A disfigured foot with ulcer

Treat the pressure ulcer before Charcot joint

The mainstays of treatment for pressure ulcers are relieving local pressure, keeping the area clean, using antibiotics for infection (if needed), debriding as necessary, and applying a dressing.

Relieving local pressure is important to reduce formation/progression of pressure ulcers. This can be achieved by careful evaluation of the patient’s skin and bony prominences. If the skin is red or irritated—suggesting that the tissue is under increased pressure—the patient can reduce pressure on the area. Custom orthotics can help toward that end. Frequent evaluation for skin breakdown is key to determining whether the intervention is working.

In our patient’s case, steps had been taken to relieve pressure. Her physician had instructed her to spend part of her days in a wheelchair (to reduce time spent with direct pressure on the soles of her feet) and the other part wearing custom orthotics. Unfortunately, she had not been wearing the orthotics. She felt that her regular shoes were more comfortable.

Keeping the area clean is of course essential, but there is no need to treat with systemic antibiotics unless there are signs of systemic cellulitis or osteomyelitis on MRI. Topical antibiotics may be used, but be sure to avoid any topical agents or disinfectants that can inadvertently damage new tissue growth.

Debriding necrotic tissue decreases bacterial load, increases effectiveness of topical antimicrobials, improves the body’s own antimicrobial function, and shortens the inflammatory phase of the wound. It can be accomplished in various ways, including: sharp debridement, mechanical debridement via gauze dressing changes or whirlpool, applied enzymatic agents, autolytic debridement via occlusive dressings, and biologic debridement using sterile maggots to remove necrotic tissue.

Applying an appropriate dressing is of course essential. Options include films, hydrogels, hydrocolloids, alginates, foams, and vacuum dressings. Topical dressings help maintain moisture and facilitate healing. Occlusive dressings facilitate autolytic debridement and act as a barrier against soiling. Hydrogels, hydrocolloids, and alginates help to absorb moisture. Vacuum dressings remove excess moisture and facilitate wound contracture and healing.