expert opinion was used when direct or indirect evidence was unavailable. Many “expert opinion” recommendations provide guidance on how to implement evidence-based recommendations. All recommendations were made available for review by members of the sponsoring organizations, guideline working groups and approximately 1,000 stakeholders in 63 countries. All comments were carefully considered before finalizing the guideline. Recommendations were then formally evaluated by the development team using the GRADE methodology.
The editorial accompanying publication of the ACP pressure ulcer guidelines (5), highlighted situations where “research alone” fails to provide adequate clinical guidance. However, it may have created the impression that the majority of recommendations in the 2014 international guideline were based solely on expert opinion. In fact, many of the recommendations were based on indirect evidence.
We agree that more quality research is needed. Given the substantial lack of evidence addressing pressure ulcer management today it is unlikely that these gaps will be closed in the near future. Concurrently, there is the need to provide best evidence-based practices at the bedside. Guidelines that leave unanswered questions might be of limited help. The GDG believes that consideration of indirect evidence and expert opinion using a transparent and unbiased process is necessary and appropriate in the development of clinically-relevant recommendations when direct research evidence is lacking.
References

1. Qaseem A, Mir TP, Starkey M, Denberg TD. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the american college of physicians. Annals Of Internal Medicine. 2015;162(5):359-69.
2. Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD. Treatment of pressure ulcers: a clinical practice guideline from the american college of physicians. Ann Intern Med. 2015;162(5):370-9.
3. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Osborne Park, Western Australia: Cambridge Media; 2014.
4. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Janet Cuddigan (Ed.). Washington, DC: National Pressure Ulcer Advisory Panel; 2009.
5. Black J. Pressure ulcer prevention and management: a dire need for good science. Annals Of Internal Medicine. 2015;162(5):387-8.

* The International Pressure Ulcer Guideline Development Group (GDG) is comprised of representatives from the National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and the Pan Pacific Pressure Injury Alliance (PPPIA). The primary purposes of the GDG are to conduct comprehensive reviews and appraisals of available research and develop evidence-based guidelines with the input of international pressure ulcer experts and stakeholders.

Additional Guideline Development Group Members (in alphabetical order):
Keryln Carville, PhD, RN; Perth, Australia. Michael Clark, PhD; Wales, UK. Diane Langemo, PhD, RN, FAAN; Grand Forks, ND, USA. Siu Ming Susan Law, BScN, MScN, RN, RM-ET; Hong Kong. Laurie McNichol, MSN, RN, GNP, CWOCN, CWON-AP; Greensboro, NC, USA. Pamela Mitchell, MN, RN, PGDipWHTR; Christchurch, New Zealand. Cees Oomens, PhD, Ir; Eindhoven, The Netherlands. Lisette Schoonhoven, PhD; Southampton, UK. Joyce Stechmiller, PhD, ACNP-BD, FAAN; Gainesville, FL, USA. Ai Choo Tay, BN, CWS; Singapore, Republic of Singapore.

Author's Response
Posted on August 12, 2015
Amir Qaseem MD, PhD, Mary Ann Forciea, MD, Linda Humphrey, MD, MPH
ACP, University of Pennsylvania, Oregon Health Science Universtiy
Conflict of Interest: None Declared
We agree with Dr. Cereda that nutrition is an important component of pressure ulcer treatment, and found moderate-quality evidence that protein-containing nutritional supplements resulted in wound improvement. We are aware of the recent Annals article on arginine supplementation and although it was not included in our evidence review because it was published after our literature search dates, it would likely be included in an update of the guideline. In response to Dr. Finucane’s comments about the nutritional data, although the protein supplementation studies used a wide variety of formulations, these supplements overall showed benefits for pressure ulcer outcomes and are therefore a suitable treatment option in conjunction with other therapies.

To address Drs. Monfre and Endo’s concerns about the evidence review, we reiterate that the guideline is based on a systematic evidence review conducted by an experienced evidence based practice center commissioned by AHRQ. The reviewers used well-established methodology for acquiring, summarizing, and grading the evidence, and included experts in the field during the review’s development, as well as during public comment and peer review periods. This guideline follows the recently published standards from the Guidelines International Network and Institute of Medicine (1, 2). As to the issue of donut cushions, no studies on donut cushions met the inclusion criteria in the evidence review, thus we do not discuss this intervention in the guideline. Further, it is beyond the scope of the guideline to identify every available device which has or has not been studied for harm or benefit.

Dr. Cuddigan and colleagues seek advice beyond what is available from direct evidence. However, a guideline, by definition, should be based on a systematic literature review and not expert opinion (1, 2) and the American College of Physicians’s guidelines are always based on evidence from systematic literature reviews. While we agree that clinicians need guidance even in the absence of direct evidence, resources such as point of care tools are better suited to provide such advice rather than guidelines.


Mary Ann Forciea, MD, FACP
University of Pennsylvania Health System, Philadelphia, PA

Linda L. Humphrey, MD, MPH, MACP
Oregon Health and Science University, Portland, OR

Amir Qaseem, MD, PhD, MHA, FACP
American College of Physicians, Philadelphia, PA


References

1. Institute of Medicine. Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Pr; 2011.
2. Qaseem A, Forland F, Macbeth F, Ollenschlager G, Phillips S, van der Wees P. Guidelines International Network: toward international standards for clinical practice guidelines. Ann Intern Med. 2012;156(7):525-31.


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Supplement. Pressure Ulcer Treatment Strategies: Update to a Comparative Effectiveness Review

Summary for Patients

Treatment of Pressure Ulcers

The full report is titled “Treatment of Pressure Ulcers: A Clinical Practice Guideline From the American College of Physicians.” It is in the 3 March 2015 issue of Annals of Internal Medicine (volume 162, pages 370-379). The authors are A. Qaseem, L.L. Humphrey, M.A. Forciea, M. Starkey, and T.D. Denberg, for the Clinical Guidelines Committee of the American College of Physicians.

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