17. Treatment of Skin Breakdown

Actionable Nuggets for SCI (2nd ed., 2013)

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

The Problem:

Approximately 75% of pressure ulcers 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 ulcers can lead to decreased mobility, loss of independence, amputation, and even fatal infections. Pressure ulcers are most effectively treated when diagnosed and treated early.

Additional information: International classification for wound care

Evidence-based Best Practice:

Standard wound care for Stage I and II ulcers includes cleansing, debridement, and pressure dressing. Promising results have been found with occlusive hydrocolloid, electrical stimulation, powdered arginine, and platelet gel, all of which can be administered by a wound care team in the community. Early intervention, self-management training and decision support are all recommended. Referral to rehabilitation is also recommended for seating and preventive strategies. Referral to a dietician may be beneficial, since nutritional status can significantly affect healing, especially energy and protein needs.

Surgical management is recommended for Stage III and IV ulcers, and has been shown to have significant positive effects on wound healing and quality of life. Telephone and video conferencing have been highly effective in making specialized wound care more accessible, with good rates of agreement with in-person assessment.

Key reference:

    European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel (2009). Pressure Ulcer Prevention: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel

Additional references:

    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
    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.
    Baker, L.L., et al. (1996). Effect of electrical stimulation waveform on healing of ulcers in human beings with spinal cord injury. Wound Repair & Regeneration4(1): 21-8.
    Breslow, R.A., et al. (1993). The importance of dietary protein in healing pressure ulcers. Journal of the American Geriatric Society41(4): 357-62.
    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 Care19(7): 311-6.
    Chan, B.C., Nanwa, N., Mittmann, N., Bryant, D., Coyte, P.C., & Houghton, P.E. (2012). The average cost of pressure ulcer management in a community dwelling spinal cord injury population. International Wound Journal, epub ahead of print.
    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.
    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.
    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
    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.
    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; discussion 442-4.
    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.
    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 Dermatology4(1): 18. http://www.biomedcentral.com/1471-5945/4/18
    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.
    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
    Liu, M.H., et al. (1996). Increased energy needs in patients with quadriplegia and pressure ulcers. Advanced Wound Care9(3): 41-5. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=8716273
    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 Care19(13): 96-103.
    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.
    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 Telecare16(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 Journal7(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.
    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.
    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).