A 70-year-old female presented with a 1-year history of bedsore. On her right greater trochanter and sacrum, two 3cm-diameter size ulcers showed full -thickness skin loss with subcutaneous tissue necrosis but no exposure of muscle or bone (Fig. 1, Fig. 2). NPIAP Stage-3 decubitus ulcer was diagnosed . Treatment was begun with topical herbal medicine HLQ ointment [2-4] dressed with cotton wool and gauze. HLQ ointment dressing was replaced daily. Patient’s family member recorded ulcer recovery progress with photographs (Fig. 1, Fig. 2); ulcer healed in 5 months.
Any form of mechanical trauma to the skin can result in the formation of an ulcer if factors that compromise the skin’s ability to recover from physical insults are present. The most common form of the ulceration are bedsores, also called pressure ulcers or decubitus ulcers (decubitus means lying down in Latin), which are caused by unrelieved pressure to soft tissues compressed between a bony prominence and an external hard surface.
Risk factors include
- Age > 65 (possibly due to reduced subcutaneous fat and capillary blood flow)
- Unrelieved mechanical pressure in combination with friction, shearing forces, and moisture (due to prolonged hospital stay, bed rest, spinal cord injury, sedation, weakness that decreases spontaneous movement, and/or cognitive impairment)
- Exposure to skin irritants (due to urinary incontinence and/or fecal incontinence)
- Impaired circulation for wound healing (due to undernutrition, diabetes)
- Impaired tissue perfusion (due to peripheral arterial disease, immobility, venous insufficiency)
- Decreased sensation
When soft tissues are compressed for prolonged periods between bony prominences and external surfaces, microvascular occlusion with tissue ischemia and hypoxia occurs. Pressures exceeding normal capillary pressure (range is 12 to 32 mm Hg) result in reduced oxygenation and compromise the microcirculation of the affected tissue. If compression is not relieved, a pressure ulcer can develop in 3 to 4 hours. The most common bony prominences involved are the sacrum, ischial tuberosities, greater trochanters, heels, and lateral malleoli .
Treatment includes pressure reduction, avoidance of friction and shearing forces, and diligent wound care. Sometimes, skin grafts or myocutaneous flaps are needed to facilitate healing.
- Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Continence Nurs, 43(6), 585-597. doi:10.1097/won.0000000000000281
- Tony Tang Yuqi, Wang Feng, Li Fangzhou, et al. Second Degree Burn Healed in 10 Days with Herbal Formulated HLQ Ointment. Dermatol Res. 2021; 3(1); 1-3.
- Wang Feng, Li Yuanxin. Non-operative self-healing of intestinal fistula after appendix cancer. Tsinghua Changgeng Hospital Bulletin. 2018. Accessed on August 2020.
- Wang Feng, Li Yuanxin. Intestinal fistula with abdominal hemorrhage. Tsinghua Changgeng Hospital Bulletin. 2018. Accessed on August 2020.
- Olesen CG, de Zee M, Rasmussen J . Missing links in pressure ulcer research — an interdisciplinary overview . J Appl Physiol 2010;108:1458–64 .