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A Grade 4 pressure ulcer is the most severe type of pressure ulcer. The skin is severely damaged, and the surrounding tissue begins to die tissue necrosis. The underlying muscles, bone or joint may also be damaged [ Figure 1d ], sometimes very severely [ Figure 1e ]. People with grade four pressure ulcers have a high risk of developing a life-threatening infection.

Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, for example, tendon or joint capsule.

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Undermining and sinus tracts may be associated with this stage of wound progression. Similar to grading a burn with the addition of a stage 4 that is deeper than a stage 3 ulcer or 3 rd degree burn. Where possible, treatment of ulcers is planned with an aim to reverse the factors that have originally caused the ulcer. Ulcers are often the result of combined pathology like diabetes, pressure, loss of sensation.

Careful assessment is needed before planning for treatment. In general the possible causative factor should be removed pressure, shear, friction and the associated general condition should be taken into the control like treatment of associated co-morbid illness and improvement in the nutrition. The affected area requires thorough cleaning and dressing. The limb must be elevated to improve the venous and lymphatic drainage, and the part must be given some rest from the weight bearing, pressure and friction.

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However, since the full range of motion and active physiotherapy of joints do improve circulation, even non-weight bearing physiotherapy is desirable. Wound healing requires adequate protein, iron, Vitamin-C and zinc. Supplements may be prescribed if they are deficient in the diet. Rest of the management of ulcer depends on many factors, and Table 3 illustrates an algorithm to help formulate a treatment plan. Various treatment options are available to treat pressure ulcers, they include:.

Cleaning of the wound and meticulous skin care are the most essential part of the treatment. The process involves removal of surface contamination and meticulous excision of all dead tissue. This is debridement. Besides the conventional surgical debridement other types of debridement like mechanical debridement which includes use of repeated wet to dry dressings to removes slough,[ 26 ] enzymatic debridement using enzymes to liquefy dead tissue in the wound and remove them with the dressings,[ 27 ] and biological debridement or maggots and larval therapy[ 28 , 29 ] in which the larvae eat all the dead tissue and make the wound clean without harming the living tissues also find a mention in literature.

Maggots also help to fight infection by releasing substances that kill bacteria and stimulate the healing process. Dead tissue may be removed using mechanical means.

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Some mechanical debridement techniques include:. Where dead tissue is removed using high-pressure water jets. There is no evidence available to support any specific and effective cleansing techniques or solution, in particular. Dead tissue is removed using low-frequency energy waves. Dead tissue is removed using focused beams of light. Basically, debridement is done for converting the chronic wound into an acute wound so that it can progress through the normal stages of healing.

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The dressing used for various stages of wound healing is specialised for every stage; in fact there is a whole range of dressings available to assist with the different stages of wound healing. These are classified as non-absorbent, absorbent, debriding, self-adhering and many others. Dressings are usually occlusive, so the ulcers heal better in a moist environment.

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If the ulcer is clean and dry, occlusive dressings are usually changed weekly, and more frequent changes are avoided as dressing changes remove healthy cells along with debris. Contaminated or weeping wounds may require more frequent dressing changes, sometimes every few hours.

Heavily contaminated ulcers are treated with negative pressure wound therapy NPWT. Specialised dressings and bandages are used to protect and speed up the healing process of the pressure ulcers. These dressings include:. These contain a special gel that encourages the growth of new skin cells in the ulcer and keeps the nearby healthy area of skin dry.

These are made from seaweed that contains sodium and calcium known to speed up the healing process. Honey-impregnated alginate dressings are known to accomplish total wound healing to pressure ulcers. These use the antibacterial property of silver to clean the ulcer.

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To prevent further tissue damage and help speed up the healing process, topical preparations, such as cream and ointments are frequently used. All pressure sores do not require antibiotics. If tissue infection exists, antibiotics are necessary to treat the infection, but effort must be made to debride the ulcer thoroughly and leave all viable tissues only, otherwise antibiotics alone will not clean up the ulcer.

Antibiotics are adjunct to surgical debridement and not an alternative to it. Topical antibiotics should be avoided because their use may increase antibiotic resistance and allergy. Antiseptic cream may also be applied topically to pressure ulcers to clear out any bacteria that may be present.

It has been noticed that the longstanding pressure ulcers are frequently colonised by micro-organisms in a biofilm. The biofilm may be composed of bacteria, fungi or other organisms, which are embedded in and adherent to the underlying wound. The organisms are protected from the effect of conventional antibiotics; unnecessary prescription of antibiotics may, in fact, select more resistant organisms.

We address the problem of biofilm by changing the pH of the wound — dressing with dilute ascetic acid if it is alkaline, which it usually is and curetting out all the underminings, cracks and crevices of the ulcer or by surgical debridement. This is an invaluable tool in the management of pressure sores and involves the application of sub-atmospheric pressure to a wound using a computerised unit to intermittently or continuously convey negative pressure to promote wound healing.

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NPWT, is effective for deep, cavitating, infected and copiously discharging pressure ulcers, particularly with exposed bone. There are many supportive therapies to promote healing of pressure ulcers.

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While some are in clinical use others are in the realm of research. Many products are available to aid wound healing but should be prescribed only under strict medical advice, as they still require further research to determine their effectiveness. These include:.

Growth factors and cytokines. Hyperbaric oxygen HBO to increase tissue oxygen tension. Skin graft substitutes bioengineered skin. Epidermal stem cells. Chronic pressure ulcers display high levels of inflammation and disruption of the collagen matrix, along with increased indications of apoptosis and decreased levels of growth factors and their receptors. These characteristics can be used to comprehensively evaluate the aetiology and treatment of these ulcers. Patients with the greatest amount of healing showed higher levels of platelet-derived growth factor on day 10 and transforming growth-factor beta-1 on day Message for the bFGF gene was upregulated after treatment with exogenous bFGF, suggesting autoinduction of the cytokine.

Both cytokines and growth factors may have a big role to play in the treatment of pressure ulcers in future.

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Hyperbaric oxygen therapy HBO is being used for treatment of pressure sores. Specially constructed devices equipped with controlled pressure sealings, and automatic relief valves are fitted in HBO chambers. A constant pressure of 22 mm Hg 1. It facilitates growth of new capillaries angiogenesis improving the microcirculation.

It reduces infection by eliminating bacteria directly and increasing capacity of white blood cell to fight infection. Cultured keratinocytes have been used for the treatment of various types of wounds for more than a decade. However, it is difficult to apply collagen matrix to pressure ulcers, because they are usually accompanied by infection with discharge of excessive amounts of exudate or pus and generally exposed to external forces that prevent graft fixation.

The aim of such therapy is to repair, replace or restore the biological function of a damaged tissue or organ. Bone Marrow BM -mono nuclear cells MNCs can be easily obtained in large numbers by aspiration without extensive manipulation or cultivation before transplant and cells can be transplanted directly without in vitro expansion. Using the entire mononuclear fraction, no potentially beneficial cell type is omitted and MNCs from a patient's own BM promote angiogenesis[ 46 ] and this seems to be a key factor for optimal healing of skin wounds. Marrow stem cells MSCs , which make up a small proportion of BM-MNCs, secrete paracrine factors that could recruit macrophages and endothelial cells to enhance wound healing.

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