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Treatment of pressure ulcers: a systematic review

Reddy M, Gill SS, Kalkar SR, Wu W, Anderson PJ, Rochon PA. JAMA. 2008; 300(22):2647-62.

Context — Many treatments for pressure ulcers are promoted, but their relative efficacy is unclear.

Objective — To systematically review published randomized controlled trials (RCTs) evaluating therapies for pressure ulcers.

Data Sources and Study Selection — The databases of MEDLINE, EMBASE, and CINAHL were searched (from inception through August 23, 2008) to identify relevant RCTs published in the English language.

Data Extraction — Methodological characteristics and outcomes were extracted by 3 investigators.

Data Synthesis — A total of 103 RCTs met inclusion criteria. Of these, 83 did not provide sufficient information about authors' potential financial conflicts of interest. Methodological quality was variable. Most trials were conducted in acute care (38 [37%]), mixed care (25 [24%]), or long-term care (22 [21%]) settings. Among 12 RCTs evaluating support surfaces, no clear evidence favored one support surface over another. No trials compared a specialized support surface with a standard mattress and repositioning. Among 7 RCTs evaluating nutritional supplements, 1 higher-quality trial found that protein supplementation of long-term care residents improved wound healing compared with placebo (improvement in Pressure Ulcer Scale for Healing mean [SD] score of 3.55 [4.66] vs 3.22 [4.11], respectively; P < .05). Other nutritional supplement RCTs showed mixed results. Among 54 RCTs evaluating absorbent wound dressings, 1 found calcium alginate dressings improved healing compared with dextranomer paste (mean wound surface area reduction per week, 2.39 cm2 vs 0.27 cm2, respectively; P<.001). No other dressing was superior to alternatives. Among 9 RCTs evaluating biological agents, several trials reported benefits with different topical growth factors. However, the incremental benefit of these biological agents over less expensive standard wound care remains uncertain. No clear benefit was identified in 21 RCTs evaluating adjunctive therapies including electric current, ultrasound, light therapy, and vacuum therapy.

Conclusions — Little evidence supports the use of a specific support surface or dressing over other alternatives. Similarly, there is little evidence to support routine nutritional supplementation or adjunctive therapies compared with standard care.

Pressure ulcers are regions of localized damage to the skin and underlying tissues that usually develop over bony prominences such as the sacrum or heels.1- 3 These lesions are an important source of suffering for patients and their caregivers. Pressure ulcer prevalence varies widely depending on patient factors (eg, age, physical impairments) and treatment setting.4- 7

Treatment strategies for pressure ulcers can be both costly and complex. Hundreds of different mattresses and local wound care products are currently promoted,4 and few have been evaluated in randomized controlled trials (RCTs). It remains unclear which of the many available treatments promote the most effective healing of pressure ulcers.8- 11

While several effective strategies to prevent pressure ulcers exist,6 many patients continue to develop them. This is especially true in high-risk settings such as acute care hospitals, in which patients have reduced mobility.12,13 Thus, clinicians require an understanding of effective treatment options. We examined the evidence supporting interventions for the treatment of pressure ulcers.

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Keywords: Systematic review Treatment outcomes