​​​Backgroun​d

Pressure Injur​​ies

PIs are skin lesions caused by unrelieved pressure or shear resulting in damage to underlying tissue. Wounds often develop over bony prominences (sacrum, ischium, trochanter, and heel) in wheelchair- or bed-bound patients. Prolonged ischemia in the underlying tissue leads to necrosis and eventually an open wound. Preventing PIs is a primary goal in any at-risk patient. Patients typically undergo a risk assessment that includes a comprehensive history and physical examination. Pressure redistribution is key to PI prevention and involves using pressure-reducing devices and support surfaces. Multilayer foam dressings may be placed over bony prominences to relieve loading pressures over at-risk areas. This report examines the evidence supporting advanced dressing as a preventive measure for at-risk individuals. (See the UptoDate article Prevention of Pressure-induced Skin and Soft Tissue Injury.)

Foam Dres​​sing

Foam dressings have two layers, a hydrophilic silicone or polyurethane-based foam inner layer and a hydrophobic, gas-permeable outer layer. The foam collects exudate, and the outer layer prevents leakage and bacterial contamination. Foam dressings include Tegaderm Silicone Foam Dressing (3M, Saint Paul, MN, USA), Aquacel Foam Dressing (Convatec, Bridgewater, NJ, USA), Allevyn (Smith & Nephew, London, UK), Kendall Foam Dressing (Cardinal Health, Dublin, OH, USA), and Mepilex Border Flex (Mölnlycke Health Care US, Peachtree Corners, GA, USA).

Hydrocolloid D​​ressing

Hydrocolloid dressings contain gel-forming agents attached to a polyurethane film. The colloid portion absorbs exudate to form a gel and create a moist wound environment. Hydrocolloid dressings include Tegaderm Hydrocolloid Dressing, DuoDerm CGF Border Dressing (Convatec), Comfeel Plus (Coloplast Corp., Minneapolis, MN, USA), and Cardinal Health Hydrocolloids.

Film Dre​ssing

Film dressings are transparent, synthetic, self-adhesive sheets that allow gases, including oxygen and water vapor, to pass through the sheet but maintain a barrier to proteins and bacteria. These dressings have limited absorptive ability, are not appropriate for moderately to heavily exudative wounds, and are often used to cover other dressings. Film dressings include Tegaderm Transparent Film Dressing, Opsite Film Dressings (Smith & Nephew), and Kendall Transparent Film Dressing (Cardinal Health).

​Clinical​​ Literature

Search dates: all available literature published from January 1, 2017, through November 30, 2022. We reviewed full text of 5 SRs reporting on 15,771 patients (some patient overlap is likely).

We searched PubMed, Embase, and selected web-based resources for documents relevant to this topic. Our search strategies included the following keywords: "wound dressing" AND "pressure ulcer." Please see the Selected Resources and References section for detailed search strategies.

Study selection criteria: We sought SRs that compared advanced wound dressings with other types of advanced or basic dressings and reported on patient-oriented PI outcomes, primarily PI incidence, in patients at risk for developing a PI. Because of the large retrieval, we selected the best available evidence and included SRs only.

We identified and reviewed full text of five published SRs.

Included studies:

• 1 SR (Gong and Xu 2022, 11 studies, n = 5,150) assessed prophylactic sacral protective dressings (9 of 11 studies used a foam dressing) and reported PI incidence.(1)
• 1 SR (Lovegrove et al. 2022, 6 prophylactic dressing studies, n = 1,522) assessed PI preventive interventions (foam and hydrocolloid) in intensive care settings and reported PI incidence for the sacrum and heel.(2)
• 1 SR (Rahman-Synthia et al. 2022, 11 studies, n = 3,410) assessed hospital-acquired PI prevention using silicone foam dressings and reported PI incidence.(3)
• 1 SR (Sillmon et al. 2021, 14 studies, n = 3,170) assessed PI prevention using silicone foam dressings.(4)
• 1 SR (Cai et al. 2019, 22 RCTs, n = 2,519) assessed PI prevention using hydrocolloid dressing in patients on noninvasive ventilation.(5)

See Table 1 for SR summaries. We review full text of the included studies available through open access or our library subscriptions.

We also identified but excluded from review three SRs that meet the inclusion criteria but were superseded by a later and more comprehensive SR.(6-8)

​Findings

We assessed five SRs that addressed advanced wound dressing use for preventing PIs.

• Multiple dressing types:
• An SR (Gong and Xu 2022) reported that sacral dressing protection (mostly foam dressings examined) significantly reduced PI incidence compared with no sacral protection. (Odds ratio, 0.39; 95% confidence interval [CI] 0.28 to 0.53, p <0.001).(1)
• An SR (Lovegrove et al. 2022) reported prophylactic dressings (foam, hydrocolloid, hydrocellular, and thin foam) significantly reduce PI incidence at both sacrum (relative risk [RR] 0.22, p <0.001) and heel (0.31, p <0.02).(2)

• ​​Foa​m:

• An SR (Rahman-Synthia et al. 2022) reported silicone foam dressing significantly reduced PI incidence compared with usual care (RR 0.30, 95% CI 0.19 to 0.45, p <0.01). Subgroup analysis showed similar reduction of PI incidence in intensive care and nonintensive care settings.(3)

• An SR (Sillmon et al. 2021) reported sacral foam dressings reduced hospital-acquired PI (no meta-analysis).(4)

• ​​Hydrocolloid: An SR (Cai et al. 2019) reported hydrocolloid dressings significantly reduced facial PI incidence caused by noninvasive ventilation (odds ratio 0.15, 95% CI 0.11 to 0.20) compared with no dressing controls.(5)

Evidence limitations: The SRs consistently reported that foam and hydrocolloid dressings reduced PI incidence. Small sample size was the primary limitation noted by SR authors. Larger studies may be informative.

Table 1. Systematic Reviews on Prevention

​Guidelines, Position and Consensus Statements

Searched PubMed, Embase, and ECRI Guidelines Trust® (EGT) for relevant documents published January 1, 2016, through November 28, 2022. We reviewed five documents.

We searched ECRI Guidelines Trust and prominent specialty societies for clinical practice guidelines, consensus statements, and position statements published from January 1, 2016, through November 28, 2022. We sought guidelines that are clearly supported by published SRs or that meet certain U.S. National Academy of Medicine criteria.

Guidelines S​upported by Systematic Review

• Health Improvement Scotland. Standards for Prevention and Management of Pressure Ulcers. 2020. The guideline presents information on standards required for prevention and management of PIs but does not provide specific standards for dressing use.
• European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injures: Quick Reference Guide. 2019. The guideline has numerous recommendations related to preventing and treating PIs. The full Clinical Practice Guideline includes the SR. The guideline made the following primary statements regarding dressings for PI prevention:

Develop and implement a risk-based prevention plan for individuals identified as being at risk of developing [PIs].

Use a soft silicone multi-layered foam dressing to protect the skin for individuals at risk of [PIs].

• Japanese Society of Pressure Ulcers. Wound, Pressure Ulcer and Burn Guidelines - 2: Guidelines for the Diagnosis and Treatment of Pressure Ulcers, Second Edition. 2018. The guideline's goals are “systematically presenting evidence-based recommendations to support clinical decisions in the prevention, care and treatment of pressure ulcers, serving as a tool for improving the quality of diagnosis and treatment of pressure ulcer patients, and improving the care for pressure ulcers in Japan as a whole." The guideline designated recommendations as 1 (strong) and 2 (weak) and strength of evidence as A (strong evidence), B (moderate evidence), C (weak), and D (very weak). The guideline made the following recommendations:
  

The application of a polyurethane film (1A), polyurethane foam (1A), polyurethane foam/soft silicone (1A) or the like to bone protrusions for the prevention of pressure ulcers is recommended.

• European Union Seventh Framework Program. Non-pharmacological Interventions to Prevent or Treat Pressure Ulcers in Older Patients: Clinical Practice Recommendations. 2016. This document contains recommendations for non-pharmacological interventions for older subjects at risk of developing PIs] as well as for older subjects with PIs.
• Wound, Ostomy and Continence Nurses Society (WOCN). WOCN Guideline for Prevention and Management of Pressure Ulcers. 2016. The guideline provides specific recommendations for assessing, preventing, and treating PIs. The guideline made the following recommendation regarding dressings: “Consider prophylactic dressings to prevent sacral and heel ulcers in at-risk patients. Level of Evidence = A (Benefit/Effectiveness/Harm = Class I)."