5th April 2023
A consultant physician and dermatologist at the Edo State University, Uzairue, and Edo Specialist Hospital, Benin City, Dr Aisha Sokunbi, tells ALEXANDER OKERE the causes of pressure ulcers, also known as bedsores, and how they can be prevented
How will you define bedsore?
Bedsores, also known as pressure sores, can simply be defined as sores which appear on the skin, especially, in areas of bony prominence due to localised damage to the skin and its underlying structures from prolonged pressure on the skin. They occur due to damage from the disintegration of the skin, leading to loss of the skin and subcutaneous tissue and fat.
Prolonged pressure on the skin is a common cause of bedsores. Are there other causes?
The major cause of bedsores is prolonged pressure on the skin. However, there are other causes like frictional force acting on the skin due to the rubbing of skin on surfaces for a long time; shear force on the skin, which is a pulling force on the skin that can impair blood supply to the skin; moisture and wetness on the skin surface from urine, faeces and sweat leading to maceration of the skin.
Yes. These waste products cause sustained wetness on the skin which along with the persistent pressure and frictional force can lead to the breakdown of the skin and its tissues.
Are bedsores the same as pressure ulcers?
Yes, they can also be called pressure ulcers, pressure sores and decubitus ulcers.
What parts of the body does bedsore commonly affect?
Pressure sores frequently occur around areas of bony prominences on the body such as buttocks, elbows, ankles, heels, hips, back (especially around the shoulder blades), back of the head and the coccyx (an area around the tailbone).
You emphasized that bedsores affect bony areas of the body. Why is that so?
Bedsores occur in these areas because these parts of the body generally have less cushion from muscles and fat, making them more prone to pressure effects from pressing on surfaces, which will eventually lead to compression of the skin, its underlying tissues and blood vessels, causing the death of the tissues with sores forming.
Who are those at risk of pressure ulcer?
The main risk for bedsores is immobilisation. It is common among persons who are bed-bound for a long period and also those in wheelchairs or paralysed because they cannot move easily.
Some other risk factors include diabetes mellitus, peripheral vascular disease, neuropathies, stroke, malnutrition, spinal cord injuries, conditions associated with urinary or faecal incontinence and chronic kidney disease. Other risk factors include the elderly age group, smoking and obesity.
Why are people with diabetes and kidney disease at a higher risk?
People with diabetes and kidney disease have a greater risk because of the association with poor wound healing and poor blood supply to tissues from peripheral vascular diseases. Diabetes mellitus, which can cause kidney failure, is also associated with nerve damage which affects sensation and can also hamper the movement of the body. Both conditions cause impaired immunity leading to secondary bacterial infection in the broken-down skin.
Is this skin condition common in public hospitals in Nigeria?
Yes, bedsores are a common occurrence in Nigerian hospitals. A study by Gbeneol et al in Port Harcourt (Rivers State) showed that bedsores are common among patients in the University of Port Harcourt Teaching Hospital.
Since bedsore is caused by a long period of pressure on the skin, how long does it take for it to occur?
Depending on the susceptibility of individuals, bedsores can begin to form as early as one to three hours following the insult to the skin, though the wound may not become obvious until after a few days.
Can you elaborately explain the different stages of the skin condition and the symptoms?
There are four stages in the formation of a pressure ulcer. Stage one is the earliest stage of the disease. At this stage, the skin is not broken but the affected area changes colour to red in lighter skin individuals blue or purple in darker skin tones for more than 30 minutes after pressure was applied to the area. There may be accompanying pain, itching, warmth and swelling of the affected part.
In stage two, the pain and discolouration persist with a breach in the continuity of the skin (wound). There may also be blister formation. In stage three, the wound (ulcer) becomes deeper extending to the deeper layers of the skin up to the fat layer, with marked pain and a foul smell. The wound may drain pus-like material.
In stage four, the ulcer layer extends deeper to the muscles, bones and tendons of the affected part. This is the most severe presentation with the skin turning black, dark hard eschar (dead wound tissue), associated severe pain, foul smell and pus draining from the wound.
At what stage should a diagnosis be carried out?
Pressure sores can be suspected in susceptible individuals (based on immobility and other systemic diseases) right from stage one due to the obvious skin discolouration, pain and other accompanying symptoms. But the diagnosis becomes obvious in stage two with the sore forming.
What does a medical professional look out for during diagnosis?
In evaluating a patient for likely pressure ulcers, a medical professional needs a detailed history from the patient or caregivers. History of being bed-bound and immobilised for long periods. History of other conditions like diabetes mellitus, kidney failure, stroke, dementia, malnutrition, peripheral vascular disease and other predisposing conditions. A proper clinical examination of the patient as a whole, with particular attention to the areas where the ulcer is forming, looking at the features and staging the ulcer.
Is there a general treatment for bedsores or does it depend on the stage?
Treatment of bedsores is usually based on the stage of the disease.
Can you, please, explain in detail the appropriate treatment for each stage of bedsore?
In stage one where there is suspicion of an ulcer forming, the pressure should quickly be removed by adjusting the patient’s position. The area should be clean and dry at all times and friction. Shear and traction should be avoided in this part of the skin. Also, nutrition (high protein diet with calcium and vitamins) and hydration should be optimised.
Stage two treatment is similar to that of stage one. In addition, proper wound dressing should be applied to prevent the wound from getting infected and also keep the area clean and dry.
In stage three, the treatment involves specialised care. The wound has to be thoroughly debrided to remove dead tissues and slough before appropriate dressings can be applied. Also, antibiotics are important in this stage while also using special beds or mattresses, for example, a pneumatic bed, which helps to remove pressure from the affected areas. Appropriate nutrition, hydration and hygiene should be maintained to encourage wound healing.
For stage four pressure ulcers, the patient will likely require surgery. The patient should be adequately prepared for surgery. The wound has to be properly debrided–dead tissue and slough removed and the wound made clean. The patient will also benefit from pain relief, antibiotics and proper nutrition with a high-protein diet.
Are there others?
Other modalities of treatment include negative pressure wound therapy, phototherapy, support surfaces, the use of pressure relieving devices and reconstructive surgery. There should also be management of other background conditions such as diabetes, stroke, kidney failure etc, which will assist with healing. Attention should also be given to the treatment of complications which can arise from bedsores e.g osteomyelitis, sepsis etc.
How long does it take for healing to take place?
The time for healing varies with the different stages of the pressure ulcer. With prompt diagnosis and adequate care instituted, the different stages of pressures will resolve in about two to three days in stage one; three days to two weeks in stage two; and about one to four months in stage three. In stage four, the pressure ulcer lasts very long and may take months to years to heal completely.
Are there specific food, fruits, or vegetables that are medically proven to aid the healing process?
An adequate diet plays a role in wound healing and skin health. A balanced diet with high protein content is required for pressure sores. This should also contain lots of fruits and vegetables. The diet must also include adequate amounts of calcium and vitamins, especially vitamins A, C and E, which are good for the skin; as well as iron, zinc and selenium. Adequate hydration is also essential to aid wound healing.
SOURCE PUNCH