Pressure ulcers and hydrocolloids Made Easy
21/11/11 | Complex wounds, Pressure ulcers, Skin integrity | Fletcher J, Moore Z, Anderson I, Matsuzaki K.
Pressure ulcers pose a significant challenge to healthcare systems, and subject patients to considerable discomfort, pain and indignity. Although every effort should be made to prevent pressure ulcers, not all can be prevented. This article discusses the role of hydrocolloid dressings in the management of Category/Stage I and II pressure ulcers (Box 1).
The scale of the problem
The true frequency and associated cost of pressure ulcers is not known. Estimates suggest that in Europe approximately 18% of inpatients may have a pressure ulcer. In 2004, it was estimated that the total cost of pressure ulcer care accounted for about 4% of UK National Health Service expenditure (approximately £2 billion). Furthermore, in the UK between 2003 and 2008, pressure ulcers were directly attributed as a cause of death in 4,708 people. In the USA, it is believed that in the hospital sector the costs associated with pressure ulcers may be as high as $11 billion per annum.
Hydrocolloids and pressure ulcers
Hydrocolloids are widely used in the management of pressure ulcers5. They have been recommended for use in Category/Stage II and III pressure ulcers6, and increasingly are being used in the management of Category/Stage I pressure ulcers.
What is a hydrocolloid dressing?
Hydrocolloid dressings are made from a layer of gel-forming material attached to a semi-permeable film or foam backing. The gel layer comprises an adhesive matrix that contains a combination of absorbent materials such as sodium carboxymethylcellulose, pectin and gelatin. The resulting dressing is absorbent and self adhesive, even in moist conditions.
Even though different hydrocolloid dressings may look similar, their fluid handling abilities can differ markedly9. Many hydrocolloid dressings are available in a variety of shapes, sizes and thicknesses. These may include products designed for specific anatomical areas (eg the sacrum or heel). Some products are very thin or have tapered edges that make them less likely to wrinkle, ruck or roll at the edges. These thinner products may also be semi-transparent allowing visualisation of the wound without the need to remove the dressing.
Variations in the backing materials may alter the 'slipperiness' of the dressing. Dressings that have a more 'slippery' outer surface reduce the coefficient of friction between the support surface and the patient, and so reduce the amount of shear and friction transmitted to the underlying skin. In this way, they may help to reduce the risk of further damage.
Many of the more recently available hydrocolloid dressings, including some thicker products, combine tapered edges and a smooth backing surface.
How do hydrocolloid dressings work?
Hydrocolloid dressings are believed to have a number of key properties that are useful in the management of pressure ulcers including:
- production of a moist wound environment
- management of exudate
- facilitation of autolytic debridement
- provision of a barrier to micro-organisms
- helping with pain management.
Creating an optimal environment for healing
Hydrocolloid dressings create a moist wound environment that is known to be beneficial to wound healing11. Specifically, hydrocolloids are believed to promote angiogenesis, increase the number of dermal fibroblasts, stimulate the production of granulation tissue, and increase the amount of collagen synthesised.
The moisture retentive properties of hydrocolloids help to gently soften and rehydrate necrotic tissue and slough, aiding autolytic debridement. This may take longer than sharp or biosurgical debridement (eg larval therapy), but may be more appropriate in some situations.
Prevention of infection and cross-infection
Hydrocolloids are adhesive and waterproof, and some hydrocolloids have been shown to act as a viral and bacterial barrier (eg to methicillin-resistant Staphylococcus aureus (MRSA), hepatitis B virus (HBV) and the human immunodeficiency virus (HIV-1)) provided the dressing remains intact and without leakage[12-14]. Hydrocolloid dressings may therefore be advantageous for use in areas such as the sacrum that are regularly subjected to heavy contamination. Several studies have examined whether the occlusive nature of hydrocolloid dressings increases the risk of infection. However, no evidence has been found to suggest that this is the case[15,16].
Protection of newly forming skin or Category/Stage I pressure ulcers
A hydrocolloid dressing with a smooth slippery backing reduces the friction coefficient of the patient-support surface interface. The reduction in friction means that the patient is able to move more easily over the support surface and the area covered by the dressing is likely to be exposed to lower levels of pressure, shear and friction[7,18], reducing the risk of a Category/Stage I pressure ulcer progressing to deeper damage.
Semi-transparent hydrocolloid dressings may be used over reddened skin (Category/Stage I pressure ulcers) as it is possible to observe for deterioration without removing the dressing.