Pressure ulcers are common wounds in patients who are immobile and have to lie in one position for a long time, wheelchair users, frail elderly people, comatose patients, those on mechanical ventilation… These wounds heal slowly and require long-term medical care, causing pain for patients and becoming a heavy burden for their families and the healthcare system.
1. What are pressure ulcers? Causes of pressure ulcers
According to statistics in at-risk groups, just 2 continuous hours of lying or sitting can lead to pressure ulcers, and it takes on average from 3 months to 2 years to heal a stage 4 pressure ulcer with significant financial burden. So what kind of wound is a pressure ulcer? How does it form?
1.1. What is a pressure ulcer?
Pressure ulcers (also called pressure sores, decubitus ulcers, or bedsores) are injuries to the skin/soft tissue caused by prolonged pressure on the skin leading to localized ischemia. Pressure ulcers form when tissues are compressed for too long between bony prominences and hard surfaces such as beds, chairs, or indented by medical tubing…
In Vietnam, there is currently no comprehensive data on the cost of treating pressure ulcers, but in the United Kingdom, the treatment cost for uncomplicated stage 4 pressure ulcers is nearly 280 million VND (equivalent to £9,670). This was a survey conducted by Bennet and colleagues in 2000.
In the United States, the annual medical cost for about 1 million people affected by pressure ulcers is up to 1.6 billion USD… This shows that pressure ulcers are a major healthcare burden, and the best solution is to focus on preventing pressure ulcers in at-risk individuals as early as possible, rather than allowing wounds to progress severely.
1.2. Causes of pressure ulcers
When immobilized for a long time, patients are at risk of pressure ulcers due to ischemic necrosis of the skin and subcutaneous tissue. The causes of pressure ulcers can be a combination of many factors, including internal factors (depending on the patient’s condition) and/or external factors (unrelated to the patient’s condition). Specifically:
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External factors (due to mechanical forces)
– Pressure: The areas under the greatest pressure are at bony prominences, and the soft tissue between bone and skin is usually compressed leading to pressure damage. This often happens at the sacrum, ankle, heel, trochanter, ischial tuberosity…
– Friction: Most initial skin injuries are caused by friction with other surfaces, for example, skin rubbing against the edge of the bed, clothing, etc. When friction occurs, the skin can be abraded locally and form ulcers due to damage to the epidermis and skin surface.
– Shear: When the patient turns in a reclined position, shear forces appear which twist and compress the subcutaneous tissue, causing skin damage.
=> Caregivers need to understand these forces so that when supporting or turning the patient, they avoid causing friction or shear that worsen the injury.
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Internal factors
– Skin condition: Long-term use of corticosteroids and aging (age > 65) can reduce skin resistance, thinning of the dermis layer, making it easier to form ulcers when the patient is immobile. Furthermore, elderly people undergo natural aging, so skin cell regeneration takes longer than in young people.
– Comorbidities: Diseases such as vascular disorders, diabetes, infections, high fever, anemia, cancer… can cause localized oxygen deficiency in the pressure areas.
– Loss of sensation: When neurological or spinal disorders occur, skin sensation is lost and patients do not know ulcers are forming because they do not feel pain.
– Other factors: Malnutrition, exposure to skin irritants (incontinence, sweat)…
2. Classification of pressure ulcers
Depending on the wound appearance, pressure ulcers can be classified into 4 different stages. However, many ulcers may not progress sequentially or may have additional manifestations. Below are the 4 stages of pressure ulcers:
Stage 1: Reddened skin (damage to the epidermis & dermis)
At this stage, the pressure ulcer area has started to turn red and shows signs of swelling. When touched, it feels firm, warm, or cooler than surrounding skin and may be painful or itchy. For people with darker skin tones, the affected area may turn purple or blue.
Although the skin is still intact, these signs indicate damage in the epidermis and dermis layers. Therefore, careful special care is needed to prevent the injury from progressing to an ulcer. Unless directed by healthcare staff, do not massage the reddened areas.
Stage 2: Appearance of ulcers on the skin surface & epidermis (additional damage to the subcutaneous layer)
In stage 2, damage has extended to the subcutaneous layer due to blisters causing separation and damage to the epidermis. The affected area may lose part of the epidermis, showing a shallow, open ulcer without scabbing and no necrotic tissue; the ulcer base is pink, shallow, and dry.
Visually, the area may have blisters like burns (intact or broken) or resemble a cut. The wound is painful and the skin around the ulcer is discolored.
Stage 3: Tissue necrosis (damage to dermis and hypodermis)
At this stage, the ulcer affects fat and subcutaneous layers, with necrotic tissue but without muscle involvement. The wound has deepened with a “volcano mouth” shape. The surrounding area is covered by black necrotic tissue adjacent to healthy tissue, showing clear underlying tissue deterioration.
However, external observation alone cannot assess the depth or internal damage of a stage 3 pressure ulcer.
Stage 4: Deep tissue damage (damage extends to tendons and muscles)
Stage 4 is the most severe with a large wound that may have infection, tunneling, or fistulas. All skin and subcutaneous tissue are lost. Muscle, tendons, bones, and joints may be visible, with yellow necrotic scabs or eschar at the wound base.
Signs of infection in stage 4 ulcers include:
– Thick yellow or green pus
– Foul odor from the wound
– Redness or warmth when touched
– Swelling and pain around the ulcer
If infection spreads, additional signs appear: fever, chills, irregular heartbeat, confusion, difficulty concentrating, exhaustion…
Stages 3 and 4 are extremely dangerous as patients may develop life-threatening complications such as cellulitis, joint infections, osteomyelitis, tetanus, or acute septic arthritis.
Note: To prevent pressure ulcers, healthcare professionals also classify an additional stage called stage 0: the skin turns red but is still intact. This is a clinical warning for pressure ulcer risk. At this stage, when pressure is applied to the red skin area, it turns white (unlike stage 1, where pressing on the red area does not cause whitening).
In addition to the above staging, doctors can also assess pressure ulcer severity based on certain criteria:
– Suspected deep tissue injury: Localized skin areas turn dark purple or reddish-brown, with blood-filled blisters caused by internal soft tissue injury, shear, or pressure forces. The skin may be soft, mushy, or firm; touching causes abnormal pain, warmth, or cold compared to healthy surrounding skin.
– Unstageable: The wound has lost all tissue, and the wound base is covered by scabs consisting of necrotic or dead cells (reddish-brown, green, yellow, gray). The wound bed may have brown, reddish-brown, or black eschar. Sometimes the depth of the ulcer is not clearly visible.
3. Prevention and treatment of pressure ulcers
Treatment of pressure ulcers is costly and time-consuming, burdening the healthcare system and posing great pressure on patients and caregivers. Therefore, prevention is extremely important. If ulcers occur, patients should be treated as early as possible to prevent wound spread and infection.
3.1. Prevention of pressure ulcers
The first important step to prevent pressure ulcers is to identify those at risk and apply appropriate preventive measures. Clinical studies show the prevalence of pressure ulcers ranges from 3-30%, commonly seen in:
– Patients with hemiplegia or paraplegia due to stroke.
– Patients on mechanical ventilation, oxygen therapy, comatose, or bedridden.
– Elderly with fractures, frailty, mobility difficulties, wheelchair users, or bedridden for long periods…
For these risk groups, regular assessment and placing them in an environment promoting soft tissue development is essential by:
– Using proper positioning techniques: When changing positions, do not drag the patient across the bed or wheelchair, but lift them to avoid friction damaging the epidermis. Also, to limit shear forces, caregivers should not raise the patient’s upper body more than 30 degrees.
– Using supportive surfaces: Special beds, mattresses, and mechanical devices can help prevent pressure ulcers. Caregivers can use chair cushions, sheepskin pads, foam, or gel pads to prevent ulcers at anatomical pressure points. Additionally, switching to air-filled mattresses or fluidized beds can reduce pressure because air and fluid materials distribute patient weight evenly.
However, note that no single support device can comprehensively prevent pressure ulcers and cannot replace basic nursing care.
Besides these methods, patients should have regular skin examinations by doctors to detect early red areas—signs of pressure changes. Patients also need proper nutrition care to limit deficiencies. Hygiene care must focus on:
– Careful skin hygiene, keeping skin clean and dry.
– Prevent soiling of the genital, pelvic, and urinary areas.
– Massage at least 3-4 times daily, especially on pressure-prone areas.
– Always keep bed linens dry and smooth to avoid pressure on the skin.
Regarding doctor-recommended products for pressure ulcer prevention, the new generation spray solution Sanyrene by Urgo Medical contains essential fatty acids that improve oxygen delivery to pressure areas and increase skin moisture and elasticity. This protects skin durability and prevents pressure ulcers.
For best preventive effect, Sanyrene acts on at-risk skin based on two mechanisms:
– External action: Supplementing essential fatty acids that are main skin components → Restores stratum corneum and epidermis function → Enhances elasticity, prevents dehydration, maintains moisture.
– Internal action: Supplementing 99% highly oxidized essential fatty acids → Supports critical reactions → Enhances skin regeneration and improves blood circulation.
Notably, the preventive efficacy of Sanyrene has been proven in clinical trials with outstanding results:
– GIPPS clinical trial: Reduced risk of pressure injury formation by 40%.
– Clinical trial at Da Nang Hospital: Saved 67% of total treatment costs compared to pressure ulcer treatment.
The product is now available in over 2000 pharmacies nationwide and widely used in more than 150 hospitals across the country for patients at risk of pressure ulcers.
You can find out more about Sanyrene here.
3.2. Treatment of pressure ulcer wounds
If the pressure ulcer is at stage 1 & 2: the wound does not require surgery and can be treated conservatively. However, if the ulcer has penetrated deep into the subcutaneous layer at stages 3 & 4, treatment may involve surgical intervention combined with conservative care (if the patient has comorbidities).
Generally, treatment should be initiated as early as possible but must strictly follow the doctor’s prescription. Family members should not arbitrarily use topical medications, externally bought ulcer treatments, or advice from unqualified individuals.
Below are common treatment methods for pressure ulcers used alone or in combination depending on the patient’s condition and ulcer severity:
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Supporting patient’s general condition
Maintaining the patient’s best possible condition helps control pressure ulcers. This includes:
– Pain relief.
– Care for urinary and fecal incontinence.
– Proper hygiene of pressure ulcers and surrounding skin.
– Balanced nutrition to enhance immunity.
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Reducing pressure on the patient’s skin
– Change the patient’s position every 2 hours.
– When lying down, ensure the head is raised 30 degrees.
– If possible, encourage patient movement to improve blood circulation.
– Use special beds or wheelchairs maintaining pressure below 32 mmHg to reduce pressure from immobility.
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Proper wound care
– Remove necrotic tissue by debridement, povidone-iodine, proteolytic enzymes, or water irrigation.
– Clean pressure ulcers with saline, sodium hypochlorite (2.5%), diluted povidone-iodine, or acetic acid (0.5%).
– Dress wounds to promote healing by maintaining moisture, keeping surrounding skin dry, and controlling exudate.
– Other methods: negative pressure therapy, hyperbaric oxygen, growth factors, electrotherapy…
– Spray Sanyrene on surrounding skin to prevent ulcer spread.
* Whatever method is applied, caregivers must strictly follow doctor’s instructions.
3.3. Nutrition for patients with pressure ulcers
Malnutrition is a risk factor that delays healing in pressure ulcer patients. Therefore, caregivers must develop an appropriate nutrition plan ensuring a balanced intake of essential nutrients: protein, calories, vitamins, and trace elements (minerals). Specifically:
– Minerals: Copper, iron, and zinc are trace elements linked to healing.
– Vitamins: Vitamins A, E, C, K enhance immunity and accelerate healing; especially vitamin C.
During wound care, also monitor wound exudate to adjust diet accordingly. Additionally, remind patients:
– Do not smoke
– Avoid alcohol
– Limit staying up late
– Follow treatment regimens and use anti-pressure ulcer medications and topical treatments as prescribed by doctors…
Pressure ulcers cause not only physical pain but also mental distress, including feelings of inferiority, depression, and social isolation. Therefore, caregivers need strong psychological preparation and knowledge to help patients heal quickly and live more comfortably. For pressure ulcers, the best treatment is prevention. For at-risk individuals, focus on keeping their skin intact and healthy. Among products, Sanyrene is widely used in hospitals nationwide to prevent pressure ulcers due to its advantages, affordability, and ease of use.
- Survey on pressure ulcer risk and related factors in inpatients at Thanh Nhan ICU Department: https://sti.vista.gov.vn/tw/Lists/TaiLieuKHCN/Attachments/307714/CVv417S502019134.pdf
- Prevention solutions for pressure ulcers inpatients at Hanoi Viet Duc Hospital ICU – Neurology ICU – 2016: http://safevietnam.org.vn/Images/FileAttach/loet.pdf
- https://familydoctor.org/condition/pressure-sores/
- https://msktc.org/sci/factsheets/skincare/Recognizing-and-Treating-Pressure-Sores
- https://www.vinmec.com/vi/tin-tuc/thong-tin-suc-khoe/suc-khoe-tong-quat/cac-giai-doan-phat-trien-cua-loet-do-ti-de/
- https://www.vinmec.com/vi/tin-tuc/thong-tin-suc-khoe/suc-khoe-tong-quat/xu-ly-loet-do-ty-de/
- According to MSD Manual – Professional version: https://www.msdmanuals.com/vi/chuy%C3%AAn-gia/r%E1%BB%91i-lo%E1%BA%A1n-da-li%E1%BB%85u/lo%C3%A9t-t%C3%AC-%C4%91%C3%A8/lo%C3%A9t-t%C3%AC-%C4%91%C3%A8#v8381516_vi
8.https://www.vinmec.com/vi/tin-tuc/thong-tin-suc-khoe/suc-khoe-tong-quat/xu-ly-loet-do-ty-de/#:~:text=M%E1%BB%A5c%20%C4%91%C3%ADch%20ch%C3%ADnh%20c%E1%BB%A7a%20%C4%91i%E1%BB%81u,peroxit%20hydro%20v%C3%A0%20povidon%2Diod.