Pertinent Insights On Offloading For Ulcerations
For a minor pressure ulcer of stage 1 or 2, Dr. Suzuki will use Calmoseptine ointment (Calmoseptine, Inc.), a 20% zinc oxide ointment with a small amount of menthol as an anti-itch ingredient. It is an over-the-counter formulation available in most pharmacies and he frequently gives patients the manufacturer’s sample packets. Dr. Suzuki will apply a liberal amount over the wound and cover it with a gauze dressing to keep it from smearing.
Dr. Giovinco uses padding protection for pressure wounds, saying wounds will continue to worsen with sustained pressure. He notes this protection is likely to include foam or cotton cast padding.
Are there any new studies or emerging modalities in the treatment of pressure ulcers?
Dr. Suzuki’s institution uses Mepilex (Molnlycke Health Care), a bordered foam dressing with a silicone adhesive, on the buttocks of the intensive care patients — even before the pressure ulcer arises — and replaces the dressing once a week. He cites a study to back up this practice to prevent pressure ulcers.2 In a similar fashion, for elderly and frail patients with a history of pressure ulcers, Dr. Suzuki may recommend that they apply soft foam dressings over the “pressure points,” such as the posterior heel or lateral and medial malleolus, as a proactive preventive measure for pressure ulcers. He notes patients can purchase most wound dressings from Web sites like Amazon.com.
Dr. Giovinco notes some intriguing research for offloading modalities, such as exoskeletons and wearable offloading braces. He says there is a “huge influx of interest” and financial investment in wearable offloading braces as the technology can allow management of wounds and ulcers while keeping the patient in motion.
“Overall, there is still very little substitute for a total contact cast,” notes Dr. Giovinco.
When it comes to pressure ulcers for immobile or bedbound patients, Dr. Bell emphasizes that prevention is still the key. He cites new pressure sensing technologies such as the Mattress Sensing MAP System (Wellsense), which can determine focal pressure areas for bedridden patients. Dr. Bell also cites PressureStat and TempStat (Visual Footcare Technologies), which allow patients and physicians to monitor foot pressure in a proactive manner.
“Undeniably, we need more research into the daily practice of pressure ulcer care,” asserts Dr. Suzuki. “When I see patients who come from skilled nursing facilities, I often see the patients treated with flimsy heel cups and trypsin spray, which have no clinical evidence to justify their use.”
Do you have any other pearls regarding offloading methods?
While in training, Dr. Suzuki learned that in the 1970s, DPMs used to admit diabetic foot ulcer patients and keep them in the hospital bed until the wound healed completely as a way of forced adherence to non-weightbearing, which was effective. He shares that story all the time with patients, explaining why he needs their awareness and adherence to heal the wound as part of a “team effort.”
“I strongly believe that patient education is the most important factor in effective offloading and, consequently, effective wound healing of pressure ulcers,” asserts Dr. Suzuki.
Dr. Bell notes that for any kind of offloading to be effective, whether it is total contact casting, a specialized bed or a device that offers mobility with wheels (Roll-a-Bout or a wheelchair, for instance), one must consider the patient’s overall status. As offloading is not “one size fits all,” he says the patient should not dictate to the physician what is the best option.
“Don’t rely on patients to do their own offloading at home,” says Dr. Bell. “You wouldn’t send your patients home with a scalpel and instruct them to do their own debridement so why would you expect them to be proficient (or adherent) when offloading is left up to them? Be the expert and be consistent when it comes to offloading wounds.”