17. Treatment of Skin Breakdown

Actionable Nuggets for SCI (3rd ed., 2016)

The Problem:Man using hand to brake wheelchair

Approximately 75% of pressure injuries in the SCI population are Stage I or II, and can be managed conservatively. The remaining 25% are Stage III or IV, and require more specialized management. Severe pressure injuries can lead to decreased mobility, loss of independence, amputation, and even fatal infections. Pressure injuries are most effectively treated when diagnosed and treated early.

Actionable Nugget

Treat stage I or II wounds with standard wound care. Treat stage III or IV wounds with specialist / surgical intervention.


Link to: International Classification for Wound Care

Evidence-based Best Practice:

Standard wound care for Stage I and II injuries includes cleansing, debridement and infection management.  A wide array of dressings is available, such as hydrocolloid, transparent film, hydrogel, alginate, foam, silver, silicone, collagen matrix, honey and iodine.  Referral to rehabilitation is recommended for seating and activity protocols.  Referral to a dietician may be beneficial, since nutritional status can significantly affect healing, especially energy and protein needs.

For Stage III and IV injuries, prompt referral to a surgeon is indicated, and discovery and treatment of osteomyelitis is a priority.  A variety of biophysical modalities may also be considered, including electrical stimulation, electromagnetic agents, pulsed radio frequency, phototherapy (laser, infrared, ultraviolet), ultrasound, negative pressure therapy, and hydrotherapy.  Evidence is building for electrical stimulation, but standardization of administration protocols is needed.

Telephone and video conferencing have been highly effective in making specialized wound care more accessible to community clinicians, with good rates of agreement with in-person specialist care.

Key reference:

    European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. (2014). Prevention and Treatment of Pressure Ulcers : Quick Reference Guide. Clinical Practice Guideline. http://www.npuap.org/wp-content/uploads/2014/08/Updated-10-16-14-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf

 Additional References (chronological order):

     Ponce de Leon, M. (2015). Teamwork approach to prevention and treatment of skin breakdown in spinal cord patients. Continuum (Minneapolis, Minn.), 21(1 Spinal Cord Disorders), 206–210. http://doi.org/10.1212/01.CON.0000461095.84186.a0
    Sunn, G. (2014). Spinal cord injury pressure ulcer treatment: an experience-based approach. Physical medicine and rehabilitation clinics of North America25(3), 671-680.
    Van Asbeck, F. W. A., & Post, M. W. M. (2015). Bedside prediction of the progress of pressure ulcer healing in patients with spinal cord injury using the ‘Decu-stick’. Spinal cord53(7), 539-543.
    Liu, L. Q., Moody, J., Traynor, M., Dyson, S., & Gall, A. (2014). A systematic review of electrical stimulation for pressure ulcer prevention and treatment in people with spinal cord injuries. The journal of spinal cord medicine37(6), 703-718.
    Singh, R., Rohilla, R. K., Dhayal, R. K., Sen, R., & Sehgal, P. K. (2014). Role of local application of autologous platelet-rich plasma in the management of pressure ulcers in spinal cord injury patients. Spinal cord, 52(11), 809-816.
    Chan, B.C., Nanwa, N., Mittmann, N., Bryant, D., Coyte, P.C., & Houghton, P.E. (2013). The average cost of pressure ulcer management in a community dwelling spinal cord injury population. International wound journal, 10(4), 431-440.
    Kruger, E. A., Pires, M., Ngann, Y., Sterling, M., & Rubayi, S. (2013). Comprehensive management of pressure ulcers in spinal cord injury: current concepts and future trends. The journal of spinal cord medicine36(6), 572-585.
    Biglari, B., Vd Linden, P. H., Simon, A., Aytac, S., Gerner, H. J., & Moghaddam, A. (2012). Use of Medihoney as a non-surgical therapy for chronic pressure ulcers in patients with spinal cord injury. Spinal cord50(2), 165-169.
    Chen X., Jiang Z., Chen Z., & Wang D. (2011). Application of skin traction for surgical treatment of grade IV pressure sore: a clinical report of 160 cases. Spinal Cord, 49(1), 76-80.
    Brewer, S., Desneves, K., Pearce., L., Mills, K., Dunn, L., Brown, D., & Crowe, T. (2010). Effect of an arginine-containing nutritional supplement on pressure ulcer healing in community spinal patients. Journal of Wound Care, 19(7), 311-6.
    Houghton, P.E., Campbell, K.E., Fraser, C.H., Harris, C., Keast, D.H., Potter, P.J., Hayes, K.C., et al. (2010). Electrical stimulation therapy increases rate of healing of pressure ulcers in community-dwelling people with spinal cord injury. Archives of Physical Medicine and Rehabilitation91(5), 669-78.
    Phillips, C., & Proter, N. (2010). Management of a complex wound in a person with spinal cord injury and mental illness. Journal of Wound Care19(9), 408-12.
    Ricci, E., & Afaragan, M. (2010). The effect of stochastic electrical noise on hard-to-heal wounds. Journal of Wound Care, 19(13), 96-103.
    Sarhan, F., Weatherburn, G., Graham, A., & Thiyagarajan, C. (2010). Use of digital images in the assessment and treatment of pressure ulcers in patients with spinal injuries in community settings. Journal of Telemedicine and Telecare, 16(4), 207-10.
    Scevola, S., Nicoletti, G., Brenta, F., Isernia, P. Maestri, M., & Faga, A. (2010). Allogenic platelet gel in the treatment of pressure sores: A pilot study. International Wound Journal, 7(3), 184-190.
    Singh, R., Rohilla, R.K., Siwach, R., Verma, V., & Kaur, K. (2010). Surgery for pressure ulcers improves general health and quality of life in patients with spinal cord injury. Journal of Spinal Cord Medicine33(4), 396-400.
    European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel (2009). Pressure Ulcer Prevention: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel
    Hill, M.L., Cronkite, R.C., Ota, D.T., Yao, E.C., & Kiratli B.J. (2009). Validation of home telehealth for pressure ulcer assessment: a study in patients with spinal cord injury. Journal of Telemedicine and Telecare15(4), 196-202.
    Saldin, L.K., & Krause, J.S. (2009). Pressure ulcer prevalence and barriers to treatment after spinal cord injury: Comparisons of four groups based on race-ethnicity. Neurorehabilitation24(1), 57-66.
    Thomas, D.R. (2009). Does pressure cause pressure ulcers? An inquiry into the etiology of pressure ulcers. Journal of the American Medical Directors Association11(6), 397-405).
    Hollisaz, M.T., H. Khedmat, & F. Yari (2004). A randomized clinical trial comparing hydrocolloid, phenytoin and simple dressings for the treatment of pressure ulcers. BMC Dermatology, 4(1), 18. http://www.biomedcentral.com/1471-5945/4/18
    Kennedy, P., et al. (2003). The effect of a specialist seating assessment clinic on the skin management of individuals with spinal cord injury. Journal of Tissue Viability13(3), 122-5.
    Krause, J.S. (1998). Skin sores after spinal cord injury: relationship to life adjustment. Spinal Cord36(1), 51-6. http://dx.doi.org/10.1038/sj.sc.3100528
    Adegoke, B.O., & Badmos, K.A. (2001). Acceleration of pressure ulcer healing in spinal cord injured patients using interrupted direct current. African Journal of Medicine and Medical Sciences30(3), 195-7. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=14510128
    Consortium for Spinal Cord Medicine (2001). Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guideline for health-care professionals. Journal of Spinal Cord Medicine24 Suppl 1, S40-101. http://www.pva.org/site/News2?page=NewsArticle&id=7658
    Baker, L.L., et al. (1996). Effect of electrical stimulation waveform on healing of ulcers in human beings with spinal cord injury. Wound Repair & Regeneration, 4(1), 21-8. http://dx.doi.org/10.1046/j.1524-475X.1996.40106.x
    Liu, M.H., et al. (1996). Increased energy needs in patients with quadriplegia and pressure ulcers. Advanced Wound Care, 9(3), 41-5. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=8716273
    Alexander, L.R., et al. (1995). Resting metabolic rate in subjects with paraplegia: the effect of pressure sores. Archives of Physical Medicine & Rehabilitation76(9), 819-22. http://dx.doi.org/10.1016/S0003-9993(95)80545-1
    Breslow, R.A., et al. (1993). The importance of dietary protein in healing pressure ulcers. Journal of the American Geriatric Society41(4), 357-62.
    Fuhrer, M.J., et al. (1993). Pressure ulcers in community-resident persons with spinal cord injury: prevalence and risk factors. Archives of Physical Medicine & Rehabilitation74(11), 1172-7. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=8239957
    Stefanovska, A., et al. (1993). Treatment of chronic wounds by means of electric and electromagnetic fields. Part 2. Value of FES parameters for pressure sore treatment. Medical & Biological Engineering & Computing31(3), 213-20.
    Dover, H., et al. (1992). The effectiveness of a pressure clinic in preventing pressure sores. Paraplegia30(4), 267-72. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=1625896
    Griffin, J.W., et al. (1991). Efficacy of high voltage pulsed current for healing of pressure ulcers in patients with spinal cord injury. Physical Therapy71(6), 433-42.