The risk assessment for developing PIs should be structured, including a valid and reliable risk prediction scale, a thorough skin assessment, and a critical interpretation of the results.7 The latter has been emphasized as a key element in identifying potential risk factors that the scales may not cover.8

Risk assessment for PIs assists in the selection of effective preventive interventions, including the frequency of skin assessment and repositioning. Some interventions are directly related to specific risk factors (e.g., managing moisture when present), while others are assigned based on the overall estimated risk score.9 Thus, risk prediction scales highlight vulnerable areas, reinforce the importance of continuous assessment, and support preventive mechanisms.10 In addition, the scales can contribute to epidemiological studies by identifying groups of individuals at risk. Ideally, risk prediction scales for PIs should be used specifically for the population for which they were developed.7 For adult patients in general, the gold standard is currently the Braden Scale,11 which was translated into Brazilian Portuguese in 1999,12 it covers six risk domains: mobility (ability to change and control body position); activity (degree of physical activity); sensory perception (ability to respond appropriately to discomfort related to pressure); moisture (degree of skin exposure to moisture); friction and shear (horizontal forces acting in conjunction with the vertical pressure); and nutrition (usual dietary intake pattern). These domains are scored from one to four (except the last one, which is scored from one to three). The score ranges from six to 23, classifying individuals based on the total score obtained as follows: no risk (score 19‒23), low risk (score 15‒18), moderate risk (score 13‒14), high risk (score 10‒12), and very high risk (score ≤ 9).12

The Braden-Q Scale was modified for children, specifically developed for neonates up to 18-years-old.13,14 More recently, for neonates, the Braden QD Scale has been introduced,15 and it has already been adapted for Brazil.16 The Glamorgan Scale,17 developed for hospitalized children and adapted to Portuguese, has demonstrated higher accuracy than the Braden-Q.18 More recently, it has been applied to pediatric Intensive Care Units (ICUs).19

Patients are at high risk for the development of PIs during surgical procedures. The first scale developed to assess this risk was the Munro Scale.20,21 However, in addition to the intrinsic characteristics of the patient, surgical positioning during the perioperative period becomes the most important challenge in preventing PIs. The ELPO Scale22 developed by a Brazilian nurse for this purpose, is widely used and validated, and utilized in other countries.23,24 Recently, a new scale called PRASI (Proactive Risk Assessment for Skin Integrity) has been introduced, primarily assessing skin integrity.25

For critically ill patients in ICUs, the most studied scales currently, which have already been adapted to Portuguese, are: EVARUCI,26,27 CALCULATE28,29 and Cubbin & Jackson.30,31 Studies have shown that these scales have superior risk prediction compared to the Braden Scale.32,33 In agreement, a systematic review from 2024,34 highlighted that the use of the Braden Scale in ICUs is not recommended due to the inconsistency of its psychometric properties, as it does not fully address the risk factors for this patient profile.34

In addition to scales and clinical judgment, prevention bundles have become more widespread. These are a set of evidence-based interventions that, when implemented together, aim to impact patient outcomes,35,36 including risk assessment, moisture control, patient mobility, nutrition, support surfaces,7 and team training.37 However, in a systematic review, studies on bundles showed bias, particularly in the post-intervention assessment of the application of these measures, indicating that further research is needed to evaluate their effectiveness.38

Clinical awareness and appropriate resource allocation are necessary to prevent PIs.39 Minimizing compressive (pressure) and shear forces at the interface between the body and the support surface or between the body and a medical device are valid clinical interventions to reduce the risk of developing PIs.7

Table 1 lists the main preventive measures recommended for patients at risk of developing PIs, including evidence related to skin assessment and care,7 and preventive dressings (Fig. 1), repositioning,7,37,44,45 bed head,7,40,46 surfaces (bed and mattresses),7,40,47,52 and nutrition.7,40,48–51,53

Fig. 1.

Prophylactic polyurethane foam and silicone dressing on the sacral region in a patient at high risk for developing pressure injuries.

Assessment of tissue viability in the injury bed involves identifying devitalized or non-viable tissue, which hinders the healing process and facilitates infections.1 Removal of devitalized tissue (debridement) is essential, including slough, necrotic tissue, debris, toxins, microorganisms, and biofilm, both in the ulcer bed and in the peri-wound area, as well as hyperkeratosis.70

Cleaning or hygiene is the first step in the process. Its primary goal is to minimize microbial load and remove surface contaminants, debris, and microorganisms from the wound, aiming to establish a clean environment that reduces the risk of infection and promotes the formation of healthy granulation tissue.65,70 Cleaning also ensures better visualization of the wound bed and access to non-viable tissue.7,70 Proper hygiene should be performed on the wound bed and the peri-wound skin.1,55 It is primarily recommended to use 0.9% sodium chloride solution or clean (drinking) water for irrigation.71

Therefore, in cases of hard-to-heal PIs, it is necessary to clean both the wound and the peri-wound area with antiseptic products suitable for skin (Ph 4–6), such as Polyhexamethylene Biguanide (PHMB).71

Debridement, on the other hand, is a critical step in wound bed preparation, aiming to remove barriers that impede the healing process.65 Its goal is to remove necrotic and sloughy tissue, reduce bacterial load, and eliminate biofilm.1 It contributes to removing fibroblasts and keratinocytes that undergo phenotypic changes (senescence), leading to chronic inflammation, fibrosis, and delayed healing.72 Thus, debridement converts chronic wounds stagnated in the inflammatory phase into an environment more similar to acute wounds, promoting healing.1,73 The following non-viable tissues require management with debridement (Fig. 2):

• •

  Necrotic tissue: Resulting from localized tissue death due to infection or ischemia. It may appear black, brown, or Gray, and can be dry (generally non-infected) or moist (often infected), and is usually adhered to the wound bed.

• •

  Slough: A complex mixture of exudate proteins, degraded extracellular matrix proteins, white blood cells, and various microorganisms in planktonic and biofilm phenotypes.70

The different types of debridement are described in Fig. 2. Integrated debridement involves combining debridement methods according to the individual needs of the patient, preferences, and environment, as well as available resources and the skills of healthcare professionals.70 In addition, professionals need to be aware of the contraindications for each procedure. Surgical debridement, for example, should be carefully evaluated in patients on anticoagulants, those with a high surgical risk, or those who have ischemia, especially if the wounds are extensive.1 Other debridement methods, such as autolytic or mechanical debridement, are less invasive and require less training, making them more widely used.70 However, autolytic debridement (e.g., with hydrogels and hydrocolloids) is not the method of choice in cases of active infection with large amounts of devitalized tissue (e.g., gangrenous tissue). In these cases, surgical debridement should be considered.”

Infection and inflammation prevent healing and are crucial factors to be monitored.74

Local infection is characterized by the presence and proliferation of microorganisms within the wound, triggering a host response that often causes delayed healing.75 Local infection is confined to the wound and the immediate peri-wound area (less than 2 cm) and often presents with subtle signs and symptoms that may not be immediately recognized, such as hypertrophic granulation tissue, bleeding, friable granulation, epithelial bridges, formation of pockets in the granulation tissue, and increased exudation.75

Almost all chronic wounds contain biofilms, complex community structures surrounded by an extracellular polymeric substance secreted by various pathogenic bacteria to evade host defenses and increase resistance to antimicrobial drugs.76,77 Combined with laboratory and clinical studies, biofilm in the wound can manifest as a thin layer of yellowish, gelatinous, and translucent material visible to the naked eye.78 Additionally, it can be present both on the surface and in deep tissues, stimulating chronic inflammation and delaying the healing process.77 Surgical debridement is the gold standard for removing biofilm, making the wound clean and conducive to repair by temporarily disrupting the mature biofilm.77 In addition, there is treatment with nanotechnology where dressings containing silver or zinc ions compete with the extracellular polymeric matrix of biofilms for binding sites, reducing the intercellular adhesion of pathogenic bacteria.77

In general, topical antibiotics alone are no longer recommended for wounds, as they may promote the development of bacterial resistance.1 Antiseptics rarely induce antimicrobial resistance.1 A wide range of antiseptics is available, like povidone iodine, cadexomer iodine, chlorhexidine, PHMB, silver (nanocrystalline or ionic), octenidine, reactive oxygen, and hypochlorous acid. However, according to a systematic review, the effects of topical antimicrobial treatments on PIs are not clear, and the quality of the evidence ranges from moderate to very low.79

Signs of deep infection, such as increased erythema, foul odor, warmth, increased exudate, fever, new or increasing pain, and elevated white blood cell count, should be treated with systemic antibiotics, and wound care should be done using topical treatments similar to those used for local infections.75 Other indicators, such as slow healing after two weeks of standard treatment, discoloration of granulation tissue to pale or dark tones instead of healthy red, and friable tissue, indicate possible infection in wounds.40

In disseminated infection, such as cellulitis, microorganisms invade the surrounding tissue, spreading from a lesion, and the signs and symptoms extend beyond the wound edges. Disseminated infection can involve deep tissues, muscles, fascia, organs, or body cavities, with possible signs of increasing induration, lymphangitis, crepitus, wound dehiscence with or without satellite lesions, and widespread inflammation or erythema greater than 2 cm from the wound edge.75 Systemic infection is the phase in which microorganisms spread throughout the body via the vascular or lymphatic systems, eliciting a host response. A local wound infection can also trigger the systemic inflammatory response through other pathways, such as toxin release or a dysregulated immune system. Symptoms may include malaise, lethargy or general nonspecific deterioration, fever/pyrexia, severe sepsis, septic shock, organ failure, and death.75

Routine wound culture is not recommended when there is no suspicion of infection. However, when a clinical diagnosis of disseminated and systemic infection is made, an ulcer culture method is recommended to confirm the initial diagnosis, identify resident microorganism species, and determine effective antibiotics to treat the wound. Current literature provides three laboratory techniques for diagnosing wound infections: deep tissue biopsy, needle aspiration, and swab culture. A blood culture should also be performed in the case of systemic infection.75

Deep wounds or those with bone exposure are susceptible to osteomyelitis, which is better detected by magnetic resonance imaging or bone biopsy, and requires intravenous antibiotic therapy,1 based on culture results.40 However, clinical diagnoses related to PIs have been discussed. A systematic review found that no alternative diagnostic method (clinical, microbiological, or radiological) is reliable for diagnosing osteomyelitis associated with pelvic PIs.80 Another systematic review81 describes osteomyelitis in the sacral region, which is the most affected area by PIs according to incidence studies.2 In this review, bone biopsy remains the only accurate diagnostic method, but osteomyelitis is relatively rare in patients with stage 4 sacral PIs.81 Furthermore, it indicates that short-term antibiotics can treat acute soft tissue infections, with a duration of 2- to 6-weeks depending on the infection's depth; there is no evidence to support extending treatment beyond 6-weeks.81 More recently, a review explains that evidence remains inconclusive for microbiological and histological diagnoses, suggesting that bone biopsy remains limited for patient management.82 This highlights the importance of understanding patient frailty and the underlying evidence for bone biopsy in order to consider changes in clinical management and the risk-benefit ratio.

One of the keys to wound care is maintaining the ideal moist environment, aiming to create a balanced setting that facilitates healing.83 However, when a wound exhibits either excessive or insufficient exudate production, it can hinder the healing process and cause damage to the surrounding skin.1

Considerations include the characteristics of the exudate regarding its quantity, color, odor, viscosity, potential constituents, and appearance.84 Purulent, hemorrhagic-purulent, or seropurulent exudate may indicate infection. Additionally, color and odor can indicate microbial influence in the wound, including biofilm and infection.1

Dressings are considered to have a unique potential for addressing issues related to exudate.83 Selecting a dressing that manages the exudate from PIs and protects the peri-wound skin, as maceration and continuous contact with exudate hinder the healing process.40 Viscous exudate requires different management than thin watery exudate, as products designed to handle thin exudate may become blocked by viscous exudate, reducing absorption and causing buildup in the dressing.1 Low-viscosity exudate can be managed using a variety of absorbent dressings, including foams, calcium alginates, gelling fibers, superabsorbent dressings, multilayer dressings, polymer pads, and Negative Pressure Wound Therapy.1

Low moisture levels can be treated with products that donate fluid to the wound, such as hydrogels and hydrocolloid dressings.1

Monitoring the epithelial margin guides the management approach to optimize the necessary conditions. The quality of the wound bed is crucial to facilitating epithelial advancement from the edges.1

The edge needs to be assessed to see if it has hyperkeratotic tissue, epibole (rolled edge), or is not advancing, and the edges should be clean and level, as this facilitates epithelial migration.70

The implementation of advanced therapies for repair should only occur once risk factors are addressed in difficult-to-heal wounds. Some experts limit the use of advanced therapies to wounds that have responded to standard treatment by less than 40%‒50% in four weeks.1

Different technologies can be selected based on their suitability for the wound and the patient’s characteristics. These technologies include topical and systemic interventions (Fig. 2).1 When epithelial advancement is slow, several alternatives can accelerate the process. In the field of regenerative medicine, based, for example, on tissue engineering, it could be an interesting option in patients with difficult-to-treat ulcers, such as patients with spinal cord injuries.85 The findings from the systematic review suggest that cell-based therapies present a promising approach for improving PI outcomes, however, more extensive research is needed on this topic.86

The latest technologies for regeneration include mesenchymal and epidermal stem cells, which can be applied to promote tissue regeneration; 3D bio-printing technologies to create biomimetic structures that facilitate healing; genetic therapy and gene editing to modify cellular behaviours; nanotechnology with nanomaterials used as drug carriers or to promote wound healing through controlled release of bioactive substances; and biomimetic scaffolds that develop acellular scaffolds mimicking the extracellular matrix to guide tissue regeneration.87

Another therapy that has gained prominence is Platelet-Rich Plasma (PRP). However, it should be noted that it is still in the early stages of use, and possible variations need to be analyzed. A recent systematic review concluded that PRP stands out as a promising and safe therapeutic approach for injuries, but to improve the quality of the evidence, there is a need for new high-quality randomized clinical trials.88

It encompasses overall health and well-being, including physical and psychological factors, and the impact on the patient's lifestyle.1 Listening to and understanding the patient is key to treatment; involving them in their care and decision-making can improve outcomes and adherence.89 The most negative impact on the quality of life of individuals with PIs occurs in the social dimension. PIs affect both patients and their caregivers by limiting their ability to carry out daily activities and making them more dependent on healthcare services and support environments.90

The patient should be assessed holistically, including sleep, physical activity, and extrinsic factors such as family and health care facility support. Interdisciplinary actions are essential to alleviate potential problems and risks, particularly related to the proper management of odor and pain, which contribute to low self-esteem, depression, and social stigma.55,91

Palliative wound care is a complex discipline that differs significantly from conventional wound treatment, with the primary goal being symptom relief and the provision of empathetic care by healthcare professionals.92 Factors that classify a wound as palliative include unmodifiable risk factors or medical conditions such as malnutrition with sarcopenia, inadequate perfusion, multisystem organ failure, immunocompromised states, anasarca, metastatic cancer, and a terminal prognosis that hinders normal healing processes.69 A palliative approach can alleviate suffering, enhance quality of life, and reduce healthcare costs by avoiding futile and/or painful procedures and unnecessary expenses.69

Education among the patient, family, and healthcare professionals is essential to promote understanding and define the desired care goals.93

Another current concept has defined the importance of the peri-wound area, even including it at the end of TIMERS as PW (peri-wound).55 This area deserves attention, as it may have hyperkeratosis, erythema, maceration, eczema, xerosis, contact dermatitis (both allergic or irritant), or infection.67,94Fig. 2 shows the main measures directed at each condition in this area.

Surgical management is usually reserved for recalcitrant wounds or wounds with full-thickness skin loss and exposure of deeper structures such as muscle, fascia or bone (stage 3 and 4 – Table 2).55,95,96 Reconstructive surgery usually includes debridement of the wound, followed by filling the wound with new tissue. The surgical approach involves a multidisciplinary team, including the expertise of a plastic surgeon. A systematic review to assess the effects of different types of reconstructive surgery for treating PI, compared with no surgery or alternative reconstructive surgical approaches, included only one randomized clinical trial.97 This trial included 20 participants with stage 4 ischial or sacral PI. The study compared two reconstructive techniques: conventional flap surgery and cone of pressure flap surgery, in which a large portion of the flap tip is de-epithelialized and deeply inset to obliterate dead space. The outcomes about complete wound healing, wound dehiscence, PI recurrence and wound infection were collected. The evidence for these outcomes as very low certainty. The authors concluded that there is very little randomized evidence on the role of reconstructive surgery in PI management, although it is considered a priority area. More rigorous and robust research is needed to explore this intervention.

It is important to emphasize that the choice of any dressing or product should consider TIMERS, the location and size of the lesion, particularly in advanced therapies. Another consideration is the cost-effectiveness and making choices that are appropriate and consistent with the patient's social condition and treatment goals, with a focused approach whenever relevant to infection/biofilm, as many products are incompatible and should not be used on infected wounds.1

Based on guidelines,7,55 the most used indications according to the classification of PIs were summarized in Table 2. An algorithm based on the Depth, Infection, and Perfusion (DIP) classification is also useful to clinicians in the initial evaluation, classification, and management of PI.95,96