褥瘡会誌（Jpn J PU），16（1）：12〜90，2014― 12 ―

JSPU Guidelines for the Prevention and Managementof Pressure Ulcers（3rd Ed.）
The Japanese Society of Pressure Ulcers Guideline Revision Committee
1)

Committee Chairperson : *Ryoji Tsuboi
2)
Vice Chairperson : Makiko Tanaka
3)
4)5)Committee Members : Takafumi Kadono , Yayoi Nagai , Katsunori Furuta ,6)7)8)Yasuhiro Noda , Yusuke Sekine , Toshiko Kaitani ,
9)
10)
11)
Hitomi Kataoka , Hiromi Nakagawa , Taku Iwamoto ,
12)
13)
14)
Masakazu Kurita , Mikio Kinoshita , Yuta Kurashige ,
15)
16)
17)
Gojiro Nakagami , Shoko Kakizaki , Masami Hidaka ,
18)
19)
20)
Hideyuki Hirose , Masaharu Sugimoto , Masako Miyajima ,
21)
22)
23)
Madoka Noguchi , Mayumi Okuwa , Mihoko Ishizawa ,
24)

25)

26)

Yukiko Kinoshita , Masayo Sobue , Yoko Murooka ,27)
28)
Yuko Matsui , Tomoko Ohura
29)
30)
22)
Advisers : Chizuko Konya , Shigeru Ichioka , Junko Sugama ,
26)
16)
31)
Hideko Tanaka , Kayoko Adachi , Takeo Nakayama
32）
Trustee : Yoshiki Miyachi
1 ) Tokyo Medical University, Department of Dermatology; 2 ) Yamaguchi Prefectural University, Faculty of
Nursing and Human Nutrition; 3)University of Tokyo Faculty of Medicine, Department of Dermatology; 4)Gunma University Graduate School of Medicine, Department of Dermatology; 5)National Center for Geriatrics
and Gerontology, Department of Clinical Research and Development; 6 ) Kinjo Gakuin University College of
Pharmacy; 7)Tokyo Medical University Hospital, Department of Pharmacy; 8)Sapporo City University School of
Nursing, Adult Nursing; 9)Yamagata University School of Medicine, Department of Nursing; 10)Yokohama Soei
University Faculty of Nursing; 11)Tomei Atsugi Hospital, Department of Plastic Surgery; 12)Kyorin University
School of Medicine Department of Plastic Surgery; 13)Tokyo-Nishi Tokushukai Hospital, Department of Plastic
and Reconstructive Surgery; 14 ) Tokyo Medical University Hachioji Medical Center, Department of
Dermatology; 15)University of Tokyo Graduate School of Medicine, Division of Health Science and Nursing,
Department of Gerontological Nursing/ Wound Care Management; 16 ) Sempo Tokyo Takanawa Hospital,
Department of Clinical Nutrition; 17)Hyogo University of Health Sciences, School of Rehabilitation, Departmentof Physical Therapy; 18)Research Institute, National Rehabilitation Center for Persons with Disabilities; 19)
Kobegakuin University Faculty of Rehabilitation; 20)Wakayama Medical University, Department of Health andNursing Sciences; 21)Kobe University Hospital; 22)Kanazawa University Faculty of Health Sciences, Institute ofMedical, Pharmaceutical and Health Sciences; 23 ) Nara Medical University School of Medicine, Faculty of
Nursing; 24)Gifu University Hospital Health Administration Center; 25)JA Aichi Konan Kosei Hospital; 26)
Shukutoku University School of Nursing and Nutrition; 27)Kanazawa Medical University, School of Nursing,
Department of Human Science and Fundamental Nursing; 28 ) Seijoh University Faculty of Care andRehabilitation, Division of Occupational Therapy; 29 ) Kanazawa Medical University School of Nursing; 30 )Saitama Medical University, Department of Plastic and Reconstructive Surgery; 31)Kyoto University School of＊Correspondence : Ryoji Tsuboi, MD, PhD
Department of Dermatology, Tokyo Medical University
6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan
Tel & Fax :（+ 81）-3-3340-1855
E-mail : tsuboi@tokyo-med.ac.jp― G− 1 ―― 13 ―

Public Health, Department of Health Informatics; 32)Kyoto University Graduate School of Medicine, Departmentof Dermatology.
Abstract
The Japanese Society of Pressure Ulcers（JSPU）has compiled an English version of the updated third edition of the
Guidelines for the Prevention and Management of Pressure Ulcers. The guidelines set forth here include a collection anddiscussion of medical issues specific to Japan as well as new evidence from research conducted abroad. Clinical questions（CQs）and their analyses were organized in the order of treatment followed by prevention: topical agents, dressings,
surgical intervention, general management, rehabilitation, risk assessment, skin assessment, skin care, repositioning,support surfaces, patient education, outcome management, and QOL/pain. Each recommendation was assigned one of fiveratings（A, B, C1, C2 and D）.A CQ discussing the so-calledXwrap therapyYused in Japan was also included. As a new
approach, algorithms and flow-charts were prepared for each topic. The present guidelines provide the best and mostcomprehensive recommendations currently available to health care professionals worldwide.

Introduction
1．BackgroundIn 2005, the Japanese Society of Pressure Ulcers
publishedXGuidelines for Local Treatment of Press1）
ure UlcersY and followed this in 2009 by a revised
edition,X Guideline for Prevention and Management2）of Pressure Ulcers . The current guidelines represent the culmination of an effort headed by the Fourth
Academic Education Committee to present an up-todate set of guidelines in article format incorporating
new evidence collected since the publication of thelast edition. In addition to these new guidelines, a
handbook designed for quick reference, containing
photographs and diagrams to facilitate the prevention
and management of pressure ulcers, has been
published.
While Europe and North America jointly published
NPUAP/EPUAP guidelines for pressure ulcers in3）2009 , the guidelines set forth here were designedwith due consideration of medical issues specific toJapan. This fact, together with the volume and qualityof the data gathered, as well as the recommendation

4）A journal-style format consisting of discussion oftreatment followed by that of prevention.
5）Inclusion of algorithms and flow-charts.
2．Purpose and Scope
The purpose of the present guidelines is to provide
the best and most comprehensive recommendations
possible, based on the most recent and reliable
evidence, for the treatment of pressure ulcers for the
benefit of the full range of health care professionals
who are in any way involved in the management andprevention of this condition. Crucially, the recommendations offered in the guidelines have beenformulated with a view to addressing the special
needs of such health care professionals in theirrespective clinical settings and to helping them tomake the best clinical decisions possible in theircircumstances.
It should be noted that while these guidelines aim tobe comprehensive in their scope, they are also
designed to maximize the expertise and experience of
the individual health care professional and theresources available in each particular clinical setting
in order to achieve the best possible outcome forratings provided, make the current set of guidelines
fundamentally superior to the latest revised edition in

individual patients and their family or caretakers. Bymeans of these new guidelines, we hope to set a newterms of clinical utility.
Special attention was paid to a number of issues in
the compilation of the new guidelines, including thefollowing:

and higher standard for pressure ulcer care in Japanthrough improvements in the quality of pressure
ulcer prevention and management, as well as in the
better guidance which health care professionals will

1）The addition of new Clinical Questions（CQs）.
2）The inclusion of CQs reflecting the latest medical issues and the recommendations tailored specifically to the conditions of clinical practice.
3 ）The inclusion of a CQ on the so-calledX wrap
therapyYused in Japan.

be able to offer patients and their families.
3．Guideline Developers
The present guidelines are the result of a collaborative effort between members of the Fourth Academic
Education Committee of the Japanese Society ofPressure Ulcers（see list of authors）,and incorporate― G− 2 ―― 14 ―

some of the aims and contents of theXGuidelines for
1）
Local Treatment of Pressure Ulcers Y （ first ed.,2005 ）and theX Guideline for Prevention and Man2）
agement of Pressure Ulcers （Second edition, 2009）.
A list of those who participated in the development ofequipment, materials, topical medications, and dressings mentioned in the present guidelines are
obtainable in Japan. If any are unavailable in Japan,

these past editions is presented below, by way of
acknowledging their valuable efforts.
1）
First Edition（2005）
Yoshiki Miyachi（ Chairperson ）, Hiromi Sanada（Vice Chairperson）, Junko Sugama, Takao Tachibana,The criteria for determining the evidence levels andratings for recommendation of the present guidelines
were formulated with reference to the Japanese
5）
Guidelines for the Management of Stroke 2009, theMotonari Fukui, Katsunori Furuta, Toshiko Kaitani,
Keiko Tokunaga, Toshio Nakajo, Yoshio Mino, Takehiko Oura, Hiroaki Oka, Masahiro Tachi, Toru Fujii,
Takahiko Moriguchi, Takeo Nakayama, Takashi
Nagase, Masaharu Sugimoto, Masami Hidaka.
2）Second Edition（2009）
Masutaka Furue（ Chairperson ）, Hiromi Sanada（ Vice Chairperson ）, Takao Tachibana, Takafumi
Kadono, Toshiko Kaitani, Hiroaki Oka, Takashi
Nagase, Masahiro Tachi, Takeo Nakayama Makiko
Tanaka, Mayumi Okuwa, Junko Sugama, NorikoMatsui, Yukie Kitayama, Keiko Tokunaga, Kayoko
Adachi, Shingo Okada, Masami Hidaka, Hideyuki
Hirose, Chizuko Konya.
4．Method1）Sources of Evidence
The databases used to assemble relevant information were MEDLINE（ Pubmed ）, Ichushi online
database, CINAHL, and ALL EBM Reviews which
include the Cochrane Database Systematic Reviews,
ACP Journal Club, Database of Abstracts of Reviewsof Effect（DARE）and Cochrane Central Register ofControlled Trials（ CCTR ）. The information was
sourced from various other relevant guidelines, aswell as data assembled by individual contributors.
This information was assembled from January, 1980
to June, 2011. Systematic reviews and clinical trials,
especially randomized clinical trials, were prioritized.
When these sources were unavailable, observational
studies such as cohort studies and case-control studies
were collected. In the event that the latter were
unavailable, the range of acceptable sources was
expanded to include case series. As a rule, evidence
dealing chiefly with the outcome index was prioritized; however, for the Clinical Questions dealing withnursing, evidence focusing on QOL as the chiefoutcome measure was also used. Animal studies andbasic research was not included. As a rule, medical

this fact has been duly noted.
2）Evidence level and recommendation rating

Minds Reference Guide 2007 for Writing Clinical4）
Practice Guidelines, and Clinical Practice Guidelines
6）for Skin Cancer .
（1）Classification of Evidence Levels
Ⅰ：Systematic reviews/ meta-analysesⅰ）Randomized controlled trials onlyⅱ）Randomized controlled trials, cohort studies, case-control studiesⅲ）Sources not including i）and ii）
Ⅱ：Randomized controlled trials
Ⅲ：Non-randomized controlled trials（Including historical controlled trials,* and selfcontrolled studies）
Ⅳ：Analytical epidemiological research（in cohort
studies and case-control studies）（Includes retrospective cohort studies, historical controlled studies,**time series analyses, selfcontrolled studies）
Ⅴ : Descriptive studies（case reports and case series）（Including non-controlled intervention studies
and cross-sectional studies）
Ⅵ : Expert opinion of specialist committees orindivi-duals. Not based on patient data.
The evidence levels of each guideline used todetermine the recommendation ratings have not been
described.
*An historical controlled trial is a form of intervention study done in order to test the efficacy of a newform of treatment, and requires approval by the ethics
committee of the relevant institution before it isperformed. Unlike the randomized controlled study inwhich subjects are divided into a randomized
intervention group and the control group, and theoutcomes for each group are compared, the historicalcontrolled trial examines cases which were observed
at some time in the past for a comparison of theirtreatment outcomes with those of the intervention
group receiving a new treatment.
**An historical controlled study, like the historical― G− 3 ―― 15 ―

controlled trial, examines cases which were observed
at some time in the past for comparison with anintervention group receiving a new form of treatment.
However, it differs from the historical controlled trailin that it is a form of observational study conducted asa part of daily consultation rather than an intervention
study conducted for the purposes of testing a newform of treatment.
（2）Recommendation Ratings
Ａ：Strongly recommended because supported
by adequate evidence.
Ｂ：Recommended because supported by someevidence
C1：May be considered because supported bylimited evidence
C2：Not recommended because no supporting
evidence found
Ｄ：Not recommended because of invalid or

dealing with injuries and cutaneous ulcers as well. In
such cases, however, the strength of the recommendation was accordingly lowered.
The endorsement of the guideline committee was
required for inclusion into the guidelines of treatments which earned the rating C1, insofar as suchtreatments were deemed valuable for clinical practice,even if they lacked sufficient evidence.
5．Funding and Conflict of Interest
Funding for the compilation of the present guidelines was provided entirely by the Japanese Society ofPressure Ulcers and does not derive in any part fromother organizations or industries. Further, the content
of each rating was decided by a vote of the guideline
revision committee. If any member of the guideline
revision committee was found to have a conflict ofpossibly harmful findingse* Evidence fis defined as the findings of clinical
trials and epidemiological research.
（3）Criteria for Determining Recommendation Rating
The criteria for determining the recommendation
ratings have been carried over from the previous
1, 2）
editions A rating of A therefore requires one Level I
or high quality Level II source of evidentiary support.
However, any systematic review not dealing exclusively with randomized controlled trials weakens thestrength of the rating. A rating of B requires at least
one source of inferior quality Level II or high quality

interest in connection with any item, he or she was
asked to abstain from voting on the item in question.
6．Definition of Terms
The definition of the terms used in the present
guidelines conforms to that laid down by theTechnical Definitions Committee of the JapaneseSociety of Pressure Ulcers. A separate set of terms
was prepared herein for use with the DESIGN and
DESIGN-R scales published by the Japanese Society ofPressure Ulcers to reflect the unique history anddevelopment of this project.
7．Peer Reviews and Plans for Future Revisions
The present guidelines were made possible by thecontributions and peer reviews of numerous members

Level III evidence, or failing this, an extremely highquality source of Level IV evidence. However,randomized controlled trials with small numbers ofsubjects and industry sponsorship earn a lower rating.

of the guideline revision committee and based on theunanimous approval of all of the members, arrived atthrough the process of debate and discussion. During
this process, feedback from other members of the

A rating of C1 requires an inferior Level II-IV, or ahigh quality Level V, source of evidence, or alterna-

Japanese Society of Pressure Ulcers was sought at
two symposia held by the Society. Members were also

tively a Level VI evidence source endorsed by thecommittee. A rating of C2 is based on sources lacking
valid evidence, or providing invalid evidence, while arating of D is based on high-quality sources withencouraged to submit their opinions via the Societyfswebsite.
The present guidelines will be revised under theleadership of the Academic Education Committee ofinvalid or harmful findings.
The commentary and recommendations in guide-

the Japanese Society of Pressure Ulcers at intervals of
every several years.

lines published outside Japan were referred tofrequently for their value in helping us to establish thecriteria for determining the ratings presented here.
In some of the CQs for which there was a paucity ofevidence relating directly to pressure ulcers, the1 ）Japanese Society of Pressure Ulcers: Guideline forrange of sources was broadened to include those2 ）Japanese Society of Pressure Ulcers: Guideline for

References
local treatment of pressure ulcers, Shorinsha, Tokyo,
2005.

― G− 4 ―― 16 ―

Prevention and Management of pressure ulcers,
Shorinsha, Tokyo, 2009.
3）European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel: Prevention andtreatment of pressure ulcers: clinical practice guideline. National Pressure Ulcer Advisory Panel,
Washington DC, 2009.
4）The Minds Committee on Clinical Practice Guidelines:
The Minds Reference Guide 2007 for Writing Clinical
Practice Guidelines, IGAKU-SHOIN Ltd., Tokyo, 2007.
5）The Joint Committee on Guidelines for the Management of Stroke: Japanese Guidelines for the Management of Stroke 2009, KYOWA KIKAKU Ltd., Tokyo,
2009.
6）Saida T, Manabe M, Takenouchi T, et al : The Committee on Clinical Practice Guidelines for Skin Cancer:
Clinical Practice Guidelines for Skin Cancer. Jpn J
Dermatol, 117（12）, 1855-1925, 2007.

From DESGIN to DESIGN-R
In 2002, the Academic Education Committee of theJapanese Society of Pressure Ulcers announced the
DESIGN（Depth, Exudate, Size, Inflammation/Infection and Necrosis）scale in answer to needs: namely,
first, the need for a means of assessing pressure ulcers
according to severity, and second, for a means ofquantifying aspects of the treatment process in termsof the wound parameters of depth, exudate, size,
inflammation/infection, granulation, and necrosis.
Although scales with similar purposes, such as the1）
Bates-Jansenf
s Pressure Sore Status Tool（PSST） ,2）
NPUAPfs Pressure Ulcer Scale for Healing（PUSH） ,and Ohura fs Assessment of Pressure Ulcer-Healing
3）
Process（PUHP） have already been put to practicaluse, each scale presents some difficulties which
DESIGN attempts to address. DESIGN was developedon the basis of expert opinion and incorporates fourfeatures, namely, its ability to: 1）quantify severity ofpressure ulcers and the healing process 2）monitor
intervention in term of each of the parameters
mentioned above and changes in wound surface 3 ）provide a standard and convenient tool for use in theclinical setting and 4）be compatible with international standards for care and intervention.
In order for such a scale to be readily accepted, it
was necessary to test its inter-rater reliability, content
validity, construct validity, concurrent validity andpredictive validity. When DESIGN was developed,

testing of its predictive validity was omitted

5−8）

with
the result that questions were raised as to its fitness toquantitate the severity of patients fconditions,although there was no question as to its ability toassess changes in the condition of individual cases.
Thus with a view to realizing a scale which would
enable the health care professional not only toevaluate pressure ulcer progression but also predict
its severity reliably and accurately, revision of thescale was begun in 2005. Since DESIGN had alreadybeen widely used clinically, some preconditions werecalled for, that is, the seven parameters measured by
DESIGN-P（P indicatesepocketforeunderminingf）were to remain unaltered. In order to make thisfeasible, first, a large-scale（2598 cases）retrospective
case-series study was conducted, followed by aprospective case-series study with 1003 cases. For
each study, a large number of subjects were enrolled
in both the healing and non-healing groups using theCox hazard analysis.
As a result, the parameters were ranked according
to their weight as follows: pocket, size, inflammation/
infection, granulation tissue, exudates, and necrosis. A
positive correlation was found among these parameters, excluding inflammation/infection, where ahigher degree of severity was accompanied by a
9−11）
. In
higher weighting of the individual parameters
terms of background information, a comparatively
large number of aged persons were enrolled. The
facilities examined were mostly university hospitals
and the number of home care settings was small.
However, when Cox hazard analysis was conductedusing these factors as adjusted variables, there was nochange in weighting, demonstrating that the bias interms of the age and types of institution had no effect9）

on the scalefs weighting.
In order to make the statistically calculated
weightings more convenient for clinical use, theweighted values were simplified to be multiples of 3.
Comparison of the weightings before and after theirsimplification showed that correlation was high at 0.
991 while also affirming that the procedure did not
influence severity evaluation. Finally, the depth
parameter values were found to be unrelated to theweighted values but rather to reflect the status of thepressure ulcer. For this reason it was not included in
the total score. In order to draw attention to the factthat weighting had been added as a novel feature, the― G− 5 ―― 17 ―

name of the scale was changed from DESIGN to
DESIGN-R witheRfstanding forerating.fIn 2008

Education Committee of the Japanese Society of

DESIGN-R was published and has since been widelyused throughout the Japan as a pressure ulcer
assessment scale with acceptable predictive validity.

DESIGN-R total score can predict pressure ulcer

Pressure Ulcers. Clinical wound assessment using
healing: pooled analysis from two multicenter cohort
studies. Wound Repair Regen, 19（5）: 559-567, 2011.

References
Algorithm for Prevention and Managementof Pressure Ulcers1）Bates-Jansen BM, Vredevoe DL, Brecht M: Reliabilityof the pressure sore status tool. Decubitus, 5（ 6 ）:20-28, 1992.
2 ）National Pressure Ulcer Advisory Panel: Pressure
ulcer scale for healing（PUSH）,1998.
3）Ohura T : Practical Guide for Pressure Ulcer Care.
Shorinsha Inc, Tokyo, 102-109, 2001.
4）Ohura T, Miyachi Y, Sanada H, et al : The pressure
ulcers state rating system: How to put and usage of
the DESIGN. Shorinsha Inc, Tokyo, 6-9, 2003.
5）Moriguchi T, Miyachi Y, Sanada H, et al : DESIGN-A
new assessment tool for the classification and thehealing process in pressure ulcers-. Jpn JPU, 4（1）：1-7, 2002.
6）Sanada H, Tokunaga K, Miyachi Y, et al : DESIGNReliability of the new pressure ulcer assessment tool-.
Jpn JPU, 4（1）：8-12, 2002.
7）Sanada H, Moriguchi T, Miyachi Y, et al : Reliability
and validity of DESIGN, a tool for that classifies
pressure ulcer severity and monitors healing. Wound
Care,13（1）: 13-18, 2004.
8 ）Matsui Y, Sugama J, Sanada H, et al : Predictive
validity and weighting of D-E-S-I-G-N: A woundhealing progression tool. Jpn JPU, 7（1）：67-75, 2005.
9）Tachibana T, Matsui Y, Sugama J, et al : The Reportof arts and sciences Board of Education- Revision of
DESIGN-. Jpn JPU, 10（4）：586-596, 2008.

The decision tree（Fig. 1）illustrates the process
by which procedures for the prevention and/or
management of pressure ulcers in the target population may be designed.
First, subjects are given a general physical examination and their risk of developing pressure ulcers
is assessed. In cases in which there is no risk ofdeveloping pressure ulcers, the condition of thesubject continues to be monitored regularly. In cases
where there is risk of developing pressure ulcers, local
inspection of the skin is performed and the presenceor absence of pressure ulcers is confirmed. In theabsence of pressure ulcers, a suitable regimen of
preventive care（ Fig. 6 ）or general care（ Fig. 4 ）may be designed and implemented. If a pressure ulcer
is found, Fig. 7 or 5 may be consulted in order todesign an effective care regimen for treatment. Fig. 2
and 3 may be also consulted in order to determine themost suitable treatment modality, such as conservative treatment or surgical intervention. Following
successful implementation of this phase of patientcare, risk of further occurrence（ or recurrence ）ofpressure ulcers, the patientfs general physical condition, and state of existing pressure ulcers may beassessed as appropriate.

10）Matsui Y, Furue M, Sanada H, et al : Development ofTable of Clinical Questions（CQ）s andthe DESIGN-R with an observational study: an

Accompanying Recommendations

absolute evaluation tool for monitoring pressure ulcer
wound healing. Wound Repair Regen, 19（ 3 ）: 309315, 2011.

Clinical questions（CQ）s and their accompanying
recommendations are shown in Table 1〜13.

11 ）Sanada H, Iizaka S, Matsui Y, et al : Scientific― G− 6 ―― 18 ―

Fig. 1 Algorithm illustrating options for prevention and management of pressure ulcers― G− 7 ―― 19 ―

Table 1
Clinical Question

Topical agentsRatingRecommendation

CQ 1.1

Which topical agents are recommended totreat acute pressure ulcers?

C1

Oleaginous preparations such as zinc oxide, dimethyl isopropylazulene,
white petrolatum, with a high degree of efficacy in protecting woundsurfaces, and silver sulfadiazine may be considered.

CQ 1.2Which topical agents are indicated in caseswith suspected deep tissue injury(DTI)?

C1

Close monitoring of the wound is important. Oleaginous preparations suchas zinc oxide, dimethyl isopropylazulene and white petrolatum may beconsidered.

CQ 1.3Which topical agents are recommended forcases involving redness/purpura?

C1

It is important in cases of redness/purpura to protect the wound surfaces.
Dimethylisopropylazulene and white petrolatum may be used for thispurpose.

CQ 1.4Which topical agents are recommended forcases involving blistering?

C1

White petrolatum or zinc oxide may be used to protect the wound surface.

CQ 1.5Which topical agents are recommended totreat erosions and shallow ulcers?

C1

Zinc oxide or dimethyl isopropylazulene may be used. Alprostadil alfadex,
bucladesine sodium, or lysozyme hydrochloride may also be used topromote re-epithelialization.

CQ 1.6

Are topical agents recommended if pain
accompanies the pressure ulcer?

C2

There is no evidence supporting the use of topical agents to alleviate pain.

B

CQ 1.7Which topical agents are recommended forpressure ulcers with excessive exudate?

Cadexomer-iodine and povidone-iodine sugar are both highly absorbant
and are recommended for pressure ulcers with excessive exudate.

C1

Dextranomer and iodine ointment may be considered.

CQ 1.8Which topical agents are recommended inpressure ulcers with minimal exudate?

C1

Ointments with emulsion bases are preferred. Silver sulfadiazine may beconsidered to treat infected wounds while tretinoin tocoferil may beconsidered to treat uninfected wounds.

CQ 1.9How should a pressure ulcer be cleaned?

C1

Cleanse the pressure ulcer using isotonic saline or tap water in sufficientquantities to reduce the microbial count on the wound surface.

CQ 1.10 How should pressure ulcers be disinfected?

C1

Wound cleansing is usually adequate to prevent infection. However, if thewound is clearly infected or if there is excessive exudate or pus, the wound
may be disinfected using antiseptics prior to cleansing.

Which topical agents are recommended forCQ 1.11 pressure ulcers accompanied by infection andinflammation?

B

Cadexomer-iodine, silver sulfadiazine, and povidone-iodine sugar are
recommended for their ability to control infections.

C1

Fradiomycin sulfate-trypsin, povidone-iodine, iodine ointment, and iodoform gauze may be considered.

B

Aluminium chlorohydroxy allantoinate, trafermin, tretinoin tocoferil andpovidone-iodine sugar, all of which are known to accelerate granulation
formation, are recommended.

C1

Alprostadil alfadex, bucladesine sodium, or lysozyme hydrochloride may
be considered.

C1

Topical medications with an anti-microbial properties, such as cadexomeriodine ointment, povidone-iodine sugar, iodine ointment, or silver sulfadiazine may be used.

B

Alprostadil alfadex, aluminum chlorohydroxy allantoinate, trafermin,
bucladesine sodium, and povidone-iodine sugar are recommended.

C1

Zinc oxides, dimethyl isopropylazulene, extract from hemolyzed blood ofyoung calves, and lysozyme hydrochloride may be used.

Which topical agents are recommended toCQ 1.12 accelerate granulation formation in pressure
ulcers with deficient granulation formation?
Which topical agents are recommended in
CQ 1.13 pressure ulcers with deficient granulation
formation and suspected critical colonization?
Which topical agents are recommended forCQ 1.14 wound reduction in pressure ulcers with
sufficient granulation formation?
CQ1.15Which topical agents are recommended if
necrotic tissue is observed?

C1

Cadexomer-iodine, silver sulfadiazine, dextranomer, bromelain or
povidone-iodine sugar may be considered.

CQ 1.16

Which topical agents are recommended when
undermining has occurred?

C1

If the undermining is covered by necrotic tissue, the wound surfaces
should first be cleaned. Also, if there is excessive exudate, povidone iodinesugar may be used. If the amount of exudation is minimal, consider using
trafermin or tretinoin tocoferil.

― G− 8 ―― 20 ―

Table 2

Dressings

RatingRecommendation

CQ2.1

Which dressings are recommended totreat acute pressure ulcers?

C1

In order to protect the wound surface while allowing daily monitoring of the condition,transparent film dressings or dressings designed to treat dermal wounds may be used.

CQ 2.2Which dressings are indicated inpressure ulcers with suspected deep
tissue injury(DTI)?

C1

In order to protect the wound surface while allowing daily monitoring of the condition,either transparent film dressings or dressings designed to treat dermal wounds may beconsidered.

CQ 2.3Which dressings are recommended
for pressure ulcers involving redness/purpura?

C1

In order to protect the wound surface while allowing daily monitoring of the condition,either film dressings or dressings designed to treat transparent dermal wounds may beconsidered.

CQ 2.4Which dressings are recommended
for cases involving blistering?

C1

While leaving the blisters intact, consider using a transparent film dressing to protect thewound surface. A dressing for dermal wounds that allows observation may also be
considered.

B

A health insurance-covered hydrocolloid dressing used to treat dermal wounds isrecommended. A hydrocolloid dressing used to treat subcutaneous wounds is also an
option, but is not covered by health insurance.

C1

Health insurance-covered dressings designed to treat dermal wounds, such as hydrogel,polyurethane foam sheets, alginate foam dressing, and chitin membrane may beconsidered. Dressings designed to treat subcutaneous wounds, such as hydrogel,hydropolymer, polyurethane foam, polyurethane foam/soft silicone, alginate, and chitin
membrane can also be employed with equal effect, but are not covered by healthinsurance.

C1

Dressings cannot remove pain but can lessen it by protecting the wound surface andmaintaining a moist environment conducive to wound healing. When changing dressings,
perform adequate pain assessment and apply a hydrocolloid, polyurethane foam,
polyurethane foam/soft silicone, Hydrofiber®, chitin membrane, or hydrogel.

B

Recommend using polyurethane foam dressings, which can absorb excess exudates.

C1

Dressings normally used for subcutaneous wounds as well as dressings used to treat
deeper wounds involving muscle and bone, such as alginate/CMC, polyurethane foam/softsilicone dressings, alginate, alginate foam, chitin membrane, Hydrofiber®, or hydropolymer
dressings, may be applied.

B

Using a hydrocolloid dressing is recommended.

C1

Using a hydrogel may be considered.

C1

Consider using topical agents to suppress infection. Alternatively, silver-containing
Hydrofiber® or alginate silver may be used.

C2

Alginate is sometimes used to dress wounds with excessive exudates because of its
superior absorptive ability, but cannot be recommended here due to its inability tosuppress infection.

Which dressings are recommended
for promoting granulation tissue
CQ 2.10formation in pressure ulcers where it
is deficient?

C1

Alginate, hydrocolloid, hydropolymer, polyurethane foam, polyurethane foam/soft silicone,chitin membrane and Hydrofiber® may be considered.

Which dressings are recommended inpressure ulcers with deficient graCQ 2.11
nulation tissue formation and suspected critical colonization?

C1

Consider using silver-containing Hydrofiber® or alginate silver.

B

Using silver-containing Hydrofiber®, alginate silver, or alginate is recommended.

C1

Hydrocolloid, hydrogel, hydropolymer, polyurethane foam, polyurethane foam/softsilicone dressing, alginate foam, chitin membrane, Hydrofiber®, alginate/CMC are also
options, depending on the amount of exudate present.

Clinical Question

CQ 2.5Which dressings are recommended
for treating erosions or shallow
ulcers?

CQ 2.6

Which dressings are recommended
for pressure ulcers involving pain?

CQ 2.7Which dressings are recommended inpressure ulcers with excessive exudate?

CQ 2.8CQ 2.9Which dressings are recommended
for pressure ulcers with minimal
amounts of exudates?

Which dressings are recommended
for infected and inflamed pressure
ulcers?

Which dressings are recommended topromote the reduction of the size of
CQ 2.12
wounds with adequate/normal granulation tissue formation?
CQ 2.13Which dressings are recommended
when necrotic tissue is present?

C1

If surgical debridement or topical agents capable of removing necrotic tissue areunavailable, hydrogel may be considered.

CQ 2.14Which dressings are recommended if
undermining is found?

C1

If necrotic tissue is present within the undermining, first remove this through lavation. If
the amount of exudate is excessive, consider using alginate, silver-containing Hydrofiber®,or alginate silver.

C1

Wrap dressings can be considered for use whenever medically approved dressings areunavailable or difficult to obtain on a continual basis, such as in a home based medical care.
However, use of the wrap dressing should be supervised by a physician with an adequate
knowledge of pressure ulcer care and only after the patients and their family have been
instructed in the procedure and given their consent.
e* Wrap dressing fis a dressing technique of covering wounds with non-medicallyapproved(unsterilized)and non-adhesive commercially available plastic wrap.

CQ 2.15Is the so-calledewrap dressingf* effective in treating pressure ulcers?

― G− 9 ―― 21 ―

Table 3Clinical Question

Surgical Intervention

RatingRecommendation

C1

Surgical debridement may be conducted if there is evidence of pus, foulodor, or osteomyelitis accompanying the infection.

C1

Surgical debridement may be considered when a clear line of demarcation
between necrotic and healthy tissue is visible.

C1

Surgical debridement is considered when preexisting infection has beenbrought under control.

C1

Surgical incision or debridement may be considered for treating
undermining which fails to respond to more conservative treatments.

C1

Conservative treatments are the preferred option, but surgical debridement may be performed when infection/inflammatory signs are undercontrol.

C1

Surgical debridement may be considered for patients with a D3 or D4
pressure ulcer.

C1

Surgical debridement may be considered according to the location of theinfected pressure ulcer, the volume and extent of the necrotic tissue, theblood supply to the surrounding tissue, and the patient's level of pain
tolerance.

C1

Reconstructive surgery may be considered for D3~D4 pressure ulcers that
do not respond to conservative treatment.

C1

Surgical reconstruction may be considered for ulcers showing a nonadvancing edge and scar formation.

C1

Reconstructive flap surgery following sequestration may be considered asa therapeutic option for osteomyelitis in pressure ulcers.

CQ 3.6

Which reconstructive surgical procedure isconsidered especially effective for pressure
ulcers?

C1

There are numerous options for reconstructive surgery for pressure
ulcers, but insufficient evidence on the outcome of any of these procedures.
For this reason, no single surgical procedure can be recommended as
applicable to all cases.

CQ3.7

What kind of physiotherapy is recommended
for pressure ulcers with low amounts of
granulation tissue?

C1

Negative pressure wound therapy（NPWT）may be considered for thetreatment of wounds following debridement of infectious or necrotic tissue.

CQ3.1

Is surgical debridement indicated when signsof infection/inflammation of the pressure
ulcer are present?

CQ3.2

What is the optimal timing for the surgicaldebridement of necrotic tissue in pressure
ulcers?

CQ 3.3

CQ3.4

CQ3.5

Is surgical incision or debridement recommended if undermining is present?

When is surgical debridement indicated?

When is reconstructive surgery indicated?

― G− 10 ―― 22 ―

Table 4General management

Clinical Question

Recommendation

CQ4.1

Which underlying medical conditions may
entail the risk of leading to pressure ulcers?

C1

Pelvic fractures, diabetes mellitus, cerebro-vascular diseases,
and spinal cord injuries potentially lead to pressure ulcer
formation due to patient immobility.

CQ4.2

What form of nutritional intervention isrecommended for the prevention of pressure ulcers in malnourished patients?

B

For patients suffering from protein-energy malnutrition（PEM）,using a enhanced energy and protein supplement afterdue consideration of any underlying conditions is recommended.

CQ4.3

How should patients incapable of oral intake
of nutrition and hydration be fed?

C1

Consider supplying the required nutrition by enteral tubefeeding. When this is not possible, consider parenteral feeding.

C1

In the absence of inflammation or dehydration, serum albumin
levels may be used.

C1

Rate of weight loss may be considered for use.

C1

Consider using the rate of food intake or the amount of foodconsumption as an index.

C1

Consider using Subjective Global Assessment（SGA）.

C1

Mini Nutritional Assessment（ MNA ）may be used withelderly patients.

C1

If physical examination findings or test results indicate
advancing cellulitis and osteomyelitis, necrotizing fasciitis,
bacteremia, or sepsis, consider administering systemic antibiotics. If only symptoms of local infection are found, administrationof systemic antibiotics need not be considered.

Preventive
generalmanagement

CQ4.4

Generalmanagement after
occurrence

RatingWhat indices can be used to assess the levelof malnutrition as a risk factor for pressure
ulcers?

CQ4.5

When is the systemic administration of
antibiotics（antimicrobials）indicated in patients with an infected pressure ulcer?

CQ4.6

Which antibiotics（ antimicrobials ）are recommended for treating infection?

C1

Consider using empiric antibiotics to suspected pathogens
common in clinical settings. Reconsider using more specificantibiotics to pathogens by referring the results of susceptibility
testing.

CQ4.7

Which underlying conditions may pose arisk of prolonging the healing of pressure
ulcers?

C1

Malignant tumors and cardiovascular diseases should beconsidered as factors which may prolong the healing of pressure
ulcers.

CQ4.8

Should a nutritional screening and assessment be performed for pressure ulcer
patients?

C1

A nutritional screening and assessment and nutritional
intervention may be considered if required.

B

In order to ensure adequate energy for healing of pressure
ulcers, recommend providing patients with 1.5 times the basal
energy expenditure（BEE）.

B

Recommend providing additional protein as required.

Should the diet of pressure ulcer patients be
supplemented with any specific nutrients?

C1

Patients fdiet may be supplemented with zinc, arginine, andascorbic acid to prevent deficiencies of these nutrients.

Should a registered dietician or multidisciCQ4.11 plinary nutritional team participate in thecare of pressure ulcer patients?

C1

Participation by a registered dietician or multidisciplinary
nutrition support team in the care of pressure ulcer patients
may be recommended.

Should body weight be used as a means of
CQ4.12 assessing the efficacy of nutritional supplementation in pressure ulcer patients?

B

Recommend using body weight as a means of assessing theeffectiveness of nutritional supplementation if edema or
dehydration can be ruled out.

CQ4.9

CQ4.10How much nutrition in general should be
provided to pressure ulcer patients?

― G− 11 ―― 23 ―

Table 5 Rehabilitation
Clinical Question
Risk
assessment

Preventive
care

Care after
occurrence

Conservative
treatment

RatingRecommendation

CQ 5.1

Which factors account for pressure ulcer
development in chronic spinal cord injury
patients?

B

For patients with a history of pressure ulcers, vigilance isrecommended to prevent recurrence.

CQ 5.2Which methods are effective for preventingpressure ulcer development in spinal cord
injury patients?

C1

Conducting rehabilitation while monitoring interfacepressure may be considered.

CQ5.3

What type of cushion should be used withelderly patients in a seated position to prevent
pressure ulcers?

B

A pressure-redistributing seat cushion for individuals
with spinal cord injury is recommended to prevent
pressure ulcer development while seated.

CQ5.4

Should limitations be set on the length of timein which the individual remains continuously
seated?

B

Limitations on sitting time should be set if the elderly
individual is unable to reposition without assistance.

CQ5.5

At what intervals should the seated individual
be repositioned?

C1

Repositioning every 15 min is recommended for seatedindividuals who are capable of changing their body
position without assistance.

CQ5.6

Should the individualf
s posture while seated beconsidered?

C1

The alignment and balance of the seated individual fsbody should be considered.

CQ5.7

Should donut-type devices be used?

D

Donut-type devices are not recommended.

CQ5.8

What kind of physical modality can be used totreat muscular atrophy?

C1

Consider using electric stimulation therapy.

CQ5.9

What kind of therapeutic exercise can be used
to treat joint contracture?

C1

Consider using passive range of motion exercises.

CQ5.10Should tissue overlying bony prominences bemassaged?

D

Massaging areas covering bony prominences is notrecommended.

CQ5.11

How can daily use of the wheelchair by patientswith shallow pressure ulcers be facilitated?

C1

A suitable sitting posture, an appropriate supportcushion, and limitation on sitting time may be considered.

CQ5.12

What kind of physical modality can be used forpatients with infected pressure ulcers?

C1

Hydrotherapy may be considered.

CQ5.13What kind of physical modality can be used forpressure ulcers containing necrotic tissue?

C1

Consider hydrotherapy or pulsatile lavage with orwithout suction.

B

Implementing electrical stimulation therapy is recommended.

C1

Near infrared therapy, ultrasonic therapy, or electromagnetic therapy may be considered.

CQ5.14

What kind of physical modality can be used topromote wound reduction?

Table 6
Clinical Question

Risk assessment
RatingRecommendation

CQ6.1

Is risk assessment effective in predicting the development of pressure ulcers?

B

Use of risk assessment scales is recommended for predicting
pressure ulcer development.

CQ6.2

Which risk assessment scale should generally be
used?

B

Use of the Braden Scale is recommended for most situations.

CQ6.3

What method of assessment used for elderly patients?

C1

Assessing the risk factors for pressure ulcer development may beconsidered.

Which risk assessment scale is recommended for use
with the elderly?

C1

The OH Scale may be used with bedridden elderly patients.

CQ6.4

C1

The K Scale may be used with bedridden elderly patients in
hospital.

CQ6.5

Which risk assessment scale is recommended forpediatric patients?

C1

The Braden Q Scale may be considered for risk assessment inpediatric patients.

CQ6.6

Which risk assessment scale is recommended forspinal cord injury patients?

C1

The SCIPUS scale may be considered for risk assessment in spinal
cord injury patients.

CQ6.7

Which risk assessment scale is recommended for
subjects in a home-care setting?

C1

A pressure ulcer risk assessment scale specifically designed forpatients in a home care setting may be used.

― G− 12 ―― 24 ―

Table 7 Skin assessment
Clinical Question

CQ 7.1

CQ7.2

CQ7.3

How can the depth of pressure ulcers
be predicted?

How can redness/d1 stage pressure
ulcer be identified?
Which methods can be used to identify
deep tissue injury（DTI）?

RatingRecommendation

C1

The prediction of d1 pressure ulcer prognosis may be based on the presence of
double erythema（graduated redness）away from a bony prominence.

C1

Ultrasonography may be used.

C1

The ABI（ankle brachial index） may be used to predict the depth of pressure
ulcers in the heel region.

C1

The transparent disk method or the finger method may be considered.

C1

Palpate the area to see whether pain, induration, edema, or changes in skintemperature（warm or cool）are present in comparison with the adjacent tissue.

C1

Consider using ultrasonography.

Table 8Skin care

Clinical Question

RatingRecommendation

CQ8.1

What kind of skin care is recommended for patients
suffering from urinary and/or fecal incontinence inorder to prevent development of pressure ulcers?

C1

After cleansing with an appropriate cleansing agent,skin emollients can be applied to the anal/genital area
and to the peripheral skin.

CQ8.2

What type of preventive skin care is recommended
for use on bony prominences in elderly patients?

B

Transparent film dressings and other dressings with a
low-friction external surface are recommended.

CQ8.3

What kind of skin care is recommended for patients
undergoing surgery in a supine position?

C1

A transparent film dressing can be applied to thesacral area.

CQ8.4

What kind of skin care is recommended for noninvasive ventilation patients to prevent pressure
ulcer formation at the face mask contact site?

C1

A transparent film dressing or a hydrocolloid dressing
may be used for this purpose.

CQ8.5

How should the skin surrounding a pressure ulcer
be cleansed in order to promote pressure ulcer
healing?

C1

Cleansing with a mildly acidic cleansing agent may beconsidered.

CQ8.6

In cases with urinary and/or fecal incontinence,
what kind of skin care is recommended to promotepressure ulcer healing?

C1

Skin emollients can be applied to the peripheral skinafter cleansing with an appropriate cleansing agent.

Preventive
care

Care after
occurrence

Table 9Repositioning

Clinical Question
CQ9.1

CQ 9.2Preventive
care

Care after
occurrence

RatingRecommendation

C1

Consider repositioning the patient at least every twohours.

C1

When a visco-elastic foam mattress is being used,consider repositioning the patient at least every fourhours.

C1

When a double-layer air-cell mattress overlay is being
used, consider repositioning the patient at least every
four hours.

How frequently should the bed bound patient be
repositioned to prevent pressure ulcer?

How frequently should bed bound patient be
repositioned when a support surface is being used?

CQ 9.3

When repositioning bed bound patients, what
positions should be undertaken to avoid pressure
ulcer formation?

C1

A 30- and 90-degree angle for the laterally recumbent
position may be considered.

CQ 9.4How can patients in intensive care be repositioned
in order to prevent pressure ulcer formation?

C1

The patient may be repositioned in an electric rolling
hospital bed.

CQ 9.5What positions should be undertaken to promotehealing in patients with pressure ulcers in thegluteal region?

C1

Any position besides the 30-degree tilted side-lying
position or head-of-bed elevated position may beundertaken.

― G− 13 ―― 25 ―

Table 10
Clinical Question
CQ10.1

Should support surfaces be used tolower the incidence of pressure ulcers?

Which support surface is recomCQ10.2 mended for completely immobile patients?

Which support surface is recomCQ10.3 mended for prevention of pressure
ulcers in elderly individuals?

Which support surfaces are recomCQ10.4 mended for prevention of pressure
ulcers in intensive care patients?

Preventive
care

Which tools, including support surfaces, are effective in preventing the
CQ10.5development of pressure ulcers during
perioperative periods?

Which support surfaces can be used to
CQ10.6 facilitate care for convalescent patientsin a home-care setting?
Which support surfaces provide theCQ10.7 greatest comfort both while awake andsleeping?

CQ10.8Care after
occurrence

What precautions should be taken
when using foam mattresses?

Which support surfaces are recomCQ10.9 mended for promoting healing in d1, d2,
and D3~D5 pressure ulcers?

Support surfaces
RatingRecommendationA

Use of support surfaces is strongly recommended in order to lower
the incidence of pressure ulcers.

B

Recommend using an alternating-pressure air mattress overlay/
replacement.

C1

Consider using a foam mattress replacement.

B

Recommend using a double-layer air-cell mattress.

C1

An alternating-pressure air mattress overlay/ replacement, airfilled mattress overlay, or foam mattress may also be used.

B

Recommend using a low air pressure mattress.

C1

A low-air-loss bed, an alternating-pressure air mattress overlay, or
an air-filled mattress replacement may also be considered.

B

Support surfaces on the operating table are recommended forpatients at risk of developing pressure ulcers.

B

In addition to using support surfaces, visco-elastic pads or gel
applied to the heel area, cubital region, and other areas with bonyprominences is recommended during operations.

C1

During and after operations, an alternating-pressure air mattressoverlays/replacement may be used.

C1

The bead bed system may be used during surgery for patients
undergoing surgery to repair femoral-neck fracture.

C1

Thermoactive viscoelastic foam overlay may be used for patients
who will undergo cardiac surgery.

C1

An automatic turning air mattress may be used.

B

Using an alternating-pressure air mattress replacement is recommended.

C1

For terminally ill patients, an alternating-pressure air mattress with
automatic adjustment to the patient's weight and position may beconsidered.

C1

Monitor the deterioration of the foam due to fatigue.

A

Use of an air-fluidized bed or low-air-loss bed is strongly
recommended to promote healing in D3~D5 pressure ulcers orpressure ulcers in multiple sites.

C1

Use of an alternating-pressure air mattress with automatic
adjustment for the patientfs position and weight function replacement, an alternating-pressure large-cell ripple mattress, a doublelayer air-cell mattress, or a low air pressure mattress may beconsidered to promote healing in d2 or deeper pressure ulcers.

C1

Use of an air-filled mattress overlay may be considered to promotehealing in d1/2 pressure ulcers.

C1

Use of an alternating-pressure air mattress with automatic
adjustment to the patientf
s weight and position may be consideredafter flap reconstruction for pressure ulcers.

― G− 14 ―― 26 ―

Table 11
Clinical Question

How can patients and their family or
Preventive
caregivers be educated to prevent the
CQ 11.1
caredevelopment or recurrence of pressure
ulcers?

Care after
occurrence

How should patients/family/caregivers
CQ11.2 be educated/trained in the care ofexisting pressure ulcers?

Table 12Clinical Question

Which measures should be undertaken in
CQ12.1 a hospital care setting to prevent pressure
ulcers?

Which measures are recommended for
CQ12.2 pressure ulcer prevention in long-termcare facilities?

Which measures are recommended to
CQ12.3 promote healing of pressure ulcers in a
hospital care setting?

Which measures are recommended to
CQ12.4 promote healing of pressure ulcers in along-term care facility?

Patient education
RatingRecommendation

C1

Education/training in repositioning and using support surfaces canbe carried out .

C1

Periodic telephone consultations with a health care professional
and/or remote assessment of the patient fs skin condition using
electronic visual media may be done.

C1

Education by an e-learning system led by the health care
professional may be given.

C1

Education/training in any or all of the following may be given: theetiology of ulcers, risk factors, staging, principles of wound healing,
nutritional support, program of skincare and skin inspection, andmanagement of incontinence.

C1

Consider informing patient/family/caregiver how to contact anappropriate medical center for help in the event the pressure ulcers
worsen.

Outcome management

RatingRecommendation

A

Choice of support surface based on the Braden Scale is strongly recommended.

C1

Choice of support surface based on the OH Scale may be considered.

C1

Deployment of a multidisciplinary wound care team may be considered.

C1

Assignment of wound ostomy and continence nurse may be considered.

C1

Introduction of reimbursement system for pressure ulcer high risk patientcare may be considered.

C1

Implementation of comprehensive programs and protocols may be considered.

C1

Implementation of comprehensive programs and protocols may be considered.

C1

Use of an algorithm incorporating the Braden Scale to implement preventive
care may be considered.

C1

Deployment of a multidisciplinary wound care team may be considered.

C1

Introduction of reimbursement system for pressure ulcer high risk patientcare may be considered.

C1

Assignment of wound ostomy and continence nurse may be recommended.

B

Deployment of a multidisciplinary wound care team is recommended.

C1

Implementation of comprehensive programs and protocols may be considered.

― G− 15 ―― 27 ―

Table 13
Clinical Question

QOL/ Pain

RatingRecommendation

CQ13.1

How can the quality of life（QOL）of pressure ulcer patients be assessed?

C1

The QOL of the patients may be assessed along physiological, psychological,
and social parameters.

CQ13.2

For which stage of pressure ulcer is pain
assessment recommended?

C1

Pain may be assessed at any stage of pressure ulcer.

CQ13.3 When should pain assessment be conducted?

C1

Pain assessment may be conducted at any time（regardless of whether
topical intervention is being administered）.

Which tools can be used to assess pressureulcer-related pain?

C1

Pain may be assessed using a validated scale.

CQ 13.4― G− 16 ―― 28 ―

Fig. 2 Algorithm illustrating conservative treatments

efficacious in protecting wound surfaces, such as1）
white petrolatum, are preferred for treatment . If the

Guidelines
CQ 1 Topical agents
CQ 1.1：Which topical agents are recommended totreat acute pressure ulcers?
［Recommendation］Oleaginous preparations suchas zinc oxide, dimethyl isopropylazulene, white
petrolatum, with a high degree of efficacy inulcer surface is infected, silver sulfadiazine and similar
preparations with nonspecific anti-bacterial properties are recommended, as antibiotic topical agentstypically fail to produce the desired effect.

protecting wound surfaces, and silver sulfadiazine
may be considered.
［Rating］C1［Analysis］At present, observations of only a most

1）Kawakami S, Shimada K：Treatment of acute pres-

References
sure ulcers. Modern Physician, 28：506-507, 2008.
（Level VI）（Japanese）

CQ 1.2：Which topical agents are indicated in cases

general nature exist regarding the choice of topical1）
agents for the treatment of acute pressure ulcers .
As a first step, it is critical to ascertain the cause of thewith suspected deep tissue injury（DTI）?
［Recommendation］Close monitoring of the wound

injury before considering the type of topical therapy
to employ. This is underscored by the fact that inmany cases of acute pressure ulcers, the presence ofdeep tissue damage may at first go unnoticed, andis important. Oleaginous preparations such as zincoxide, dimethyl isopropylazulene and white petrolatum may be considered.
［Rating］C1

lead naturally to an exacerbation of the condition. For
this reason, the basic considerations when employing［Analysis］At present, only expert opinion exists
regarding the choice of topical agents for the

topical therapy to treat acute pressure ulcers include
maintaining an optimally moist environment conducive to wound healing while closely monitoring forchanges in the condition of the wound itself. Typically,treatment of deep tissue injuries（ DTI ）. The term
DTI was proposed by the NPUAP（2007）to define a
condition in which the appearance of overlying skinconceals the actual extent of damage to underlying

oleaginous preparations that are known to be highly

tissue, which becomes more apparent with time as the― G− 17 ―― 29 ―
1）

wound evolves into deeper layers of tissue .
If deep tissue injury is suspected, pressure should
be relieved immediately and the condition of thewound closely monitored. The wound may be
occluded if necessary, but in a manner which willallow the condition of the wound to be readily
monitored. Zinc oxide, dimethyl isopropylazulene, or
white petrolatum and other oleaginous preparations
are recommended.
References
1 ）Kadono T：Deep tissue injury. Rinsho Hifuka, 63Treatments prioritize wound surface protection andtend to focus on the type of dressing used for thispurpose. However, blisters may be punctured if tense,
and ruptured blisters may require treatments usuallyemployed for erosions and ulcers. In cases where
topical agents are employed, white petrolatum orsimilar petrolatum-based topical agents are preferred
for their ability to stimulate wound healing while
protecting the wound surface. Although zinc oxide ina petrolatum-based preparation is customarily employed for this purpose not only because of its locallyastringent effects and mildly antiseptic properties, butalso for its ability to protect the wound surface and（5）：38-41, 2009.（Level VI）（Japanese）

CQ 1.3：Which topical agents are recommended forcases involving redness/purpura?
［ Recommendation ］It is important in cases ofredness/purpura to protect the wound surfaces.
Dimethyl isopropylazulene and white petrolatum may
be used for this purpose.
［Rating］C1［ Analysis ］Only expert opinions are available totreat non-blanchable redness and purpura. Treatments prioritize the protection of wound surfaces andtend to focus on the types of dressing used for thispurpose. In cases which call for treatment using
topical agents, white petrolatum or similar,
petrolatum-based topical agents are preferred fortheir ability to stimulate wound healing while
protecting the wound surfaces. Although dimethyl
isopropylazulene in a petrolatum-based preparation issometimes used for the treatment of non-blanchable
redness and purpura because of its anti-inflammatory1）
properties and reducing effects on edema , its
efficacy is generally low.
References
1）Nakamura I, Ozaki M, Watanabe B：Anti-inflammatory
effects of azulen. Rinsho Hifuka, 12：769-778, 1958.
（Level VI）（Japanese）

CQ 1.4：Which topical agents are recommended forcases involving blistering?
［Recommendation］White petrolatum or zinc oxide
may be used to protect the wound surface.
［Rating］C1［ Analysis ］The choice of topical agent for thetreatment of blisters is based only on expert opinion.

reduce inflammation while promoting tissue1）
regeneration , its efficacy is generally weak.
References
1 ）Edited by the Japanese Pharmacopoeia Instruction
Manual Editorial Committee. The Japanese Pharmacopoeia, Fourteenth Edition: Text with Annotations,
1257-1259, Hirokawa Publishing Company, Tokyo,
2001.（Level VI）（Japanese）

CQ 1.5：Which topical agents are recommended totreat erosions and shallow ulcers?
［ Recommendation ］Zinc oxide or dimethyl isopropylazulene may be used. Alprostadil alfadex,
bucladesine sodium, or lysozyme hydrochloride may
also be used to promote re-epithelialization.
［Rating］C1［ Analysis ］The choice of topical agent for thetreatment of erosion and shallow ulcers is based only
on expert opinion. As the treatment of erosion andshallow ulcers should prioritize protecting the woundsurface and maintaining an optimally moist environment, the choice of dressing becomes crucial. White
petrolatum or other preparations with a petrolatumbase are often chosen for their efficacy in promoting
wound healing while protecting the wound surface.
Although zinc oxide, available as a petrolatum-based
ointment, is not highly efficacious, it possesses mild,
locally astringent, protective, and antiseptic, properties while simultaneously reducing inflammationand promoting tissue regeneration. Dimethyl isopropylazulene, also available in a petrolatum base, iswell-known for its anti-inflammatory properties and1）
its reducing effect on edema , but its efficacy is
generally low.

― G− 18 ―― 30 ―

Alprostadil alfadex, available in a preparation using®
Plastibase , is effective in stimulating wound healing
by promoting re-epithelialization, skin blood flow, and2）angiogenesis . While being a potent pro-circulatory
agent, it is sometimes irritant to the skin. Bucladesine
sodium possesses superior absorbancy due to its
macrogol base and is recommended for cases withexcessive exudate. Other effects of bucladesine
sodium are: reduction of ulcer size, wound contraction,
local pro-circulatory effects, angiogenesis, granulation
tissue promotion, and re-epithelialization. Lysozymehydrochloride is available in an emulsion base and isused with the aim of reducing wound size. While
promoting keratinocyte and fibroblast growth, lysozyme hydrochloride is minimally irritant to the skin.
In summary, zinc oxide, and dimethyl isopropylazulene, as well as alprostadil alfadex, bucladesine
sodium, and lysozyme hydrochloride are assigned
Rating for Recommendation C1 for their efficacy inpromoting re-epithelialization.
References
1 ）Nakamura I, Ozaki M, Watanabe B, et al：Antiinflammatory effects of azulene. Rinsho Hifuka, 12：
769-778, 1958.（Level VI）（Japanese）
2 ）Imamura S, Sagami S, Ishibashi Y, et al：Clinicalstudy of prostaglandin E1 ointment（G-511 ointment）
in chronic skin ulcers. Well-controlled comparative
study with lysozyme chloride ointment. J Clin Ther
Med, 10：127-147, 1994.（Level II）（Japanese）

CQ 1. 6：Are topical agents recommended if pain
accompanies the pressure ulcer?
［Recommendation］There is no evidence supporting the use of topical agents to alleviate pain.
［Rating］C2［ Analysis ］Randomized controlled trials using
topical applications of morphine to relieve pain
associated with pressure ulcers have been conducted
1, 2）
but the use of morphine is notoutside Japan,
common in this country. However, pain control during
the acute phase of pressure ulcer is critical. Also, asmany patients are incapable of reporting sensations ofpain themselves, the task of bearing in mind thepatientSs susceptibility to pain and the possible need toadminister suitable analgesics devolves upon theattending physician. Xylocaine jelly is among the
topical medications sometimes used in Japan torelieve pain, although its usefulness for this purpose
has yet to be established. In summary, there is stillinsufficient evidence to recommend the use of topicalagents for the relief of pain associated with pressure
ulcers.
References
1）Flock P：Pilot study to determine the effectiveness of
diamorphine gel to control pressure ulcer pain. J Pain
Symptom Manage, 25：547-554, 2003.（Level II）
2）Zeppetella G, Paul J, Ribeiro MD：Analgesic efficacy
of morphine applied topically to painful ulcers. J Pain
Symptom Manage, 25：555-558, 2003.（Level II）

CQ 1.7：Which topical agents are recommended forpressure ulcers with excessive exudate?
［Recommendation］
．Cadexomer-iodine and povidone-iodine sugar
are both highly absorbant and are recommended forpressure ulcers with excessive exudate.
［Rating］B
．Dextranomer and iodine ointment may beconsidered.
［Rating］C1［ Analysis ］Cadexomer-iodine, fibrinolysindeoxyribonuclease-containing ointment, dextranomer
and dextrin-polymer-base were tested to determine
their relative efficacy in alleviating excessive exudation in pressure ulcers. The results of the test
indicated an improvement rate of 65. 8% for
cadexomer-iodine in comparison with fibrinolysindeoxyribonuclease-containing ointment（ 46. 2% ）, demonstrating a statistically greater effect for the1）
former（p ＜ 0.05） .
The study also indicated an improvement rate of 65.
2% for cadexomer-iodine in comparison with dextranomer（ 18. 2% ）, likewise demonstrating the statistically significantly greater efficacy of the former（p ＜2）0.01） . On the other hand, cadexomer-iodine showed
an efficacy rate of 33. 3% in comparison with thedextrin-polymer-base（ 24% ）with no significant dif3）
ference in efficacy observed .
The ameliorative effect of povidone-iodine sugar on
exudation has been compared with that of lysozymehydrochloride ointment in two studies, and with thatof ointment containing extract from hemolyzed bloodof young calves in one study. The latter study
demonstrated a significantly higher efficacy rate of― G− 19 ―― 31 ―

25% for povidone-iodine sugar in comparison with 0%for ointment containing extract from hemolyzed blood4）of young calves（p ＜ 0.01） .
The two studies comparing the efficacy rate of（SS-094 : Ointment）. Jpn Pharmacol Ther, 17（4）：1789-1813, 1994.（Level II）（Japanese）
5 ）Saito Y, Furuse Y, Ishii T, et al：A clinical randomized comparative study of povidone-iodine-sugar

povidone-iodine sugar and lysozyme hydrochloride
have yielded opposite results, with one study indicating an efficacy rate of 25% for povidone-iodine sugar

ointment（ U-PASTA KOWA ）versus combined
ointment with lysozyme hydrochloride ointment（ REFLAP Ointment ）and povidone-iodine-sugarand 33. 3% for lysozyme hydrochloride and no5）
statistically significant difference in the results , while
the second study indicated an efficacy rate of 49.1%

ointment（ U-PASTA KOWA ）on decubitus. Jpn

for povidone-iodine sugar and 27. 8% for lysozymehydrochloride and a statistically greater efficacy rate
6）
for the former（p ＜ 0.01） .
Further, a retrospective analysis of a case in which

6 ）lmamura S, Uchino H, Imura Y, et al：The clinicalthe DESIGN score decreased following the applicationof povidone-iodine sugar failed to establish any
relationship between the amount of exudate and the7）decrease in the DESIGN score .
The ameliorative effect of dextranomer and iodine
ointment on exudation has been documented in pastcase reports. Of the five cases reported, fourdemonstrated a decrease in the initially medium tohigh levels of exudation following treatment with8）
dextranomer . Furthermore, case reports havedocumented a significant improvement in the
DESIGN-R score and the E score in DESIGN following
9, 10）.
iodine ointment treatment
In summary, for the treatment of excessive
exudation cadexomer iodine and povidone-iodine
sugar are assigned a rating of B, while dextranomer

17（Suppl.1）：255-279, 1989.（Level II）（Japanese）

Pharmacol Ther, 22（ 5 ）：2403- 2413, 1994.（ Level
II）（Japanese）
effect of KT-136（ sugar and povidone-iodine ointment）on decubitus and skin ulcers: A comparative
study with lysozyme ointment. Jpn Pharmacol Ther,
7）Kobayashi A, Muto S, Chino K, et al：Analysis of thetherapeutic effictiveness of a topical agent in thetreatment of pressure ulcers using DESIGN. Jpn J PU,
10（ 2 ）：111-116, 2008.（ Level V ）（ Japanese, English abstract）
8）Horio T, Kawai S, Moriguchi T, et al：Therapeutic
effects of SK-P-9701（dextranomer paste）on pressure ulcers. Jpn J JPU, 3（3）：355-364, 2001.（Level
V）（Japanese, English abstract）
9）Nagai Y, Amano H, Okada E, et al：Therapeutic effe®

ctiveness of Iodocoat ointment 0.9% in the treatmentof pressure ulcers. J New Rem & Clin, 59（ 7 ）：1215-1223, 2010.（Level V）（Japanese）
10）Tachibana T, Fujii N, Wakabayashi M, et al：Therapeutic effect of 0. 9% iodine-containing ointment on

and iodine ointment are assigned a rating of C1.

yellow stage of pressure ulcers. Jpn JPU, 12（ 4 ）：513-519, 2010.（ Level V ）（ Japanese, English ab-

References

stract）

1）Kukita A, Ohura T, Aoki T, et al：Clinical evaluationof NI-009 on various cutaneous ulcers. Comparative

CQ 1.8：Which topical agents are recommended instudy with Elase-C Ointment. J Clin Ther Med, 6pressure ulcers with minimal exudate?
［ Recommendation ］Ointments with emulsion（4）：817-848, 1990.（Level II）（Japanese）
2 ）lshibashi Y, Ohkawara A, Kukita A, et al：Clinicalevaluation of NI-009 on various cutaneous ulcers.
Comparative study with Debrisan. J Clin Ther Med, 6（4）：785-816, 1990.（Level II）（Japanese）
3）Anzai T, Shiratori A, Ohtomo E, et al：Evaluation ofclinical utility of NI-009 on various cutaneous ulcers.
Comparative study with base. J Clin Ther Med, 5（12）：2585-2612, 1989.（Level II）（Japanese）
4 ）KT-136 Skin Ulcers Comparative Study Group：
Comparative clinical study of sugar and povidoneiodine ointment（ KT-136 ）and solcoseryl ointmentbases are preferred. Silver sulfadiazine may beconsidered to treat infected wounds while tretinoin
tocoferil may be considered to treat uninfected
wounds.
［Rating］C1［ Analysis ］There are no evidence-based reports
besides expert opinion recommending topical agents
1−3）.
for the treatment of minimally exudative wounds
Emulsion-base ointments are typically recommended
for such wounds, both by reason of their highmoisture content and penetrating ability. Emulsion-― G− 20 ―― 32 ―

base ointments also have the added benefit ofpromoting water retention in dry wound surfaces. A
representative example of such an emulsion-base
topical agent is silver sulfadiazine, which possesses
antibacterial properties and softens necrotic tissue,
and tretinoin tocoferil, which promotes granulation
1−3）
tissue formation .
In summary, silver sulfadiazine and tretinoin
tocoferil are assigned a recommendation of C1 for thetreatment of minimally exudative wounds.

the 12 cases cleaned with 200 ml isotonic saline.
In summary, while wound cleansing is effective in
speeding recovery, there is no evidence to endorse aparticular cleansing solution or method. Pressure
ulcers may be cleaned adequately by using sufficientquantities of isotonic saline or tap water.
References
1）Moore Z, Cowman S：A systematic review of woundcleansing for pressure ulcers. J Clin Nurs, 17（15）：1963-1972, 2008. Review.（Level I）

References2）Ohura T, Iwasawa A, Kiryu M, et al：Effect of clean-

1 ）Nagai Y：Topical drug and wound dressing . Jpn J

sing by physiological saline on bacterial counts of

PU, 10（ 1 ）：1-9, 2008.（ Level VI ）（ Japanese, En-

pressure ulcer. Jpn J PU, 9（ 2 ）：183-191, 2007.

glish abstract）（Level IV）（Japanese, English abstract）

2）Furuta K：Selection and technical aspects of topicaldrugs .Jpn J PU, 11（2）：92-100, 2009.（Level VI）（Japanese, English abstract）
3 ）Yoshida K：Tips for pressure ulcer pharmacotherapeutics with case reports .Jpn J PU, 12（2）：85-92,
2010.（Level VI）（Japanese, English abstract）

CQ 1.9：How should a pressure ulcer be cleaned?
［ Recommendation ］Cleanse the pressure ulcer
using isotonic saline or tap water in sufficientquantities to reduce the microbial count on the woundsurface.
［Rating］C1［Analysis］In the one published systematic review
comparing wound cleansing solutions and cleansing
1）
techniques , pressure ulcers cleaned with isotonicTMsaline（ Vulnopur ）containing aloe vera, silver
chloride, or decyl glucoside（ 59 cases ）showed ademonstrable improvement in their PSST（Pressure
Sore Status Tool）scores（P ＝ 0.025）compared tothose cleaned only with isotonic saline（74 cases）.
No significant difference was noted in the PSST
score of pressure ulcers cleaned with either isotonic

CQ 1. 10：How should pressure ulcers be disinfected?
［ Recommendation ］Wound cleansing is usuallyadequate to prevent infection. However, if the wound
is clearly infected or if there is excessive exudate orpus, the wound may be disinfected using antiseptics
prior to cleansing.
［Rating］C1［Analysis］A systematic review of various studies
selected by their quality and dealing with theretardative effect of povidone-iodine on wound1）
healing , has shown that the majority of cases
arguing against the use of povidone-iodine were either
in vitro or animal model studies whereas 71% of thehighly ranked human studies supported its use.
Further, 57% of the studies with the highest impact
factor supported its use as an antiseptic. There are
only scanty data regarding the relationship between
symptoms of infection and retardation of healing due
to use of antiseptics and it is not at all clear thatpovidone-iodine has a toxic or retardative effect on

saline only（four cases）or with tap water only（fourcases）. With regard to the cleansing techniques, nowound healing.
2）
The 1994 AHCPR guidelines claim that lavation
with isotonic saline is sufficient for cleansing infectedsignificant difference was noted in treatment effectbetween the so-called\ whirlpool Smethod（ 24cases）and more conventional lavation（18 cases）.Of2）
the 36 cases featured in one comparative case report
6 out of 19 cases cleaned with 50 ml isotonic saline and5 out of 29 cases cleaned with 100 ml isotonic salinepressure ulcers and that cleansing solutions andantiseptics are unnecessary. On the other hand, the3）
EPUAP guidelines of 1999 state that use of antiseptics is indicated in cases in which there are clear signsof infection and abnormally large amounts of exudates
or pus.

demonstrated an increase in microbial count, whereas
no increase in microbial count was observed in any ofIn summary, even at the wound stage at which
debridement and infection control are normally called― G− 21 ―― 33 ―

for, cleansing with isotonic saline or tap water issufficient in most cases. However, in cases in which
there are clear symptoms of infection, the wound may
be disinfected by using povidone-iodine.

ointment, and iodoform, there is as yet little evidence
on their anti-microbial effect.
In summary, in cases in which there are clear
symptoms of infection, cadexomer-iodine, silver sulfa-

1）Banwell H：What is the evidence for tissue regenera-diazine, and povidone-iodine sugar are recommended
as a means of controlling the infection. Fradiomycin
sulfate-trypsin, povidone-iodine, iodine ointment, andtion impairment when using a formulation of PVP-I

iodoform may be used for treatment on a daily basis.

References

antiseptic on open wounds?. Dermatology, 212 Suppl

References

1：66-76, 2006.（Level I）
2）Bergstrom N, Allman RM, Alvarez OM, et al：Treat-1 ）lshibashi Y, Ohkawara A, Kukita A, et al：Clinicalment of Pressure Ulcers Clinical Practice Guidelines

evaluation of NI-009 on various cutaneous ulcers.

Number 15, No95-0652,US Department of Health andComparative study of Debrisan. J Clin Ther Med, 6（4）：785-816, 1990.（Level II）（Japanese）

Human Services, Public Health Service, Agency for
Health Care Policy and Research. AHCPR Publication,2）Yura J, Ando M, Ishikawa S, et al：Clinical evaluationof silver sulfadiazine（ T107 ）in the treatment of

Rockville Maryland, 1994.
3）European Pressure Ulcer Advisory Panel: Pressure

decubitus ulcer or chronic dermal ulcers: Double-

ulcer treatment guidelines. EPUAP business office,blind study including placebo. Chemotherapy, 32：

Oxford, 1999.

208-222, 1984.（Level II）（Japanese）
3 ）lmamura S, Uchino H, Imura Y, et al：The clinical

CQ 1.11：Which topical agents are recommended
for pressure ulcers accompanied by infection andinflammation?
［Recommendation］
1. Cadexomer-iodine, silver sulfadiazine, andpovidone-iodine sugar are recommended for theirability to control infections.
［Rataing］B
2. Fradiomycin sulfate-trypsin, povidone-iodine,
iodine ointment, and iodoform gauze may be considered.
［Rating］C1［Analysis］A randomized controlled trial with 60
subjects comparing cadexomer-iodine with dextranomer demonstrated significant decreases in levels of1）
pus（p ＜ 0.05） , one of the assessment categories inthe study, following treatment with cadexomer-iodine.

effect of KT-136（ sugar and povidone-iodine ointment ）on decubitus ulcers: A comparative study
with lysozyme ointment. Jpn Pharmacol Ther, 17（Suppl.1）：255-280, 1989.（Level II）（Japanese）

CQ 1.12：Which topical agents are recommended toaccelerate granulation formation in pressure ulcers
with deficient granulation formation?
［Recommendation］
1. Aluminium chlorohydroxy allantoinate,
trafermin, tretinoin tocoferil and povidone-iodine
sugar, all of which are known to accelerate granulation formation, are recommended.
［Rating］B
2. Alprostadil alfadex, bucladesine sodium, or
lysozyme hydrochloride may be considered.
［Rating］C1

Another randomized controlled trial comparing
silver sulfadiazine with a placebo group（ total 77
subjects）reported a significant anti-microbial effect（p ＜ 0.01）in 64.7% and 27% of the subjects, respec-［Analysis］Aluminium chlorohydroxy allantoinate:
One study of the effect of aluminium chlorohydroxy
allantoinate on the acceleration of granulation formation involved a randomized controlled trial using

tively. In an open randomized controlled trial comparing povidone-iodine sugar with lysozome hydrochloride involving 141 subjects, 32. 8% and 14. 8% of thesubjects, respectively, reported a significant improve3）
ment in microbial infection rate（p ＜ 0.05） . On thesolcoseryl（ extract from hemolyzed blood of young
1）
calves ） . The results for each of the 27 subjects
enrolled showed a significantly greater increase in
granulation formation when compared with thecontrol group.

other hand, while there are case reports concerning
fradiomycin sulfate-trypsin, povidone-iodine, iodine

Trafermin: Although a randomized controlled trial
comparing the efficacy of trafermin with that of― G− 22 ―― 34 ―

povidone-iodine sugar, GM-CSF and low concentrationof fibroblast growth factor in reducing wound size
2−5）does exist , the data on granulation formation are6）
not shown. However, one historical controlled trial
has reported a significantly greater granulation
formation effect for trafermin in comparison with thecontrol. The study further reported that trafermin
was especially efficacious when administered in theearly stages of treatment and enhanced the treatment
effect. Although the evidence level for trafermin is IV,
this medication merits recommendation on the basisof case series reports documenting its efficacy as well7, 8）
as the expert opinions given in its favor .
Tretinoin tocoferil: In the two existing open
randomized controlled trials comparing the granulation formation effect of tretinoin tocoferil with that of
9, 10）,
lysozyme hydrochloride and bendazac ointment
tretinoin tocoferil was observed to have a significantly
greater effect than either of the controls.
Povidone-iodine sugar: An open randomized trial
comparing povidone-iodine sugar with lysozymehydrochloride reported a superior granulation formation effect for lysozyme hydrochloride than for11）
povidone-iodine sugar .
Alprostadil alfadex: Although there is a randomized
trial comparing the wound reduction effect ofalprostadil alfadex with that of lysozyme
12）hydrochloride with the exception of expert opinion,
there are no studies attesting to the granulation
formation effect of alprostadil alfadex.
Bucladesine sodium：At present two random

there is a significant difference between these agentsin their ability to accelerate granulation formation.
In summary, the evidence level indicated in theprevious edition of the guidelines has been modified
and one medication has been added to the list ofrecommendations on the basis of the above considerations. The determination of which topical agents to
use in a given situation calls for an assessment of theproperties of each topical agent and the condition of
the wound in question.
References
1）Mizutani H, Ootsuki T, Matsumoto H, et al：Clinicaleffects of topical aluminum chlorhydroxy allantoinate
on pressure ulcers: A comparative study of solcoseryl
ointment. Jp J Clin Exp Med, 59（6）：097-2112, 1982.
（Level II）（Japanese）
2 ）Ishibashi Y, Soeda S, Ohura T：Clinical effects of
KCB-1, a solution of recombinant human basic
fibroblast growth factor, on skin ulcers: A phase III
study with comparisons to sugar and povidone iodine
ointment. J Clin Ther Med,12（10）：2159-2187, 1996.
（Level II）（Japanese）
3）Martin CR：Sequential cytokine therapy for pressure
ulcers, clinical and mechanistic response. Ann Surg,
231：600-611, 2000.（Level II）
4）Ishibashi Y, Soeda S, Ohura T：The clinical effects of
KCB-1 on skin ulcers: A double blind trial todetermine optimal dosage. J Clin Ther Med, 12（9）：1809-1834, 1996.（Level II）（Japanese）
5 ）Robson MC, Phillips LG, Lawrence WT, et al: The

controlled trials exist comparing the effect of bucladesine sodium, lysozome hydrochloride, and macro-safety and effect of topically applied recombinant

gol ointment on accelerating granulation formation. In
both reports, bucladesine sodium reportedly showed
an accelerative effect equal to that of lysozomehydrochloride, but significantly greater than that of
13, 14）. However, at present there aremacrogol ointment
no studies documenting its effect on granulation
formation.
Lysozome hydrochloride：Two open randomized

chronic pressure sores. Ann Surg, 216（4）: 401-408,

trials have been conducted comparing lysozomehydrochloride with bendazac ointment（ evidence
15）level II ） . In addition, there are currently two
randomized trials comparing lysozome hydrochloride
with povidone-iodine or lysozome hydrochloride
16, 17）, although nocontaining povidone-iodine sugar
study has yet been conducted to determine whether

basic fibroblast growth factor on the healing of1992.（Level II）
6）Ohura T, Nakajyo T, Moriguchi T：Clinical efficacyof bFGF on pressure ulcers: A case controlled study
employing a new method for evaluation. Jp J PU, 6（ 1 ）：23-34, 2004.（ Level IV ）（ Japanese, English
abstract）
7）Furuta K, Miura H, Endo T：Clinical effects of fiblast
spray on pressure ulcers. Jp J Clin Exp Med, 80（7）：187-194, 2003.（Level V）（Japanese）
8）Ishibashi Y, Harada S, Takemura T: Clinical effects of
KCB-1（ bFGF ）on skin ulcers, Clinical trial for 12
weeks. J Clin Ther Med, 12：2117-2129, 1996.（Level
V）（Japanese）
9）L-300 clinical trial study group: Controlled compara-― G− 23 ―― 35 ―

tive study of the effect of L-300 and lysozymehydrochloride on skin ulcers. J Clin Ther Med, 7：654-665, 1991.（Level II）（Japanese）
10）L-300 clinical trial study group：Clinical evaluation of
L-300 ointment for treatment of skin ulcers: A
controlled comparative study using bendazac ointment as a control. J Clin Therap Med, 7（ 2 ）：437-456, 1991.（Level II）（Japanese）

ointment, povidone-iodine sugar, iodine ointment, or
silver sulfadiazine may be used.
［Rating］C1［Analysis］Although critical colonization is a serious pathological condition which has the potential todelay wound recovery in pressure ulcers, there are as
yet no controlled studies dealing specifically with thiscondition. Further, although two case studies exist

effect of KT-136（ sugar and povidone-iodine oint-

which mention the anti-microbial effect of iodine
1, 2）
ointment and one evidence level III report which

ment ）on decubitus ulcers: A comparative study

compares the effect of cadexomer-iodine ointment andusing lysozyme ointment. Jpn Pharmacol Ther, 17

povidone-iodine sugar, only one study deals specifical3）
ly with pressure ulcers .
The use of the above-mentioned topical agents is11 ）Imamura S, Uchino H, Imura H, et al：The clinical（Suppl.1）：255-280, 1989.（Level II）（Japanese）
12）Imamura S, Sagami S, Ishibashi Y：Clinical study of
prostaglandin E1 ointment（ G-511 Ointment ）inchronic skin ulcers. Well-controlled comparative

recommended on the basis of the case studies
4−6）
mentioned as well as expert opinion .

study with lysozyme chloride ointment. J Clin Ther

References

Med, 10：127-147, 1994.（Level II）（Japanese）
13）Niimura M, Ishibashi Y, Imamura S，et al：Clinical1）Nagai Y, Amano H, Okada E, et al：Clinical effects ofstudy of the effect of dibutyryl cyclic AMP ointment

iodine ointment 0.9% on pressure ulcers. J New Rem（ DT-5621 ）on chronic skin ulcers. Well-controlled& Clin, 59：1215-1223, 2010.（Level V）（Japanese）

comparative study with lysozyme ointment. J Clin

2 ）Tachibana T, Fujii N, Wakabayashi M, et al：

Ther Med, 7（ 3 ）：677-692, 1991.（ Level II ）Therapeutic effect of 0.9% iodine-containing ointment（Japanese）

on yellow-stage of pressure ulcers. Jpn J PU, 12：513-519, 2010.（ Level V ）（ Japanese, English ab-14）Niimura M, Yamamoto K, Kishimoto S, et al：Clinicalstract）

study of the effect of dibutyryl cyclic AMP ointment（ DT-5621 ）on chronic skin ulcers. Jpn Pharmacol

3）Takagi S, Makino T, Kosaka M, et al：Comparison ofTher, 18：2757-2770, 1990.（Level II）（Japanese）

the antibacterial effects of two iodine-containing

15 ）KH101 study group：Clinical study of the effect ofantiseptics．Jpn J PU, 11（4）：528-532, 2009.（Level
III）（Japanese, English abstract）

KH101（ Reflap ointment ）on chronic skin ulcers．
Nishinihon J Dermatol, 48（ 3 ）：553-562, 1986.

4）Imamura S：Efficacy and safety in chronic administration of white sugar and povidone-iodine phar-（Level II）（Japanese, English abstract）
16 ）Syukuwa T, Okada S, Tukazaki N：The effects ofmaceuticals（ U-pasta Kowa ）for decubitus. Acta

therapy combining lysozyme ointment（Reflap oint-

Dermatologica, 89：727-735, 1994.（ Level V ）（Japanese）

ment ）and povidone iodine sugar ointment on
decubitus．Skin, 32（4）：564-573, 1990.（Level IV）

5 ）Tachibana T：Critical colonization. Jan J Clin Dermatol, 63：42-46, 2009.（Level VI）（Japanese）（Japanese）
17）Miyauchi H, Shimada T, Sikai T, et al：Comparative

6 ）Tachi M: Management of chronic wound infection．

study on the treatment of decubitus using three

Jpn J PU, 11（ 2 ）：101-104, 2009.（ Level VI ）ointments: Reflap, povidone iodine sugar, and their（Japanese, English abstract）

combination. Skin, 32（ 4 ）：547-563, 1989.（ Level

CQ 1.14：Which topical agents are recommended

IV）（Japanese）

CQ 1.13：Which topical agents are recommended inpressure ulcers with deficient granulation formationand suspected critical colonization?
［ Recommendation ］Topical medications with ananti-microbial properties, such as cadexomer-iodine

for wound reduction in pressure ulcers with sufficientgranulation formation?
［Recommendation］
1. Alprostadil alfadex, aluminum chlorohydroxy
allantoinate, trafermin, bucladesine sodium, andpovidone-iodine sugar are recommended.

― G− 24 ―― 36 ―

［Rating］B
2. Zinc oxides, dimethyl isopropylazulene, extract

study with lysozyme chloride ointment. J Clin Therfrom hemolyzed blood of young calves, and lysozymehydrochloride may be used.
［Rating］C12）Mizutani H, Ootsuki T, Matsumoto H, et al：Clinical［ Analysis ］An open randomized trial with 44
subjects comparing alprostadil alfadex and lysozymehydrochloride found that treatment with the former

comparison with Solcoseryl ointment. Jp J Clin Exp

Med, 10：127-147, 1994.（Level II）（Japanese）
evaluation of Aluminum chlorohydroxy allantoinate
powder（ ISP ）in patients with pressure ulcers: A
Med, 59：2097-2112, 1982.（Level II）（Japanese）
3 ）Robson MC, Phillips LG, Lawrence WT, et al：The

resulted in a significantly greater reduction ratio in
1）wound size（p ＜ 0.05） .
Similarly, an open randomized trial with 54 subjects

safety and effect of topically applied recombinantcomparing aluminum chlorohydroxy allantoinate andointment containing extract from the hemolyzed
blood of calves found that treatment with the former

1992.（Level II）

basic fibroblast growth factor on the healing ofchronic pressure sores. Ann Surg, 216（4）：401-408,
4）Niimura M, Yamamoto K, Kishimoto S, et al：Clinicalevaluation of DT-5621 in patients with chronic skinresulted in a significantly greater reduction in wound2）
size（p ＜ 0.05） . Trafermin produced a significantly
greater reduction in wound size ratio（ p ＜ 0. 05 ）when compared with a placebo in an open randomized
3）
trial（n = 119） . A randomized controlled trial comparing bucladesine sodium and macrogol（ n = 91 ）showed that treatment with the former resulted in asignificantly greater（p ＜ 0.05）reduction in wound4）
size . A randomized controlled trial comparing
povidone-iodine sugar and trafermin（ n = 63 ）showed that both agents produced an equal reduction
in wound size. Similarly, a randomized controlled trial（ n = 68 ）comparing lysozyme hydrochloride withbucladesine sodium resulted in equal wound size
6）
reduction ratio . However, it is unclear whether or
not the percentage of wound size reduction wasmeasured following adequate granulation formation.
In view of the wound treatment process, in actual
clinical practice it is advisable to assess epithelialization after sufficient granulation formation has been
confirmed.
In view of the information given above and theactual conditions of clinical practice, alprostadil
alfadex, aluminum chlorohydroxy allantoinate,
trafermin, bucladesine sodium, and povidone-iodine
sugar are recommended for reducing wound size.
Zinc oxide, dimethylisopropylazulen, extract fromhemolyzed blood of young calves, or lysozymehydrochloride may also be used.
References
1 ）Imamura S, Sagami S, Ishibashi Y, et al：Clinicalstudy of prostaglandin E1 ointment（G-511 ointment）
in chronic skin ulcers. Well-controlled comparative

ulcer: A multicenter, placebo-controlled double blind
study. Jpn Pharmacol Ther, 18（7）：2757-2770, 1990.
（Level II）（Japanese）
5）Ishibashi Y, Soeda S, Ohura T, et al：Clinical effects of
KCB-1, a solution of recombinant human basic
fibroblast growth factor, on skin ulcers: A phase III
study with comparison to sugar and povidone iodine
ointment. J Clin Ther Med, 12（10）：2159-2189, 1996.
（Level II）（Japanese）
6 ）Niimura M, lshibashi Y, lmamura S, et al：Clinicalstudy of dibutyryl cyclic AMP ointment（DT-5621）
on chronic skin ulcers. Well-controlled comparative
study with lysozyme ointment. J Clin Ther Med, 7（3）：667-692, 1991.（Level II）（Japanese）

CQ1.15：Which topical agents are recommended if
necrotic tissue is observed?
［Recommendation］Cadexomer-iodine, silver sulfadiazine, dextranomer, bromelain
or povidone-iodine sugar may be considered.
［Rating］C1［ Analysis ］The wound debridement efficacy of
cadexomer-iodine, fibrinolysin-deoxyribonuclease, dextranomer, and dextrin polymer（ base ）has been
documented in a controlled study which reported asignificantly greater improvement rate（p ＞ 0.01）of
45. 5% for cadexomer-iodine in comparison with1）
fibrinolysin-deoxyribonuclease（18.8%） . A comparison of cadexomer-iodine with dextranomer showed anefficacy rate of 71.4% and 45.5%, respectively, with nosignificant difference observed between these two
2）
agents . Likewise a comparison of dextrin polymer（ base ）showed an efficacy rate of 8. 3% and 26. 7%,
respectively, and no significant difference between― G− 25 ―― 37 ―
3）

the two was observed .
At present the use of silver sulfadiazine for wounddebridement is endorsed only by expert opinion. As
yet there are no studies endorsing its use for thispurpose.

cutaneous ulcers: Comparative study with base. J Clin
Ther Med, 5（ 12 ）：2585-2612, 1989.（ Level II ）（Japanese）
4）Tachibana T, Miyachi Y：Drug therapy. Jpn J Plast
Surg, 46（5）: 459-470, 2003.（Level VI）（Japanese）

The ability of the emulsion base to penetrate theskin and to soften and fuse necrotic tissue largely
accounts for the wound-cleaning effects of silver
4）
sulfadiazine .
A case report comparing the effectiveness of5）Horio T, Kawai S, Moriguchi T, et al：Therapeutic

dextranomer with that of bromelain in debriding
necrotic tissue indicated a reduction in the number of5）cases of tissue necrosis from six cases to one .
Two separate studies have reported a moderate toation of the effect of bromelain ointment on theeffects of SK-P-9701（dextranomer paste）on pressure ulcers. Jpn J PU, 3（ 3 ）：355-364, 2001.（ Level
V）（Japanese, English abstract）
6）Ogawa Y, Kurooka S, Katakami S, et al：The evaludebridement of eschar in burn, decubitus and various
wound. J New Rem & Clin, 48（10）：1301-1309, 1999.
（Level V）（Japanese）

high level of wound debridement efficacy of 57% and6, 7）
72.5% for bromelain .
The first of two controlled trials comparing the7）Kawai S：Report on the clinical experience of using

wound debridement efficacy of povidone-iodine sugar
and lysozome hydrochloride showed a 41.7% efficacy
rate for povidone-iodine sugar and 66.7% for lysozome
8）hydrochloride ointment . The second controlled trialof povidone-iodine sugar with lysozome hydrochloride
indicated an efficacy rate of 34. 2% and 31. 1%,
9）respectively . A similar study comparing ointment
containing extract from hemolyzed blood of young
calves with povidone-iodine sugar indicated anefficacy rate of 12.5% for the latter, and 23.1% for the10）
former. No significant difference was observed .
Further, a retrospective study of cases showing a
reduction in DESIGN scores following povidoneiodine sugar treatment failed to indicate any correla-8 ）Imamura S, Uchino H, Imura Y, et al：The clinicaltion between tissue debridement and decrease in
11）
DESIGN score .
In summary, cadexomer-iodine, sufadiazine silver,
dextranomer, bromelain, and povidone-iodine sugar
are assigned a recommendation rating of C1.

bromelain ointment on pressure ulcers. J New Rem
Clin, 52（8）：1210-1216, 2003.（Level V）（Japanese）
effect of KT-136（ sugar and povidone-iodine ointment）on decubitus and skin, ulcers: A comparison
with lysozyme ointment. Jpn Pharmacol Ther, 17（1）：255-279, 1989.（Level II）（Japanese）
9 ）KT-136 Skin Ulcers Comparative Study Group：
Comparative clinical study of sugar and povidoneiodine ointment（ KT-136 ）and solcoseryl ointment（ SS-094 Ointment ）. Jpn Pharmacol Ther, 17（ 4 ）：1789-1813, 1994.（Level II）（Japanese）
10 ）Saito Y, Furuse Y, Ishii T, et al：A clinical randomized comparative stydy of povidone-iodine-sugar
ointment（ U-PASTA KOWA ）versus combined
ointment with lysozyme hydrochloride ointment（ REFLAP Ointment ）and povidone-iodine-sugar
ointment（ U-PASTA KOWA ）on decubitus. Jpn
Pharmacol Ther, 22（ 5 ）：2403-2413, 1994.（ Level
II）（Japanese）
11）Kobayashi A, Muto S, Chino K, et al：Analysis of thetherapeutic effectiveness of a topical agent in the

References

treatment of pressure ulcers using DESIGN Tool. Jpn

1）Kukita A, Ohura T, Aoki T, et al：Clinical evaluation

J PU, 10（2）：111-116, 2008.（Level V）（Japanese,of NI-009 on various cutaneous ulcers: Comparative

English abstract）

study with Elase-C Ointment. J Clin Ther Med, 6

CQ 1.16：Which topical agents are recommended（4）：817-848, 1990.（Level II）（Japanese）
2 ）Ishibashi Y, Ohkawara A, Kukita A, et al：Clinicalevaluation of NI-009 on various cutaneous ulcers:
Comparative study with Debrisan. J Clin Ther Med, 6（4）：785-816, 1990.（Level II）（Japanese）
3）Anzai T, Shiratori A, Ohtomo E, et al：Evaluation ofclinical utility of NI-009 in the treatment of various

when undermining has occurred?
［ Recommedation ］If the undermining is coveredby necrotic tissue, the wound surfaces should first be
cleaned. Also, if there is excessive exudate, povidone
iodine-sugar may be used. If the amount of exudation
is minimal, consider using trafermin or tretinoin― G− 26 ―― 38 ―

tocoferil.
［Rating］C1［ Analysis ］There are a limited number of references dealing with the application of topical agents onpressure ulcers which list undermining among theirassessment categories. In general, however, in cases
in which a undermining is found, all necrotic tissue
should be removed from its interior and the woundsurface cleansed. Caution needs to be exercised toprevent the occasional secondary infection.
A case-series on the efficacy of povidone-iodine
sugar with undermining as one of its evaluation items
has demonstrated the ameliorative effect of the1）
compound .
Although a case-control study with an evidence
level of IV examining the effect of trafermin on
undermining has demonstrated an ameliorative effect,
the results were not significantly different from that2）of the comparison group .
At present, the use of tretinoin tocoferil is endorsed
only by an expert opinion.
In summary, povidone-iodine sugar is indicated forthe treatment of cases with excessive exudate, while
tretinoin tocoferil is indicated for cases with low
amounts of exudate.
References
1 ）Miyachi Y, Kawamori R：Pressure ulcers complicated by diabetes mellitus: Evaluation of U-PASTA
KOWA ointment on skin ulcers. Acta Dermatologica,
93：239-248, 1998.（Level V）（Japanese）
2 ）Robson MC, Phillips LG, Lawrence WT, et al：The
safety and effect of topically applied recombinantbasic fibroblast growth factor on the healing ofchronic pressure sores. Ann Surg, 216（4）：401-408,
1992.（Level II）

CQ 2 Dressings
CQ 2.1：Which dressings are recommended to treat
acute pressure ulcers?
［Recommendation］In order to protect the woundsurface while allowing daily monitoring of thecondition, transparent film dressings or dressings
designed to treat dermal wounds may be used.
［Rating］C1［Analysis］Recommendations for the use of dressings to treat acute phase pressure ulcers are1）
supported only by expert opinion . It is important todetermine the cause of acute phase pressure ulcers.
Since the condition of tissue localized in and around
acute phase pressure ulcers has a propensity toworsen rapidly, frequent and regular monitoring of
the wound condition is vital. For this reason, atransparent dressing which will allow visual monitoring is recommended.
Transparent film dressings are recommended forthe protection of erythematous areas from friction or
shear. Before applying the transparent film dressing,cleanse the skin where the dressing is to be applied. If
there are any noticeable changes to the woundcondition, replace the dressing with a new one. As arule dressings should be changed at a frequency ofonce per week.
References
1 ）Kawakami S, Shimada K：The treatment of acutephase pressure ulcer. Modern Physician, 28（ 4 ）：506-507, 2008.（Level VI）（Japanese）

CQ 2.2：Which dressings are indicated in pressure
ulcers with suspected deep tissue injury（DTI）?
［Recommendation］In order to protect the woundsurface while allowing daily monitoring of thecondition, either transparent film dressings or dressings designed to treat dermal wounds may beconsidered.
［Rating］C1［ Analysis ］There are no studies examining theefficacy of dressings on the treatment of deep tissue
injuries（DTI）.Because DTI tends to progress moredeeply into underlying tissue, frequent monitoring of
the wound is vital. For this reason, a transparent
dressing that will allow observation of the woundcondition is recommended. Transparent film dressings are recommended for the protection of erythematous areas from friction or shear. Before applying
the polyurethane dressing, cleanse the skin where thedressing is to be applied. If there are any noticeablechanges in the condition of the wound, replace thedressing with a new one. As a rule dressings should bechanged at a frequency of once per week.
CQ 2. 3：Which dressings are recommended forpressure ulcers involving redness/purpura?
［Recommendation］In order to protect the woundsurface while allowing daily monitoring of the― G− 27 ―― 39 ―

condition, either transparent film dressings or dressings designed to treat dermal wounds may beconsidered.
［Rating］C1［Analysis］There are ten Evidence Level V casereports documenting the use of hydrocolloid for thetreatment of redness. However, these case reports do
not deal specifically with pressure ulcers with theredness/purpura, but also include discussion ofpressure ulcers at other stages, and therefore do not
specifically address the efficacy of hydrocolloid in the1）treatment of redness/purpura .
Before applying the transparent film dressing,cleanse the skin where the dressing is to be applied.
The dressing should be changed at a frequency ofonce per week. Continue visual monitoring of theredness or purpura through the dressing. If the tissue
damage progressed from the epidermis to the dermis,change treatment for erosion or shallow ulcers. Again,
in order to ensure that these steps can be taken whennecessary, a transparent dressing which allows visualmonitoring is highly recommended.
References
1 ）Itou T, Takahashi R, Suzuki C, et al：The use ofhydrocolloid dressing in the treatment of pressure
ulcer. Jpn J Nur Sci, 20（12）：75-80, 1995.（Level V）（Japanese）

CQ 2. 4：Which dressings are recommended forcases involving blistering?
［ Recommendation ］While leaving the blisters intact, consider using a transparent film dressing toprotect the wound surface. A dressing for dermal
wounds that allows observation may also be considered.
［Rating］C1［ Analysis ］The use of dressings for blisters is
1）
supported only by expert opinion . A transparent
film dressing is recommended for the protection ofblistering areas from friction or shear. Before applying
the transparent film dressing, cleanse the skin where
the dressing is to be applied. As a rule dressingsshould be changed at least once per week. If theblisters are tense, they may be punctured and drained1）
to relieve pressure . If the blisters are ruptured andthe wound begins to penetrate to the dermis, switch
to a treatment for erosion or shallow ulcers. Again, inorder to ensure that these steps can be taken whennecessary, a transparent dressing which allows visualmonitoring is highly recommended.
References
1 ）Kishinabe M：How to treat blister?, Guideline for
local treatment of pressure ulcers. Miyachi Y, Sanada
H ed, 145-149, Medical Review Co., Ltd, Tokyo, 2007.
（Level VI）（Japanese）

CQ 2. 5：Which dressings are recommended fortreating erosions or shallow ulcers?
［Recommendation］
1. A health insurance-covered hydrocolloid dressing
used to treat dermal wounds is recommended. A
hydrocolloid dressing used to treat subcutaneous
wounds is also an option, but is not covered by healthinsurance.
［Rating］B［Recommendation］
2. Health insurance-covered dressings designed totreat dermal wounds, such as hydrogel, polyurethane
foam sheets, alginate foam dressing, and chitin
membrane may be considered. Dressings designed totreat subcutaneous wounds, such as hydrogel, hydropolymer, polyurethane foam, polyurethane foam/
soft silicone, alginate, and chitin membrane can also be
employed with equal effect, but are not covered byhealth insurance.
［Rating］C1［Analysis］
1）・Hydrocolloid: One systematic review and one
2）meta-analysis have examined the use of hydrocolloid
for the topical treatment of pressure ulcers. The
systematic review compared hydrocolloid to wet-tomoist saline gauze dressings and found hydrocolloids
to be superior to the latter in terms of wound size
reduction, absorption of exudates, frequency of
replacement, pain felt when dressing is changed, side
effects, and cost. However, because stage III pressure
ulcers are included in the study, the specific relevanceof the findings to erosions and shallow ulcers remains
2）
unclear. The meta-analysis found hydrocolloid 72%
more effective（ odds ratio: 1. 72 ）than wet-to-moist
gauze or paraffin-gauze dressings, but omits any
discussion of the depth of the wounds observed in the
study. Because the specific relevance of these results
to erosions and shallow ulcers is not clear, the― G− 28 ―― 40 ―

methods described here have been assigned therecommendation rating of B.
・Hydrogel: Two randomized controlled trials haveexamined the healing rate following use of various
3, 4）
dressings . These studies found no significant
difference in efficacy between wet-to-moist gauze
dressings and hydrocolloids. Furthermore, as thestudy included stage III and IV pressure ulcers, thespecific relevance of the findings to cases of erosions

matic review of the use of hydorocolloids in thetreatment of pressure ulcers. J Clin Nurs, 17（ 9 ）：1164-1173, 2008.（Level I）
2）Singh A, Haler S, Menon GR, et al：Meta-analysis ofrandomized controlled trials on hydrocolloid occlusive
dressing vs conventional gauze dressing in thehealing of chronic wounds. Asian J Surg, 27（ 4 ）：326-332, 2004.（Level I）
3）Mulder GD, Altman M, Seeley JE, et al：Prospective

and shallow ulcers remains unclear. For this reason,
the methods discussed here have been assigned therecommendation rating of C1.

randomized study of the efficacy of hydrogel,hydrocolloid, and saline solution-moistened dressingson the management of pressure ulcers. Wound Repair

5）・Hydropolymer: One randomized controlled trial
examined the efficacy of hydropolymer on healingrate. In a comparison of hydropolymer with hydrocol-

loid using stage II and III pressure ulcers, the study
found no significant difference in healing time or
healing rate. As the study was designed as asuperiority trial, we cannot be certain that the efficacyof the hydropolymer was equal to that of thehydrocolloid.
For this reason the methods discussed here havebeen assigned the recommendation rating of C1.
・Polyurethane foam: A randomized controlled
6）
trial comparing the healing rate for stage II pressure
ulcers treated with saline gauze dressings or
polyurethane foam found no significant difference inthe time required for wound closure, but thefrequency required for changing the dressings was
significantly lower for polyurethane foam（ p ＜0.001）. However, because no significant difference intime required for wound closure was found, themethods discussed here have been assigned therecommendation rating of C1.
・Polyurethane foam/soft silicone: One randomized
controlled trial examined the recovery rate in stage II
pressure ulcers after use of polyurethane foam
dressings but found no significant difference with the7）
use of hydropolymer dressing . For this reason,
polyurethane foam/soft silicone dressing has been
given a recommendation rating of C1.
・Alginate foam, chitin membrane, and alginate: No
studies addressing the use of these dressings on
erosions and shallow ulcers exist. Recommendations
for their use are supported only by expert opinion.
References
1）Heyneman A, Beele H, Vanderwee K, et al：A syste-

Regen, 1（4）：213-218, 1993.（Level II）
4）Thomas DR, Goode PS, LaMaster K, et al：Acemannan hydrogel dressing versus saline dressing forpressure ulcers. Adv Wound Care, 11（6）：273-276,
1998.（Level II）
5）Thomas S, Banks V, Bale S, et al：A comparison of
two dressings in the management of chronic wounds.
J Wound Care, 6（8）：383-386, 1997.（Level II）
6）Payne WG, Posnett J, Alvarez O, et al：A prospective,
randomized clinical trial to assess the costeffectiveness of a modern foam dressing versus a
traditional saline gauze dressing in the treatment ofstage II pressure ulcers. Ostomy Wound Manage, 55（2）：50-55, 2009.（Level II）
7）Maume S, Van De Looverbosch D, Heyman H, et al：
A study to compare a new self-adherent soft silicone
dressing with a self-adherent polymer dressing instage II pressure ulcers. Ostomy Wound Manage, 49（9）：44-51, 2003.（Level II）

CQ 2. 6：Which dressings are recommended forpressure ulcers involving pain?
［Recommendation］Dressings cannot remove pain
but can lessen it by protecting the wound surface andmaintaining a moist environment conducive to woundhealing. When changing dressings, perform adequate
pain assessment and apply a hydrocolloid,
polyurethane foam, polyurethane foam/soft silicone,®
Hydrofiber , chitin membrane, or hydrogel.
［Rating］C1［Analysis］
1）・Hydrocolloid: One systematic review examines
the pain associated with pressure ulcers, but does notaddress the relationship between pain and different
2）types of dressing. Only one cross-sectional study
examines this relationship and reports a significantly― G− 29 ―― 41 ―
9）

greater efficacy in diminishing pain for hydrocolloid
than for saline gauze dressings or transparent filmchanged . However, no statistical data have beenoffered in the study to corroborate this claim.

dressings（ p ＜ 0. 02 ）. For this reason, hydrocolloid
has been given a recommendation rating of C1 interms of pain reduction.

*Hydrogel: There are no studies assessing theefficacy of hydrogel dressings in reducing or relieving
pain when dressings are being changed. However, its

Because pressure ulcers may cause considerable
pain, adequate pain assessment is required. Because
the pain-reducing properties of the hydrocolloid

use is endorsed by expert opinion.

dressing are most effective within a occlusive or moist
3, 4）
environment it may be used to lessen pain experienced when dressings are changed. However, when

1 ）Pieper B, Langemo D, Cuddigan J：Pressure ulcer

used on fragile skin, it should be removed with utmost
care in order to avoid damaging tissue.
・Polyurethane foam: Two randomized controlled

Wound Manage, 55（2）：16-31, 2009.（Level I）

trials have examined the pain associated with
5, 6）
pressure ulcers . Of these studies, one comparedhydrocolloid to polyurethane foam and reported asignificantly lower level of pain associated withpolyurethane foam when the dressings were changed（p ＜ 0.005）. However, the second study, examining
the pains reported by patients when saline gauze
dressings and polyurethane film dressings were
simultaneously used, to the pains reported when
polyurethane foam was used, stated that there was no
significant difference between these two groups interms of the pain or degree of discomfort reported
when the dressings were removed. On these grounds,
polyurethane foam has been assigned a recommendation rating of C1.
・Polyurethane foam/soft silicone: A case reportexamining the pain associated with the use of various
types of dressing claimed that 93% of patients treatedwith polyurethane foam/soft silicone dressings ex-

References
pain：A systematic literature review and nationalpressure ulcer advisory panel white paper. Ostomy
2）Dallam L, Smyth C, Jackson BS, et al：Pressure ulcer
pain：assessment and quantification. J Wound
Ostomy Continence Nurs, 22（5）：211-215, 1995.
3 ）Hashizume K, Kitaya R, Tsurumi M, et al：Clinicaleffect of occlusive dressing Comfeel on decubitus. J
New Rem Clin, 46（10）：1348-1360, 1997.（Level V）（Japanese）
4）Asakura K, Takahashi R, Suzuki C, et al：Utility ofocclusive dressing Comfeel on decubitus. Jpn J Med
Pharm Sci, 33（ 1 ）：87-200, 1995.（ Level V ）（Japanese）
5）Banks V, Bale S, Harding K：The use of two dressings for moderately exuding pressure sores. J Wound
Care, 3（3）：132-134, 1994.（Level II）
6 ）Banks V, Bale S, Harding K：Superficial pressure
sores：comparing two regimens. J Wound Care, 3（1）：8-10, 1994.（Level II）
7）Hurd T, Gregory J, Jones A, et al：A multi-centre inmarket evaluation of ALLEVYN Gentle Border.
Wounds UK, 5（3）：32-44, 2009.（Level V）
8）Parish LC, Dryjski M, Cadden S, et al：Prospective

perienced no pain when the dressings were beingchanged and that all subjects reported satisfaction

clinical study of a new adhesive gelling foam dressing

with the use of this product; recommendation rating
C1.
®
・Hydrofiber : One case report examined the pain
associated with pressure ulcers on the basis of results
obtained from 23 patients who were treated with
8）
Hydrofiber . Although the study found that®
Hydrofiber was effective in reducing pain 90% or（Level V）

more in stage II〜IV pressure ulcers, no comparison
to other types of dressing was included in the study.
Chitin: One case report examined the analgesic
effect of chitin dressings in 32 patients and found thatof the 19 patients who were successfully assessed, 15
reported less pain when dressings were being

in pressure ulcers. Int Wound J, 5（1）：60-67, 2008.
9 ）Ueyama T：Treatment of the decubitus by theflocculent chitin. J New Rem Clin, 43（2）：291-299,
1994.（Level V）（Japanese）

CQ 2. 7：Which dressings are recommended inpressure ulcers with excessive exudate?
［Recommendation］
1. Recommend using polyurethane foam dressings,
which can absorb excess exudates.
［Rating］B［Recommendation］
2. Dressings normally used for subcutaneous― G− 30 ―― 42 ―

wounds as well as dressings used to treat deeper
wounds involving muscle and bone, such as alginate/
CMC, polyurethane foam/soft silicone dressings,®
alginate, alginate foam, chitin membrane, Hydrofiber ,or hydropolymer dressings, may be applied.
［Rating］C1［ Analysis ］The one systematic review which
discusses the use of polyurethane foam dressings does
not mention its efficacy in absorbing exudates as an
2）outcome. Nonetheless, a randomized controlled trial
found that polyurethane foam was significantly more
effective（ p ＜ 0. 001 ）in absorbing exudates thanReferences
1）Heyneman A, Beele H, Vanderwee K, et al：A systematic review of the use of hydrocolloids in thetreatment of pressure ulcers. J Clin Nurs, 17（ 9 ）：1164-1173, 2008.（Level I）
2）Bale S, Squires D, Varnon T, et al：A comparison of
two dressings in pressure sore management. J Wound
Care, 6（10）：463-466, 1997.（Level II）
3）Beele H, Meuleneire F, Nahuys M, et al：A prospective randomized open label study to evaluate thepotential of a new silver alginate/ carboxymethylcel-hydrocolloids, and for this reason the use ofpolyurethane foam has been assigned the recommendation rating of B.

lulose antimicrobial wound dressing to promotewound healing. Int Wound J, 7（ 4 ）：262-270, 2010.
（Level II）

On the other hand, alginate/CMC（carboxymethylcellulose ）, polyurethane foam/soft silicone, alginate,®
chitin membrane, Hydrofiber , and hydropolymer, are
not discussed in any high-evidence level studies andso they have been assigned the recommendation
rating of C1.
Beele et al. examined the effect of silver-containing
alginate/CMC and non-silver-containing alginate/
CMC in a randomized controlled trial using 36
patients with moderate to high levels of exudates
from pressure ulcers or varicose ulcers and foundsignificantly higher level of wound-size reduction inpatients treated with silver-containing alginate dres3）
sings（p = 0.017） . However, due to the fact that thisstudy fails to assess the capacity of these dressings toabsorb exudates, the methods discussed here havebeen assigned a recommendation rating of C1.
4）
A randomized controlled trial . compared theability of polyurethane foam/soft silicone and hydropolymer to absorb exudates and found that while
there was no statistical difference in absorptive4）Maume S, Van De Looverbosch D, Heyman H, et al：capacity between these two types of dressing,polyurethane foam/soft silicone dressings were super-

study of a new adhesive Gelling foam dressing inior in preventing damage and maceration to skin in
the wound periphery（p ＜ 0.05）. Because there wasno difference in the absorptive capacity of thesedressings, their use has been assigned the recommendation rating of C1.
The use of alginate, alginate foam, chitin membrane®
Hydrofiber , and hydropolymer dressings is addressed only in case reports; recommendation rating:
5−10）
.
C1

A study to compare a new self-adherent soft silicone
dressing with a self-adherent polymer dressing instage II pressure ulcers. Ostomy Wound Manage, 49（9）：44-51, 2003.（Level II）
5）Harada S, Nakanishi H, Kawabata Y：Clinical Evaluation of SORBSAN（Calcium alginate fiber dressing）
for the treatment of skin ulcer. J New Rem Clin, 10（2）：473-495, 1994.（Level V）（Japanese）
6）Tsukada K：Usefulness of sponge- type alginate gel
dressing on tissue granulation of pressure ulcers. Jpn
JPU, 5（1）：27-32, 2003.（Level V）（Japanese, English abstract）
7）Ueyama T：Treatment of the decubitus by the flocculent chitin. J New Rem Clin, 43（ 2 ）：291-299,
1994.（Level V）（Japanese）
8）Coutts P, Sibbald R：The effect of a silver-containing®

Hydrofiber dressing on superficial wound bed andbacterial balance of chronic wounds. Int Wound J, 2（4）：348-356, 2005.（Level V）
9）Parish LC, Dryjski M, Cadden S：Prospective clinicalpressure ulcers. Int Wound J, 5（ 1 ）：60-67, 2008.
（Level V）
10）Ohura T：Clinical experience with a new hydropolymer dressing. Jpn JPU, 4（ 1 ）：105-110, 2002.
（Level V）（Japanese, English abstract）

CQ 2. 8：Which dressings are recommended forpressure ulcers with minimal amounts of exudates?
［Recommendation］
1. Using a hydrocolloid dressing is recommended.
［Rating］B― G− 31 ―― 43 ―

excessive exudates because of its superior absorptive［Recommendation］
2. Using a hydrogel may be considered.
［Rating］C1［Analysis］
・Hydrocolloid: One meta-analysis exists addressing
the use of hydrocolloid dressing for local treatment of1）pressure ulcers . In this study, hydrocolloid wasfound to be 72% more effective in healing pressure
ulcers than conventional saline gauze dressings orparaffin-gauze dressings（odds ratio: 1.72）.However,as no mention is made of the capacity of each type ofdressing to absorb exudates, the recommendation
merits a level of B.
Hydrogel: Two randomized controlled trials haveexamined the efficacy of hydrogel in promoting
2, 3）
granulation tissue formation , but a comparison
with saline gauze dressings and hydrocolloid dressings failed to show a significant difference in thisregard. While the study deals with the treatment ofstage II〜IV pressure ulcers, it does not address theefficacy of hydrogel dressings for the treatment ofpressure ulcers with low amounts of exudates andtherefore merits a recommendation rating of only C1.
References
1）Singh A, Haler S, Menon GR, et al：Meta-analysis ofrandomized controlled trials on hydrocolloid occlusive
dressing vs conventional gauze dressing in thehealing of chronic wounds. Asian J Surg, 27（ 4 ）：326-332, 2004.（Level I）
2）Thomas DR, Goode PS, LaMaster K, et al：Acemannan hydrogel dressing versus saline dressing forpressure ulcers. Adv Wound Care, 11（6）：273-276,
1998.（Level II）
3）Mulder GD, Altman M, Seeley JE, et al：Prospective
randomized study of the efficacy of hydrogel,hydrocolloid, and saline solution-moistened dressingson the management of pressure ulcers. Wound Repair
Regen, 1（4）：213-218, 1993.（Level III）

CQ 2. 9：Which dressings are recommended for
infected and inflamed pressure ulcers?
［Recommendation］
1. Consider using topical agents to suppress®
infection. Alternatively, silver-containing Hydrofiberor alginate silver may be used.
［Rating］C1
2. Alginate is sometimes used to dress wounds withability, but cannot be recommended here due to its
inability to suppress infection.
［Rating］C2
1）［Analysis］One systematic review has addressed®
the use of silver-containing Hydrofiber in the context
of wound infection and inflammation. In 26 randomized controlled trials dealing with the use of silver inthe localized treatment of acute phase and chronicallycontaminated and infected wounds failed to detect asignificant difference in the infection rate as an
outcome. Due to this observation, it was concluded
that there is inadequate evidence to support the use ofsilver as a means of suppressing infection. Further,even in their systematic review, which documents theefficacy of silver in the treatment of infected wounds,
Toy and Macera state that there is insufficientevidence to endorse the use of silver-containing foam
dressings to treat chronically contaminated and2）
infected wounds .
Three randomized controlled trials have addressed
the use of silver alginate to suppress infection in
3−5）pressure ulcers . The studies found that silvercontaining alginate/CMC not only resulted in agreater reduction in wound size than non-silvercontaining alginate/CMC,（p = 0.017）, but also in asignificantly better healing rate four weeks into
treatment（p = 0.044）.On the basis of these findings,
it was concluded that silver-containing alginate/CMC
has a significantly greater effect on promoting healing
in pressure ulcers and suppressing infection. On theother hand, other studies report disparate results,
with Trial et al. claiming that a comparison of alginate
and silver-containing alginate failed to show any
4）difference in the clinical scores for infection , andMeaume et al. claiming that while there was no
statistically significant difference in wound infection
rate after use of silver-containing alginate（33%）andalginate（46%）, the healing rate for silver-containing
5）
alginate was appreciably higher（p = 0.024） . On the®
basis of these findings, silver-containing Hydrofiberor silver alginate may be used to treat infected or
inflamed wounds. However, when the evidence from1, 2）
the systematic reviews is taken into account, it isclear that the use of these dressings to treat infected
wounds is not supported by adequate evidence. In
addition, because of the unavailability in Japan, andvarying silver content, of some of the products― G− 32 ―― 44 ―

examined in the aforementioned studies, the ability ofthese dressings to suppress infections cannot beclearly assessed. Therefore the methods discussed
here have been assigned the recommendation ratingof C1.
Alginate is sometimes used for its superior absorptive qualities to treat pressure ulcers with large
quantities of exudates. However, as it has no
demonstrable ability to suppress infection, its use is
not recommended.
One randomized controlled trial examined the use
5）of alginate on infected wounds . The study found thatin 71 cases of varicose ulcer and 28 cases of pressure
ulcer all requiring infection suppression, no difference
in result was seen in wound infection rate between thegroups treated with alginate and silver-containing
5）
alginate . On the basis of the reports, we may
conclude that although alginate is sometimes used forits superior ability to absorb exudates, it has no
demonstrable ability to suppress wound infection andtherefore cannot be recommended.
References
1）Storm-Versloot MN, Vos CG, Ubbink DT, et al：Topicalsilver for preventing wound infection, Cochrane
Wounds Group, Cochrane Database of Systematic
Reviews 2010, Issue 3. Art.（Level I）
2）Toy LW, Macera L：Evidence-based review of silver
dressing use on chronic wounds. J Am Acad Nurse［ Recommendation ］Alginate, hydrocolloid, hydropolymer, polyurethane foam, polyurethane foam/®
soft silicone, chitin membrane and Hydrofiber may
be considered.
［Rating］C1［Analysis］*Alginate: There is one systematic review examin1）
ing the use of silver-containing dressings and one
randomized controlled study examining the use of2）
alginate to treat pressure ulcers . The systematic
review does not draw any conclusions regarding theefficacy of silver-containing dressings in promoting
granulation tissue formation, while the randomized
controlled trial reported that significantly greater
reductions in wound size were achieved with the useof hydrocolloid following treatment with alginate thanwith the use of hydrocolloid alone（p ＜ 0.01）. However, as the study did not examine the effect of using
alginate alone, the recommendation level merits arating of C1.
*While there are randomized controlled trials
examining the use of hydrocolloid, hydropolymer,
polyurethane foam, and polyurethane foam/softsilicone, none of these studies reports on the effect ofthese dressings on granulation tissue formation;
recommendation level: C1.
®
*Chitin and Hydrofiber are addressed only in casereports. As the evidence level is low, the recommendation rating given is C1.

Pract, 23（4）：183-192, 2011.（Level I）

References

3）Beele H, Meuleneire F, Nahuys M, et al：A prospective randomized open label study to evaluate the1 ）Carter MJ, Tingley-Kelley K, Warriner RA 3rd：potential of a new silver alginate/carboxymethylcel-

Silver treatments and silver-impregnated dressingslulose antimicrobial wound dressing to promote

for the healing of leg wounds and ulcers：A

wound healing. Int Wound J, 7（ 4 ）：262-270, 2010.

systematic review and meta-analysis. J Am Acad

（Level II）

Dermatol, 63（4）：668-679, 2010.（Level I）

4）Trial C, Darbas H, Lavigne JP, et al：Assessment of2）Belmin J, Meaume S, Rabus MT, et al：Investigators

the antimicrobial effectiveness of a new silver alginateof the sequential treatment of the elderly withwound dressing：a RCT. J Wound Care, 19（ 1 ）：pressure sores（STEPS）trial. Sequential treatment

20-26, 2010.（Level II）

with calcium alginate dressings and hydrocolloid5）Meaume S, Vallet D, Morere MN, et al：Evaluation ofdressings accelerates pressure ulcer healing in older

a silver-releasing hydroalginate dressing in chronic

subjects：a multicenter randomized trial of sequen-wounds with signs of local infection. J Wound Care, 14

tial versus nonsequential treatment with hydrocolloid（9）：411-419, 2005.（Level II）

dressings alone. J Am Geriatr Soc, 50（2）：269-274,
2002.（Level II）

CQ 2. 10：Which dressings are recommended for
promoting granulation tissue formation in pressure
ulcers where it is deficient?

CQ 2. 11：Which dressings are recommended inpressure ulcers with deficient granulation tissue― G− 33 ―― 45 ―

formation and suspected critical colonization?
［Recommendation］Consider using silver-containing®
Hydrofiber or alginate silver.
［Rating］C1［Analysis］A systematic review using indicationsof critical colonization as a measure compared the®
effect of silver-containing Hydrofiber and other typesof dressing on wound size reduction and healing
1）
rate . However, this study failed to arrive at any
conclusions regarding pressure ulcers where criticalcolonization was suspected due to insufficient granulation tissue formation. Of the randomized controlled2）
trials discussed in the systematic review , althoughsignificant reductions in wound size were reported（p= 0. 0019 ）, only 8% of the subjects enrolled werepressure ulcer patients. There is also one randomized
controlled trial examining the effect of silvercontaining alginate on varicose ulcers requiring infection suppression and pressure ulcers. In a comparisonof silver-containing alginate and non-silver-containing
alginate on 24 cases of varicose ulcer in the criticalcolonization phase or at risk of infection and 12 casesof pressure ulcer, the study found that while there
was no exacerbation of infection in either group,
significantly greater reductions in wound size wereachieved in the silver-containing alginate group（p =0. 017 ）. However, because the number of pressure
ulcer patients enrolled was small, and no discussion
about granulation formation in these cases was
included, the methods discussed here have been
assigned a recommendation rating of C1.
References
1）Beam JW：Topical silver for infected wounds. J Athl
Train, 44（5）：531-533, 2009.（Level I）
2 ）Munter KC, Beele H, Russell L, et al：Effect of asustained silver-releasing dressing on ulcers withdelayed healing：the CONTOP study. J Wound Care,15（5）：199-206, 2006.（Level II）
3）Beele H, Meuleneire F, Nahuys M, et al：A prospective randomized open label study to evaluate thepotential of a new silver alginate/carboxymethylcellulose antimicrobial wound dressing to promotewound healing. Int Wound J, 7（ 4 ）：262-270, 2010.
（Level II）

CQ 2. 12：Which dressings are recommended topromote the reduction of the size of wounds withadequate/normal granulation tissue formation?
［Recommendation］®

1. Using silver-containing Hydrofiber , alginate
silver, or alginate is recommended.
［Rating］B［Recommendation］
2. Hydrocolloid, hydrogel,hydropolymer,

polyurethane foam, polyurethane foam/soft silicone
dressing, alginate foam, chitin membrane,®
Hydrofiber , alginate/CMC are also options, depending on the amount of exudate present.
［Rating］C1
1）［Analysis］The one systematic review examining®
the effect of silver-containing Hydrofiber concluded
that while wound reduction could be achieved in the®

short term, Hydrofiber could not be recommended
for promoting wound healing due to the paucity ofevidence; recommendation rating B.
In their randomized controlled trial, Beale et al.
reported the efficacy of silver alginate on wound-size
reduction, but their comparison of silver-containing
alginate/CMC and non-silver-containing alginate/
CMC concluded that the use of silver-containing
alginate led to greater reductions in wound size
compared to alginate alone（p = 0.017）and therefore
2）
to a stronger wound healing effect . On the basis of
this conclusion, the use of silver-containing alginate
has been assigned a recommendation rating of B.
Although the wound reduction effect of alginate ismentioned in a systematic review by Madhuri et al.,3）
the study failed to offer clear proof of this assertion .
4）
In a randomized controlled trial , the result of acomparison of alginate and dextranomer paste foundthat wounds treated with alginate showed greater
reduction in size. Further, in an eight-week experiment one group of subjects was treated with alginate
for the first four weeks, then with a combination ofalginate and hydrocolloid for the next four weeks.
Another group was treated for eight weeks withhydrocolloid alone. A comparison of the results
indicated greater reductions in wound size for theformer（p ＜ 0.01）. Accordingly the methods discussed here have been given the recommendation ratingof B.
On the basis of these reports, consider using silver®
containing Hydrofiber , silver alginate, or alginate
when attempting to achieve wound-size reduction incases with adequate granulation formation.

― G− 34 ―― 46 ―

A systematic review claiming greater efficacy inwound-size reduction for hydrocolloid in a comparison
5）with saline gauze dressings also states that no
significant difference in efficacy was found in a

CQ 2.13：Which dressings are recommended whennecrotic tissue is present?

comparison of hydrocolloid with alginate, hydrogel,and polyurethane foam. For this reason, the use ofhydrocolloid has been accorded the same recom-［ Recommendation ］If surgical debridement or
topical agents capable of removing necrotic tissue areunavailable, hydrogel may be considered.

mendation rating of C1 as the other types of dressing
previously discussed.
Although a number of randomized controlled trials［Rating］C1［ Analysis ］One randomized controlled trial examined the use of hydrogel and dextranomer paste inhave examined the other types of dressing, includinghydrogel, hydropolymer, and polyurethane foam, noneof these studies documented evidence pertaining totheir efficacy in wound reduction. Polyurethane®
foam/soft silicone, alginate foam, chitin, Hydrofiber ,and aliginate/CMC have been discussed in caseconnection with the removal of necrotic tissue andreported no significant difference in the rate ofremoval of necrotic tissue for either type of dressing.
The recommendation level assigned to these dres-

reports only; recommendation rating: C1.
From these reports, any of the dressings discussed
above, namely hydrocolloid, hydrogel, hydropolymer,
polyurethane foam, polyurethane foam/soft silicone,®
alginate foam, chitin, Hydrofiber , and alginate/CMC
can be used according to the amount of exudates.

hydrogel with endopeptidase was used to treat stage
II and III pressure ulcers assessed clinically as
2）
infected and requiring removal of necrotic tissue .
The stage II and III pressure ulcers which had notbeen treated for three months prior to commencement of the study healed in an average of 3.3 weeks
and 6.5 weeks, respectively, but the effect of hydrogel
could not be assessed because it was used in
combination with other dressings.

References
1 ）Carter MJ, Tingley-Kelley K, Warriner RA, et al：1164-1173, 2008.（Level I）

sings is therefore C1. In addition to these studies,
Parnell et al. have published a case report in which

Silver treatments and silver-impregnated dressings

References

for the healing of leg wounds and ulcers：A
systematic review and meta-analysis. J Am Acad

1 ）Colin D, Kurring PA, Yvon C：Managing sloughypressure sores. J Wound Care, 5（10）：444-446, 1996.

Dermatol, 63（4）：668-679, 2010.（Level I）
2）Beele H, Meuleneire F, Nahuys M, et al：A prospec-2）Parnell LK, Ciufi B, Gokoo CF：Preliminary use of ative randomized open label study to evaluate thehydrogel containing enzymes in the treatment ofpotential of a new silver alginate/ carboxymethylcel-

stage II and stage III pressure ulcers. Ostomy Woundlulose antimicrobial wound dressing to promote

Manage, 51（8）：50-60, 2005.

wound healing. Int Wound J, 7（ 4 ）：262-270, 2010.

CQ 2. 14：Which dressings are recommended if（Level II）
3 ）Madhuri R, Sudeep S, Rochon P：Treatment ofpressure ulcers：A systematic review. JAMA, 300（22）：2647-2662, 2008.（Level I）
4 ）Belmin J, Meaume S, Rabus MT, et al：Sequential
treatment with calcium alginate dressings andhydrocolloid dressings accelerates pressure ulcer
healing in older subjects：A multicenter randomized
trial of sequential versus nonsequential treatment
with hydrocolloid dressings alone. J Am Geriatr Soc,
50（2）：269-274, 2002.（Level II）
5 ）Heyneman A, Beele H, Vanderwee K, et al：A
systematic review of the use of hydrocolloids in thetreatment of pressure ulcers. J Clin Nurs, 17（ 9 ）：undermining is found?
［ Recommendation ］If necrotic tissue is present
within the undermining, first remove this throughlavation. If the amount of exudate is excessive,®
consider using alginate, silver-containing Hydrofiber ,or alginate silver.
［Rating］C1［Analysis］One case report claimed favorable results for the use of alginate inside the undermining, after
granulation formation and reduction in the size of the1）
undermining were achieved（Evidence Level V） .
No studies have been published on the efficacy of®
silver-containing Hydrofiber and silver alginate― G− 35 ―― 47 ―

when applied to undermining, and the method isendorsed only by expert opinion（ Evidence Levelthe comparison group across three parameters, the
DESIGN-R score, the PUSH score, and changes in

VI ）. When using these dressings inside the woundpocket, care must be taken not to force the dressing
too deeply into the cavity or cause undue pressure on

wound size . However, the cost of wrap dressings
was appreciably lower than that of other types ofthe surrounding tissue surfaces. If necrotic tissue
remains, prioritize debridement.
References
1）Tsukada K：Usefulness of sponge-type alginate gel
dressing on tissue granulation of pressure ulcers . Jpn
JPU, 5（ 1 ）：27-32, 2003.（ Japanese, English abstract）

CQ 2.15：Is the so-called\wrap dressingS* effective in treating pressure ulcers?
［Recommendation］Wrap dressings can be considered for use whenever medically approved dressingsare unavailable or difficult to obtain on a continual
basis, such as in a home based medical care. However,use of the wrap dressing should be supervised by aphysician with an adequate knowledge of pressure
ulcer care and only after the patients and their family
have been instructed in the procedure and given theirconsent.
\* Wrap dressing Sis a dressing technique ofcovering wounds with non-medically approved（unsterilized ）and non-adhesive commercially available
plastic wrap.
［Rating］C1［ Analysis ］A comprehensive survey of evidence
pertaining to the\wrapSmethod of dressing wounds
showed that while there is an abundance of casereports and comments by specialists, there is only one
randomized clinical trial, and two non-randomized

2）

dressing. Further, in a non-randomized controlled trial
3）
involving adult patients , no difference was recorded
in midpoint of treatment period for wrap dressingsand conventional dressings（p = 0.92）. However, thedaily cost of wrap dressings was significantly lower. In
all three of these clinical trials there was no difference
between wrap and other types of dressing in terms ofworsening symptoms or deleterious effects. However,4）
one case report claimed that there were two cases inwhich symptoms worsened as a result of the use of
wrap dressings.
On the basis of the reports discussed above, and inaccordance with the official position of the 2010 Boardof the Japan Society of Pressure Ulcers, the use of
officially approved dressings is recommended for thetreatment of pressure ulcers. As a non-medicallyapproved item, the wrap dressing may be considered
for use in home based medical care and other settings
in which the continued use of approved dressings
maybe difficult. However, its use should be supervised
by a physician with an adequate knowledge ofpressure ulcer care and only after the patients andtheir family have been instructed in the procedureand given their consent.
References
1 ）Takahashi J, Yokota O, Fujisawa Y, et al：An
evaluation of polywvinylidene film dressing fortreatment of pressure ulcers in older people. J Wound
Care, 15（10）：449-454, 2006.（Level III）
2）Mizuhara A, Bito S, Onishi S, et al：The therapeuticclinical trials systematically comparing this dressing
to standard dressings.

effectiveness of wrap therapy: A study comaring

A non-randomized controlled trial involving subjects with class III〜IV class pressure ulcers（according to the NPUAP guidelines）, found a significantly
greater reduction in wound size after 12 weeks

guidelines. Jpn JPU, 13（ 2 ）：134-141, 2011.（ Levelfollowing the use of wrap dressings in comparison to
the control dressings, as indicated by the DESIGN
1）scores（p = 0.011） . The cure rate and the exacerbation rate were the same. Furthermore, a randomized

wrap therapy to standard therapy per current
II）（Japanese, English abstract）
3）Ueda T, Shimokubo S, Honda K, et al：The evaluationof food-wrap treatment for pressure ulcers. Jpn JPU,
8（4）：551-559, 2006.（Level III）（Japanese, English
abstract）
4 ）Moriyama Y：Severe complication associated withclinical trial conducted jointly involving NPUAP class
II〜II adult pressure ulcer patients found no significant difference in effect between wrap dressings and― G− 36 ―inadequate wet dressing therapy:benefits and risks ofso-calledhwrap therapyi. Jpn J Dermatol, 120（11）：2187-2194, 2010.（ Level V ）（ Japanese, English abstract）

― 48 ―

Fig. 3 Algorithm illustrating options for surgical interventions

CQ 3 Surgical Intervention
In cases requiring surgical intervention for thetreatment of pressure ulcers, the use of anesthetics,
postoperative positioning, and other perioperative
matters must be managed with care. The timing andextent of the surgery will largely be determined byindications for reconstructive surgery separatelyfrom any discussion of the condition of the pressure
ulcer as a local factor more pertinent to the question ofwhether or not surgical debridement should be
employed. Surgical treatment of undermining is also
addressed in a separate CQ as a factor resistant to

the general state of the patientSs physical health aswell as the condition of the specific area targeted forintervention.
As indicated in thehAlgorithm on the prevention

conservative treatment.
Further, given the fact that even deep ulcers（D3）do not always require reconstructive surgery but may
be treated successfully with conservative treatments

and management of pressure ulcersi（Fig. 1）, surgical intervention is seen as one option for local

that promote granulation tissue formation to achieve
wound closure, the general topic of surgical treatment

treatment of pressure ulcers.
Importantly,\ Pressure ulcer present Sin the
hAlgorithm on surgical interventioni（Fig. 3）is tobe understood as referring to patients who have

has been divided into surgical debridement andreconstructive surgery for more separate discussion.
In addition, the use of negative pressure woundtherapy（NPWT）to treat wounds resulting from thealready received systemic care and predictive assessment, but whose existing pressure ulcers have proved

removal of necrotic tissue following surgical debridement is considered in CQ in this section.

resistant to conservative forms of treatment, such as
topical agent and dressing.
Determining the optimal area of the pressure ulcer
to be treated with surgical intervention and deciding
the best timing for the procedure are often difficult.

CQ 3. 1：Is surgical debridement indicated whensigns of infection/inflammation of the pressure ulcer
are present?
［Recommendation］Surgical debridement may be

For this reason, we have decided to discuss the

conducted if there is evidence of pus, foul odor, or― G− 37 ―― 49 ―

osteomyelitis accompanying the infection.
［Rating］C12 ）Galpin JE, Chow AW, Bayer AS, et al：Sepsis
associated with decubitus ulcers. Am J Med, 61（3）：［Analysis］Surgical debridement should be considered when infected pressure ulcers prove resistantto systemic antibiotic administration or topical346-350, 1986.（Evidence level: IV）
3 ）National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel：Surgery for

antiseptics and dressings. Local abscesses and retention fluid should be lanced and drained to prevent
expansion into surrounding intact tissue and/or

Pressure Ulcers. Prevention and treatment of press-

progression to systemic sepsis.
The presence of hardened and thickened necrotic
tissue（ eschar ）accompanied by fever, local inflammation（ redness, swelling, and pain ）, and foul2009.

ure ulcers: clinical practice guideline, 96-99, National
Pressure Ulcer Advisory Panel, Washington DC,
4）Ratliff CR, Tomaselli N：WOCN update on evidencebased guideline for pressure ulcers. J Wound Ostomy
Continence Nurs, 37（5）：459-460, 2010.

odor may point to an underlying pus-filled abscess.
For this reason an incision into a portion of the5 ）Simpson AH, Deakin M, Latham JM：Chronic

necrotic tissue is recommended to confirm the1）presence of pus . Especially in cases in which thenidus of infection in the necrotic tissue has caused

resection on infection-free survival. J Bone Joint Surg

sepsis, it is strongly recommended that first, theabscess be incised and the sinus and fistula be drained
as soon as possible, and second, that the necrotic
tissue be removed completely if the patientSs condition allows.
Indeed the efficacy of surgical debridement incontrolling infections associated with pressure ulcers
has been corroborated by the findings of a controlled2）
study . Furthermore, two guidelines issued by
3）
4）
NPUAP/ EPUAP and WOCN assign thehStrengthof Evidenceirating of C to surgical debridement in
the presence of advancing cellulitis, crepitus, fluctuance, and/or sepsis secondary to ulcer-related

CQ 3.2：What is the optimal timing for the surgicaldebridement of necrotic tissue in pressure ulcers?
［Recommendation］
1. Surgical debridement may be considered when aclear line of demarcation between necrotic andhealthy tissue is visible.
［Rating］C1［Recommendation］
2. Surgical debridement is considered when preexisting infection has been brought under control.
［Rating］C1［Analysis］In cases in which infection has resulted
in tissue necrosis, any attempt to remove the necrotic
tissue too rapidly may result in severe pain andbleeding in the wound margins. Surgical debridement

infection. The remaining sources dealing with surgicalinterventions for the treatment of infection are
general, textbook descriptions with limited utility.
There are at present no high-level studies dealing
with the efficacy of surgical treatment of osteomyelitis
accompanying pressure ulcers. However, a cohort
study comprising 50 cases of osteomyelitis unrelated
to pressure ulcers has reported a lowered recurrence
rate following wide resectioning of degraded bone5）
tissue .
References
1 ）Bergstrom N, Bemet M, Carlson C, et al：Pressure
ulcer treatment. Clinical practice guideline：Quick

osteomyelitis. The effect of the extent of surgicalBr, 83（3）：403-407, 2001.（Evidence level: IV）

is recommended after the acute phase（ about 3
weeks）when the demarcation line between necrotic
tissue and the surrounding intact tissue has become
1, 2）clear .
Necrotic tissue which is allowed to remain within
the wound bed or on the edges of the pressure ulcers
may evolve into a nidus of infection and impede thewound healing process. For this reason, the two
guidelines previously cited recommend not only
surgical but also autolytic, enzymatic, mechanical, or
biosurgical（maggot therapy）debridement as treat1, 2）
ment options .

reference guide for clinicians. No.15. Rockville, MD：

References

U. S. Department of Health and Human Services.
Public Health Service, Agency for Health Care Policy

1）Ratliff CR, Tomaselli N：WOCN update on evidencebased guideline for pressure ulcers. J Wound Ostomy

and Research. AHCPR Pub, No.95-0653, 1994.
― G− 38 ―― 50 ―

Continence Nurs. 2010 Sep-Oct; 37（ 5 ）：459-460.

Repair of Pressure Ulcers I： Operation Techniqu.

［ Update of Wound Ostomy and Continence Nurse

Jpn JPU, 2（ 3 ）：236-243, 2000.（ Level VI ）Society: Guideline for Prevention and Management ofPressure Ulcers. Adv Skin Wound Care, 18（ 4 ）：（Japanese, English abstract）
3）Kosaka M, Morotomi T, Suzuki H：Selection of per-204-208, 2005］

forator flaps for sacral pressure ulcers with a2 ）Bergstorm N, Allman RM, Alvarez MA, et al：

subdermal pocket. Jpn JPU, 4（ 3 ）：371-378, 2002.

Treatment of Pressure Ulcers Clinical Practice（Level V）（Japanese, English abstract）

Guidelines number 15, No95-0652, US Department of
Health and Human Services. Public Health Service,
Agency for Health Care Policy and research. AHCPR
Publication, Rockville Maryland, 1994.（Level: IV）

CQ 3.3：Is surgical incision or debridement recommended if undermining is present?
［ Recommendation ］Surgical incision or debridement may be considered for treating undermining
which fails to respond to more conservative treat-

CQ 3.4：When is surgical debridement indicated?
［Recommendation］
1. Conservative treatments are the preferred
option, but surgical debridement may be performed
when infection/inflammatory signs are under control.
［Rating］C1
2. Surgical debridement may be considered forpatients with a D3 or D4 pressure ulcer.

ments.
［Rating］C1［Analysis］The presence of undermining raises thepossibility of necrotic tissue underlying the formation.
In such cases, surgical intervention to lance and drain,or debride, the abscess, sinus tract, or bursa should beconsidered if no improvement results from moreconservative treatments such as wound cleansing, orapplication of topical agents. However, a thoroughsystemic assessment should be made, including anassessment of the patientSs propensity to bleed, before
the undermining is incised with the aid of the1）
appropriate tools to stop bleeding . In cases ofpressure ulcers of long duration or with an exceptionally large cavity（DESIGN score of P3 or higher）,［Rating］C1
3. Surgical debridement may be considered according to the location of the infected pressure ulcer, thevolume and extent of the necrotic tissue, the blood
supply to the surrounding tissue, and the patient's
level of pain tolerance.
［Ratingl］C1［Analysis］Surgical debridement is generally indicated when the pressure ulcer infection has beenbrought under control and the necrotic tissue or
degraded granulation tissue fails to respond toconservative treatments. The NPUAP/EPUA andWOCN guidelines recommendh maintenance debridementifor the acute phase.
This form of treatment is indicated for wound stage
D3 or deeper. Due to the long recovery period

surgical incision of the undermining should be2）
3）
considered . On the other hand, Kosaka et al . argue

required when the pressure ulcer has invaded muscle
tissue and penetrated to the bone（ D4 ）, surgicalthat a preoperative incision to the skin overlying theundermining may lead to scar contracture andhamper reconstructive flap surgery; hence theundermining should be allowed to remain if there is noinfection. However, in cases in which surgicaldebridement is recommended in order to expedite
3）
recovery .
As indicated above, surgical debridement can prove

intervention is ruled out, incision of the pocket is still
preferable to only continuing more conservative

either too invasive or insufficient. This fact needs to beconsidered pre-operatively when evaluating thebalance of risk and benefit of the procedure to the
1, 2, 4, 5）.
patient

forms of treatment.

References
References

1）Ratliff CR, Tomaselli N：WOCN update on evidence-

1）Whitney J, Phillips L, Aslam R, et al：Guidelines forbased guideline for pressure ulcers. J Wound Ostomy

the treatment of pressure ulcers. Wound Repair

Continence Nurs. 2010 Sep-Oct; 37（ 5 ）：459-460.

Regen, 14（6）：663-679, 2006.

［ Update of Wound Ostomy and Continence Nurse

2 ）Nakamura M, Ito M：Slide-swing Plasty for the― G− 39 ―Society: Guideline for Prevention and Management of

― 51 ―

Pressure Ulcers. Adv Skin Wound Care, 18（ 4 ）：204-208, 2005］

considered rather than continue a less effective
4）
regimen .

2 ）National Pressure Ulcer Advisory Panel and Euro-An advancing wound edge fibrosis and scarpean Pressure Ulcer Advisory Panel: Debridement.

formation surrounding the pressure ulcer are signs of
5）delayed wound healing . Debridement of such
fibrotic/scar tissue typically creates a wound penet-

In: Dealey C, Cuddigan J, eds. Prevention andtreatment of pressure ulcers: clinical practice guideline. 77-80, National Pressure Ulcer Advisory Panel,
Washington DC, 2009.
3 ）Motegi S：Consideration for Better Treatment ofPressure Ulcers Based on My Experienc. Jpn JPU, 2（1）：57-64, 2000.（ Level V ）（ Japanese, English
abstract）
4 ）Kurita M, Ichioka S, Oshima Y, et al：Orthopaedic

rating beyond the subcutaneous tissue. In such cases,
reconstructive surgery should be seriously considered, as mentioned above.
Surgical removal or sequestrectomy often leaves askin defect extending beyond the subcutaneous
tissue. The need for surgical repair should seriously
be considered in such cases.

POSSUM scoring system: An assessment of the risk

Referencesof debridement in patients with pressure sores. Scand
J Plast Reconstr Surg Hand Surg, 40（4）：214-218,

1）Kizek TJ, Robson MD,Kho E：Bacterial growth andskin graft survival. Surg Forum, 18：518-519, 1967.

2006.（Level: IV）（Level: I）

CQ 3.5：When is reconstructive surgery indicated?
［Recommendation］
1. Reconstructive surgery may be considered forD3〜D4 pressure ulcers that do not respond toconservative treatment.
［Rating］C1
2. Surgical reconstruction may be considered for
ulcers showing a non-advancing edge and scarformation.
［Rating］C1
3. Reconstructive flap surgery following sequestration may be considered as a therapeutic option for
osteomyelitis in pressure ulcers.
［Rating］C1
1, 2）［Analysis］Two cohort studies of direct suturing
and skin grafts support performing wound closure
under infection-free conditions. Although these studies deal with general wounds and not pressure ulcers2）Robson MC, Lea CE, Dalton JB, et al：Quantitative
bacteriology and delayed wound closure. Surg Forum,
19：501-502, 1968.（Level: I）
3 ）Disa JJ, Carlton JM, Goldberg NH：Efficacy ofoperative cure in pressure sore patients. Plast
Reconstr Surg, 89（2）：272-278, 1992.（Level: IV）
4 ）Motegi S：Consideration for Better Treatment ofPressure Ulcers Based on My Experienc. Jpn JPU, 2（1）：57-64, 2000.（ Level V ）（ Japanese, English
abstract）
5 ）Ichioka S, Ohura N, Nakatsuka T：Benefits of surgical reconstruction in pressure ulcers with a nonadvancing edge and scar formation. J Wound Care, 14（7）：301-305, 2005.（Level: V）
6 ）Whitney J, Phillips L, Aslam R：Guidelines for thetreatment of pressure ulcers. Wound Repair Regen,14（6）：663-679, 2006.

in particular, the findings are worth listing for theirvalue in assessing surgical indication.

CQ 3.6：Which reconstructive surgical procedure isconsidered especially effective for pressure ulcers?

Surgical reconstructive surgery is recommended
for D3 or D4 pressure ulcers, which penetrate beyond
3）subcutaneous tissue . When the wound depth
extends beyond the subcutaneous tissue in areas
normally favoring pressure ulcer formation, tissue
characteristically having low blood supply such as thebone cortex, ligaments, joints and tendons capsules,［ Recommendation ］There are numerous options
for reconstructive surgery for pressure ulcers, but

are often exposed in the wound bed. When pressure
ulcers fail to close after conservative treatment,
surgical intervention to repair the wound should beinsufficient evidence on the outcome of any of theseprocedures. For this reason, no single surgicalprocedure can be recommended as applicable to allcases.
［Rating］C1［Analysis］Surgical reconstruction is indicated forpressure ulcers in which complications have beenbrought under control, and wound infection and― G− 40 ―― 52 ―

necrotic tissue have been removed by systemic,
conservative, physiotherapeutic, or surgical treat-ment of wounds following debridement of infectious or
necrotic tissue.

ment. If the decision is made to perform surgicaldebridement and reconstructive surgery simultaneously, any tissues involved in the pressure ulcer［Rating］C1［ Analysis ］Negative pressure wound therapy（ NPWT ）is designed to control the wound healing

such as skin, granulation tissue, necrotic tissue,
subdermal sinuses, abscesses, bursae, and bone must1）
first be removed surgically . According to one study,
there is no significant difference in the cure rate
2）
between simultaneous and two-stage surgery .
Within the past several years, three retrospective

process under negative pressure conditions bycovering the whole wound surface with an airtightdressing.

case controlled studies have been published comparing the recurrence rate among patients who received
3−5）. However, due tounderwent surgical procedures
the small number of cases in each study, and the lackof standardization or uniformity in perioperative
management and care, the cure and recurrence rates
claimed by these reports cannot be assessed with any
accuracy.
References
1）Yamamoto Y, Koyama A, Tsutsumida S, et al：Reconstructive Surgery with the Fasciocutaneous Flap for
the Treatment of Pressure Sores．Jpn J Plast Surg,
41（ 12 ）：1113-1119. 1998.（ Level: IV ）（ Japanese,
English abstract）
2）Foster RD, Anthony JP, Mathes SJ, et al：Flap selection as a determinant of success in pressure sorecoverage. Arch Surg, 132（8）：868-873, 1997.（Evidence level: V）

The various kinds of NPWT equipment featured inreview articles and guidelines are commerciallyavailable. When using any of these products, thewound surface should first be sealed air-tight using
the sponge specially provided for this purpose. A
1−3）
pressure of -125mmHG is typically recommended .
The WOCN

and NPUAP/EPUAP guidelines

5）

assign NPWT an evidence level of（B）for its efficacy
in rapidly reducing wound depth, and improving thehealing rate and granulation tissue formation. Furth1, 2）
er, two meta-analytical studies rated NPWT more
highly than conventional treatments for its efficacy
against chronic skin ulcers, such as diabetic, stasis,and pressure ulcers, and trauma. However, a rando6）
mized controlled trial failed to demonstrate a signifi®
cant difference between the efficacy of the VAC
system and treatments based on wet-to-dry dressingsor topical agents.
NPWT is an option for treating pressure ulcers
when infection/necrosis is controlled. However, there
are no grounds for prioritizing it over other treatments.

3）Nojima K：The surgical Treatment of Pressure Ulcers :References

Analysis of 92 cases. Tokyo Jikei-kai Ika Daigaku
Zasshi. 119（ 6 ）：441-453, 2004.（ Level: V ）4）1 ）Ubbink DT, Westerbos SJ, Evans D, et al：Topicalnegative pressure for treating chronic wounds.

（Japanese, English abstract）
4 ）Kuwahara M, Tada H, Mashiba K, et al：Mortality

Cochrane Database of Systematic Reviews 2008, Issue

and recurrence rate after pressure ulcer operation for

3. Art. No.: CD001898. DOI：10. 1002/14651858.

elderly long-term bedridden patients. Ann Plast Surg,

CD001898.pub2.（Level: I）.
2 ）Wanner MB, Schwarzl F, Strub B, et al：Vacuum-54（6）：629-632, 2005.（Level: V）
5 ）Wong TC, Ip FK：Comparison of gluteal fasciocu-

assisted wound closure for cheaper and moretaneous rotational flaps and myocutaneous flaps for

comfortable healing of pressure sores: a prospective

the treatment of sacral sores. Int Orthop, 30（ 1 ）：study. Scand J Plast Reconstr Surg Hand Surg, 37（1）：28-33, 2003.（Level: II）

64-67, 2006.（Level: V）

3）Ford CN, Reinhard ER, Yeh D, et al：Interim analysis

CQ 3.7 What kind of physiotherapy is recommended
for pressure ulcers with low amounts of granulationof a prospective, randomized trial of vacuum-assisted

tissue?
［ Recommendation ］Negative pressure woundtherapy（NPWT）may be considered for the treat-ment of pressure ulcers. Ann Plast Surg, 49（ 1 ）：closure versus the healthpoint system in the manage55-61, 2002.（Level: II）
4）Ratliff CR,Tomaselli N：WOCN update on evidence-― G− 41 ―― 53 ―

based guideline for pressure ulcers. J Wound Ostomy
Continence Nurs, 37（5）：459-460, 2010.
5 ）National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel：Surgery for
Pressure Ulcers. Prevention and treatment of pressure ulcers: clinical practice guideline, 96-99, National
Pressure Ulcer Advisory Panel, Washington DC,
2009.
6）Gregor S, Maegele M, Saucherland S, et al：Negative
Pressure Wound Therapy A Vacuum of Evidence?.
Arch Surg, 143（2）：189-196, 2008.（Level: I）［Analysis］The following is evidence pertaining to
co-morbidity risk factors for pressure ulcer development.
A study involving participants with no pressure
ulcers at the time of admission to a chronic care
hospital reported a correlation between cerebrovascular accidents and the development of pressure
1）
ulcers . Further, according to a study of the database2）of nursing homes , as well as the results of a study
3）
conducted under similar conditions , pelvic fractures,
diabetes mellitus, and peripheral vascular disease

CQ 4 General management
CQ 4.1：Which underlying medical conditions may

were found to be positively correlated to the incidenceof pressure ulcer formation. Similarly, the outpatient
records of 75, 158 cases demonstrated a positive

entail the risk of leading to pressure ulcers?
［Recommendation］Pelvic fractures, diabetes mellitus, cerebro-vascular diseases, and spinal cord

correlation between pressure ulcer formation andmalignant tumors, Alzheimer Ss disease, congestive
heart failure, rheumatoid arthritis, osteoporosis, deep

injuries potentially lead to pressure ulcer formation
due to patient immobility.
［Rating］C1

venous thrombosis, diabetes mellitus, urinary tract
infections, cerebro-vascular diseases, Parkinson S
sdisease and chronic obstructive pulmonary disease. In
addition, the Wound Healing Society in the UnitedStates has reported spinal cord injuries as a risk factor
in the development of pressure ulcers.
The disease states mentioned above may beconsidered risk factors for the development ofpressure ulcers. However, other reports contradictthese findings. For the purposes of the present
guidelines, the comorbidity findings for pelvic fractures, diabetes mellitus, cerebro-vascular accidents, aswell as the spinal injuries mentioned by the American
guidelines are cited for their potential relevance asrisk factors.

Fig. 4 Algorithm illustrating options for general management of pressure ulcer prevention

Fig. 5 Algorithm illustrating general management after occurrence of pressure ulcer― G− 42 ―― 54 ―

References
1）Berlowitz DR, Wilking SV：Risk factors for pressure
sores. A comparison of cross-sectional and cohortderived data. J Am Geriatr Soc, 37（11）：1043-1050,
1989.（Level IV）

Dietary supplementation in patients with hip fractures, which are known to increase highly the risk forpressure ulcer development, demonstrated both a low
rate of occurrence of Stage II pressure ulcers and incases in which pressure ulcers eventually developed,
5）
a longer interval before occurrence .

2）Berlowitz DR, Brandeis GH, Anderson JJ, et al：Deri-

On the basis of the evidence level of these studies,ving a risk-adjustment model for pressure ulcer

nutritional intervention is assigned the recommendation rating of B with the proviso that the underlying
condition of the patient, if any, be duly considered.

development using the Minimum Data Set. J Am
Geriatr Soc, 49（7）：996-997, 2001.（Level IV）
3）Brandeis GH, Ooi WL, Hossain M, et al：A longitudin-

References

al study of risk factors associated with the formationof pressure ulcers in nursing homes. J Am Geriatr

1）Langer G, Schloemer G, Knerr A, et al：Nutritional
interventions for preventing and treating pressure

Soc, 42（4）：388-393, 2004.（Level IV）
4）Margolis DJ, Knauss J, Bilker W, et al：Medical condi-

ulcers. Cochrane Database Syst Rev, 2003.（Level I）

tions as risk factors for pressure ulcers in an2）Stratton RJ, Ek AC, Engfer M, et al：Enteral nutri-

outpatient setting. Age Ageing, 32（ 3 ）：259-264,

tional support in prevention and treatment of2003.（Level IV）

pressure ulcers：A systematic review and metaanalysis. Ageing Res Rev, 4（ 3 ）：422-450, 2005.

5）Stechmiller JK, Cowan L, Whitney JD, et al：Guide-（Level I）

lines for the prevention of pressure ulcers. Wound

3）Bourdel-Marchasson I, Barateau M, Rondeau V, et al：Repair Regen, 16（2）：151-168, 2008.

A multi-center trial of the effects of oral nutritional

CQ 4. 2：What form of nutritional intervention isrecommended for the prevention of pressure ulcers inmalnourished patients?
［ Recommendation ］For patients suffering fromprotein-energy malnutrition（ PEM ）, using a enhanced energy and protein supplement after due
consideration of any underlying conditions is recommended.
［Rating］B［ Analysis ］A high-calorie, high-protein dietary

supplementation in critically ill older inpatients.
GAGE Group. Groupe Aquitain Geriatrique dS
Evaluation. Nutrition, 16（1）：1-5, 2000.（Level II）
4）Hartgrink HH, Wille J, König P, et al：Pressure sores
and tube feeding in patients with a fracture of the
hip：A randomized clinical trial. Clin Nutr, 17（6）：287-292, 1998（Level II）
5）Houwing RH, Rozendaal M, Wouters-Wesseling W, etal：A randomised, double-blind assessment of theeffect of nutritional supplementation on the preven-supplement was found to be effective in promoting
healing of pressure ulcers among PEM（ proteinenergy malnutrition ）patients who are unable toobtain the requisite quantities of these nutrients from1, 2）
their regular meals .
According to the Cochrane Database Systematic
1）
Review , four studies examined the effects of dietary
supplementation on pressure ulcers. In these studies
the addition of 200 kcal to the total daily caloric intake
over 15 days markedly decreased the rate ofoccurrence of pressure ulcers in comparison with thecontrol group（ 295 cases, or 40. 6%; 377 cases, or3）
47.2% ） . A study of the effect of supplemental
feeding in patients with femoral fractures similarly
demonstrated an improvement in clinical course, in
4）addition to diminished incidence of complications .

tion of pressure ulcers in hip-fracture patients. Clin
Nutr, 22（4）：401-405, 2003.（Level II）

CQ 4. 3：How should patients incapable of oral
intake of nutrition and hydration be fed?
［ Recommendation ］Consider supplying the required nutrition by enteral tube-feeding. When this is
not possible, consider parenteral feeding.
［Rating］C1［Analysis］Although a randomized controlled trial
demonstrated that tube feeding clearly increased foodintake and resulted in significantly higher albumin
and total protein levels after 1.2 weeks in comparison
with the control group（ p ＜ 0. 001 ）, no significant
effect was seen in terms of pressure ulcer prevention.
There are in fact no useful studies on the relationship― G− 43 ―― 55 ―

between the method of feeding and pressure ulcer
prevention, and existing recommendations are basedon expert opinion or represent the perspective ofparticular guidelines. The NPUAP/EPUAP quickreference guide states that patients should be fed byenteral tube or intravenously if oral food intake is2）insufficient .
Similarly, the Japanese guidelines for intravenousand enteral feeding state that enteral feeding should
be used as much as possible in cases where oral foodintake is insufficient, and that intravenous feeding
should be performed if enteral feeding is not possible
3）
or insufficient . The manner in which the patient is
fed should be decided after due consideration of the
prognosis, goals of treatment, and individual differences.
References1）Hartgrink HH, Wille J, König P, et al：Pressure sores
and tube feeding in patients with a fracture of the
hip：A randomized clinical trial. Clin Nutr, 17（6）：287-292, 1998.（Level II）
2）European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel：Prevention andtreatment of pressure ulcers：quick reference guide.
National Pressure Ulcer Advisory Panel, Washington
DC, 2009.
3 ）Japanese Society for Parenteral and Enteral Nutrition：Practical guidelines for parenteral and enteralnutrition 2ndEd, 7-8, Nankodo, Tokyo, 2007.

（Japanese）

CQ 4. 4：What indices can be used to assess thelevel of malnutrition as a risk factor for pressure
ulcers?
［Recommendation］
1. In the absence of inflammation or dehydration,
serum albumin levels may be used.
［Rating］C1
2. Rate of weight loss may be considered for use.
［Rating］C1
3. Consider using the rate of food intake or theused with elderly patients.
［Rating］C1［ Analysis ］Normally in a clinical setting, biochemical measures such as serum albumin levels, as well
as physiological parameters, food intake rate, andnutritional assessment and screening tools are used toassess risk.
In analytical epidemiological studies of pressure
ulcer risk, total protein, serum albumin, and prealbumin values are examined to determine risk.
Among these, the serum albumin or prealbumin levelis a commonly used index of pressure ulcer risk. Low
serum albumin values indicate high risk for pressure
1−7）

ulcers. Values below 3.5 g/dl indicate a particularly
1−6）However, because the serum albuminhigh risk.
level varies depending on inflammation, dehydrationand other factors, this index merits a Recommendation Rating of no higher than C1.
Body weight measurements can be performed
easily without the aid of special apparatuses, and is
the most convenient tool for assessing the nutritional
state of the patient. Decrease in body weight isthought to be a risk factor for pressure ulcers. Among
newly patients at the Stage III or IV pressure ulcers, adecrease in % usual body weight（UBW）is reported8）
ly correlated to increased pressure ulcer risk .
Haydock and Hill report that moderately to severely
under-nourished surgical patients showed a decreasein body weight of 9.6% and 19.6%, respectively, andwound healing was impaired more than in patients9）assessed to be in\goodScondition（p ＜ 0.001） . Ina cohort study examining the risk for pressure ulcers
at Stage II or higher among in-patients who were
either bed-ridden or confined to a sitting position, adecrease in body weight was reported to be asignificant risk factor for pressure ulcer
10）
development . According to the EAUAP nutritionalguidelines, undesirable weight loss, defined as weightloss exceeding 10% of normal body weight over 6
months, or exceeding 5% over 1 months, may point toamount of food consumption as an index.
［Rating］C1

malnutrition, and requires regular monitoring of the11）patientSs body weight . On the basis of the quality ofthe publications from which this information is taken,
the recommendations given here merit the rating of

4. Consider using Subjective Global Assessment（SGA）.
［Rating］C1
5. Mini Nutritional Assessment（ MNA ）may be

C1.
Although there is not sufficient evidence establishing a relationship between eating rate andpressure ulcers, among the cases of pressure ulcer― G− 44 ―― 56 ―

documented in Japan, a rate of food intake below 75%
of food offered has been documented in 48% of
12）pressure ulcer patients . Further, the amount of foodintake is one of the categories included on the Braden
Scale for pressure ulcer risk assessment, with a rate offood intake below 50% thought to entail a significantly
13）
higher risk for pressure ulcer development . Use of
the food intake rate as an index of malnutrition is
assigned a recommendation rating of C1.
The Subjective Global Assessment, published by
Detsky et al. in 1987, is widely used as a comparatively

1023-1028, 2002.（Level Ⅵ）（Japanese）
5）Konagaya M, Takasaki K：The development of nutritional index for pressure ulcer incidence. Jpn J PU, 2（ 3 ）：257-263, 2000.（ Level Ⅳ ）（ Japanese, English
abstract）
6）Sugiyama M, Nishimura A, Ohura T, et al：Effect ofnutritional care for prevention and treatment forpressure ulcers: Health and labor sciences Research
Grants（H10-Comprehensive Research on Aging and
Health-012）.37-45, 2000.（Level Ⅳ）（Japanese）
7）Rochon PA, Beaudet MP, McGlinchey-Berroth R, etprecise tool for assessing the nutritional state ofpatients. However, it has been assigned the Recommendation Rating of C1 due to the fact that at present

al：Risk assessment for pressure ulcers：an adapta-

only expert opinion supports the relationship between
SGA and pressure ulcer prevention.
In a cross-sectional study of three assessment tools
for evaluating the nutritional state of patients, namely

Paraplegia Soc, 16（3）：169-177, 1993.（Level Ⅱ）

the mini nutritional assessment: MNA, bioelectrical
impedance analysis: BIA, and Barthel index: BI, the
MNA was found to have the strongest correlation to
the risk of pressure ulcer development. Further, across sectional study of MNA and other, similarassessment tools reported that screening patients S
nutritional status may be a more effective indicator ofpressure ulcer risk than serum albumin and prealbu14）
min values . Because at present there are no usefulstudies examining the relationship between nutritional assessment tools and pressure ulcer risk, therecommendation rating of C1 has been assigned to thetion of the National Pressure Ulcer Advisory Panelrisk factors to spinal cord injured patients. J Am
8 ）Guenter P, Malyszek R, Bliss DZ, et al：Survey ofnutritional status in newly hospitalized patients withstage Ⅲ or stage Ⅳ pressure ulcers. Adv Skin Wound
Care, 13（4 Pt 1）：164-168, 2000.（Level VI）
9 ）Haydock DA, Hill GL：Impaired wound healing insurgical patients with varying degrees of malnutrition. JPEN J Parenter Enteral Nutr, 10（6）：550-554,
1986.（Level IV）
10）Allman RM, Goode PS, Patrick MM, et al：Pressure
ulcer risk factors among hospitalized patients withactivity limitation. JAMA, 273（ 11 ）：865-870, 1995.
（Level IV）
11）European Pressure Ulcer Advisory Panel：Nutritional guidelines for pressure ulcer prevention andtreatment. Registered charity No：1066856, Euro-data given here.

pean Pressure Ulcer Advisory Panel, 2003.
12 ）Ohura T, Nakajo T, Okada S, et al：Influence ofReferences

nutritional intervention to the patients who have risk

1）Reed RL, Hepburn K, Adelson R, et al：Low serum

factors for pressure ulcer. Jpn JPU, 10（2）：122-129,

albumin levels, confusion, and fecal incontinenceare

2008.（Level Ⅳ）（Japanese, English abstract）

these risk factors for pressure ulcers in mobility-im-13）Hengstermann S, Fischer A, Steinhagen-Thiessen E,

paired hospitalized adults?. Gerontology, 49（ 4 ）：et al：Nutrition status and pressure ulcer：what we

255-259, 2003.（Level Ⅳ）need for nutrition screening. J Parenter Enteral Nutr,

2）Pinchcofsky-Devin GD, Kaminski MV Jr：Correlationof pressure sores and nutritional status. J Am Geriatr

31（4）：288-294, 2007.（Level IV）
14）Langkamp-Henken B, Hudgens J, Stechmiller JK, etSoc, 34（6）：435-440, 1986.（Level Ⅳ）

al：Mini nutritional assessment and screening scores

3）Yoshio M, Shigeto M, Kohya O, et al：Risk factors forare associated with nutritional indicators in elderlypressure ulcers in bedridden elderly subjects：Im-

people with pressure ulcers. J Am Diet Assoc, 105

portance of turning over in bed and serum albumin（10）：1590-1596, 2005.（Level V）

level. Geriatr Gerontol Int, 1：38-44, 2001.（Level Ⅳ）4）Nakajo T, Oishi S：Prevention of pressure ulcer andCQ 4. 5：When is the systemic administration ofnutrition management: Cutoff values of serum

antibiotics（ antimicrobials ）indicated in patientswith an infected pressure ulcer?

albumin and hemoglobin. Geriatr Med, 40（ 8 ）：― G− 45 ―― 57 ―［ Recommendation ］If physical examination findings or test results indicate advancing cellulitis andCQ 4. 6：Which antibiotics（ antimicrobials ）arerecommended for treating infection?

osteomyelitis, necrotizing fasciitis, bacteremia, or
sepsis, consider administering systemic antibiotics. If
only symptoms of local infection are found, administra-［ Recommendation ］Consider using empiric antibiotics to suspected pathogens common in clinicalsettings. Reconsider using more specific antibiotics totion of systemic antibiotics need not be considered.
［Rating］C1［Analysis］An effort was made to identify specificpathogens by referring the results of susceptibility
testing.
［Rating］C1

disease states in cases of infected pressure ulcers
which required the systemic administration of antibiotics. However, given the generally accepted notionthat failure to administer systemic antibiotics entails［Analysis］There are no studies at present indicating the best choice of systemic antibiotic for infectedpressure ulcers. In the NPUAP/EPUAP guidelines,\ Antibiotics should be chosen based on confirmed

an intolerable risk to the patientSs health, there are nocontrolled studies examining the differences in the

antibiotic susceptibilities of the suspected or known
pathogens. For life-threatening infections, empiric

effect of administering or not administering systemic
antibiotics. Our recommendations here are therefore
based on published guidelines or reviews. The
NPUAP/EPUAP guidelines recommend using\ sys-

antibiotics should be based on local antimicrobial
susceptibility patterns, and re-evaluated when defini1）
tive cultures become available S . In the present
guidelines as well, the immediate administration of
antibiotics appropriate to the suspected pathogen isrecommended.

temic antibiotics for individuals with clinical evidenceof systemic infection, such as positive blood cultures,
cellulitis, fasciitis, osteomylelitis, systemic inflammatory response syndrome, or sepsis, if consistent with1）
the individual Ss goals S . The WOCN guidelines
similarly endorse the view that systemic antibiotics
should be administered, as needed, in cases ofbacteremia, sepsis, advancing cellulitis and2）
osteomyelitis .
From a clinical point-of-view, if the physicalexamination findings or the test results are found tocorrespond to the condition of a given patient,consider the administration of systemic antibiotics.
However, for cases in which the infection is local, there
is no evidence to support the use of systemic
antibiotics. For such cases, refer to the sections
dealing with conservative treatment or surgicaltreatment.
References
1 ）National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel：Prevention
and treatment of pressure ulcers：clinical practiceguideline, National Pressure Ulcer Advisory Panel,
Washington DC, 2009.
2）Wound Ostomy Continence Nurses Society：Guidelines for prevention and management of pressure
ulcers. 2nd edition, WOCN clinical practice guidelinesseries 2, 2010.

References
1 ）National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel：Prevention
and treatment of pressure ulcers：clinical practiceguideline, National Pressure Ulcer Advisory Panel,
Washington DC, 2009.

CQ 4.7：Which underlying conditions may pose arisk of prolonging the healing of pressure ulcers?
［ Recommendation ］Malignant tumors and cardiovascular diseases should be considered as factors
which may prolong the healing of pressure ulcers.
［Rating］C1［ Analysis ］Evidence relating to co-morbidity diagnoses was assembled because of their potential
importance as factors influencing the healing ofpressure ulcers, including chronic wounds. The
majority of the information found was comprised ofexpert opinions and case reports, with only two
analytical-epidemiological and case-controlled
1, 2）
studies .
The rate of healing in pressure ulcers among
cardiovascular patients was found to be significantly
lower according to a cohort study of pressure ulcer
1）
patients . According to the findings of another cohort
study of cancer patients with pressure ulcers and2）other types of skin ulcer , cancer patients showed a― G− 46 ―― 58 ―

significant lower rate of healing than non-cancer
patients. Further, according to expert opinion in
3）
Japan , the exacerbation of diabetes mellitus, malignancies, liver cirrhosis, or peripheral vascular disease
impeded the healing rate of pressure ulcers.
In summary, malignancies and cardiovasculardiseases can be cited as comorbidity factors which

References
1）Donini LM, De Felice MR, Tagliaccica A, et al：Nutritional status and evolution of pressure sores ingeriatric patients. J Nutr Health Aging, 9（ 6 ）：446-454, 2005.（Level IV）
2）European Pressure Ulcer Advisory Panel and Nation-

may prolong the healing of pressure ulcers. Althoughspecific epidemiological figures cannot be given forlack of data, a general care regimen which includes

al Pressure Ulcer Advisory Panel：Prevention andmanagement of the patientSs condition and nutrition isrecommended in order to hasten healing of pressure
ulcers in patients whose general health has been
adversely affected by their disease state.

DC, 2009.

References
1 ）Jones KR, Fennie K：Factors influencing pressure
ulcer healing in adults over 50: an exploratory study. J
Am Med Dir Assoc, 8（ 6 ）：378-387, 2007.（ Level
IV）2）McNees P, Meneses KD : Pressure ulcers and otherchronic wounds in patients with and patients without
cancer: a retrospective, comparative analysis ofhealing patterns. Ostomy Wound Manage, 53（ 2 ）：70-78, 2007.（Level IV）
3）Mino Y：The latest basic information: How to treat arefractory pressure ulcer?. JPN J Clin Nurs（Rinsho
Kango ）, 27（ 9 ）：1377-1382, 2001.（ Level VI ）（Japanese）

CQ 4.8：Should a nutritional screening and assessment be performed for pressure ulcer patients?
［ Recommendation ］A nutritional screening andassessment and nutritional intervention may beconsidered if required.
［Rating］C1［Analysis］Assessing the nutritional status of thepressure ulcer patient and instituting the nutritional
regimen most appropriate for each case has beenfound to contribute to improving the patient Ss1）
health . The NPUAP/EPUAP quick reference2）
guide also recommends that screening and assessment of the patientSs nutritional status be conductedwhen the patient is admitted to hospital, showschanges in health condition, or shows evidence ofretardation of wound healing.

treatment of pressure ulcers：quick reference guide,
National Pressure Ulcer Advisory Panel, Washington

CQ 4.9：How much nutrition in general should be
provided to pressure ulcer patients?
［Recommendation］
1. In order to ensure adequate energy for healing ofpressure ulcers, recommend providing patients with
1.5 times the basal energy expenditure（BEE）.
［Rating］B［Recommendation］
2. Recommend providing additional protein as
required.
［Rating］B［ Analysis ］Two systematic reviews have ex1, 2）
amined the effect of nutrition on pressure ulcers .
The NPUAP/EPUAP guidelines recommend 30〜35
kcal/kg of body weight as the basic energy
3）4）requirement . A randomized controlled study ofnutritional intervention in patients with pressure
ulcers found that the intervention group, who were
given 300 kcal in addition to their daily diet（ 1. 55
times the BEE ）, showed a significantly greater
reduction in wound surface area and a faster woundhealing rate 8 weeks after the intervention than thecontrol group, who were given only 1. 16 times theBEE. Because this study eliminated factors unrelated
to nutrition and used the same nutritional source forall of its subjects, it merits the Recommendation
rating of B.
With regard to the quantity of protein in the diet,greater reduction in the wound surface area was seenin patients who had received large quantities ofprotein（energy ratio 25%）via enteral tube feedingcompared to those who had received only the5）standard diet . Further, a group of under-nourishedpatients who had received large quantities of proteinin their diet either via enteral tube feeding or as a
dietary supplement（24% protein; 61g/L）reportedly― G− 47 ―― 59 ―

showed a greater reduction in wound surface area
after 8 weeks compared to the group who had
6）received only 14% protein（ 37g/L ） . However,
because the number of subjects was small and the

Am Geriatr Soc, 41（4）：357-362, 1993.（Level II）
7）Cereda E, Gini A, Pedrolli C, et al：Disease-specific,
versus standard, nutritional support for the treatmentof pressure ulcers in institutionalized older adults：a

experimental design was inadequate, these data havebeen assigned a low Evidence Level. On the other
hand, a randomized controlled study examining theeffect of providing patients with a diet augmented
with larger quantities of specific nutrients as required,demonstrated an improved PUSH scores and woundhealing rate in the intervention group, although a
comparison of energy content and amount of added
protein with wound healing rate and PUSH scores
7）
showed no difference . However, the study employeda relatively small number of cases and failed to explain
the relationship between individual nutrients, pressure ulcer healing rate, and PUSH scores. The
3）
NPUAP/EPUAP guidelines recommend 1.25〜1.5g/
3）kg/day according to the severity of the symptoms ,but because there are no recent studies on the basis ofwhich specific recommendations can be made, wehave not indicated any specific amount for protein
supplementation.
References
1）Langer G, Schloemer G, Knerr A, et al：Nutritional
interventions for preventing and treating pressure
ulcers. Cochrane Database Syst Rev, 4：CD003216,
2003.（Level I）
2）Stratton RJ, Ek AC, Engfer M, et al：Enteral nutritional support in prevention and treatment ofpressure ulcers：a systematic review and metaanalysis. Ageing Res Rev, 4（3）：422-450, 2005.（Level I）
3 ）National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel：Prevention
and treatment of pressure ulcers：clinical practiceguideline. National Pressure Ulcer Advisory Panel,
Washington DC, 2009.
4 ）Ohura T, Nakajo T, Okada S, et al：Evaluation ofeffects of nutrition intervention on healing of pressure
ulcers and nutritional states：randomized controlled
trial. Wound Rep Reg, 19：330-336, 2011.（Level II）
5）Chernoff RS, Milton KY, Lipschitz DA：The effect ofrandomized controlled trial. J Am Geriatr Soc, 57（8）：1395-1402, 2009.（Level II）

CQ 4.10：Should the diet of pressure ulcer patientsbe supplemented with any specific nutrients?
［ Recommendation ］Patients Sdiet may be supplemented with zinc, arginine, and ascorbic acid toprevent deficiencies of these nutrients.
［Rating］C1［ Analysis ］Of the systematic reviews examining
nutritional supplementation for the prevention andhealing of pressure ulcers, one deals specifically withthe supplementation of zinc, while two are concerned
1）
specifically with ascorbic acid .
With regard to zinc, one study reported nosignificant difference in pressure ulcer healing rate
between ten individuals who had been administered
200mg/day of zinc sulphate and eight individuals who2）
had been administered a placebo over 1〜2 months .
However, the study was inadequate because of thesmall number of cases, and the lack of clarity
regarding the treatment procedures, food intake,nutritional status, and serum zinc level. The NPUAP/
3）
EPUAP guidelines recommend that 40mg/day ormore of zinc be given as a nutritional supplement topatients with zinc deficiency. However, because there
are no high-evidence level studies examining theefficacy of zinc supplementation for pressure ulcer
healing, the information discussed here has been
assigned a Recommendation Rating of C1.
4, 5）
Randomized controlled trials examining the therapeutic effect of ascorbic acid on pressure ulcer
healing found that 500 mg of ascorbic acid administered twice daily over one month resulted in a 85%
reduction in wound surface area compared with 43%
for the placebo group. However, because each groupin the study was comprised of only ten subjects, andbecause there are no other studies providing useful
information, we have confined our recommendation

6）Breslow RA, Hallfrisch J, Guy DG, et al：The impor-only to supplementing the patientSs diet with enoughascorbic acid to prevent a deficiency.
Only one historical controlled study dealing with
6）
arginine supplementation exists to date . In thistance of dietary protein in healing pressure ulcers. J

study, 18 functional spinal injury patients who werea very high-protein liquid formula on decubitus ulcers
healing in long term tube-fed institutionalized patients. J Am Diet Assoc, 90：A-130, 1990.（Level II）― G− 48 ―― 60 ―

also suffering from pressure ulcers were given 9g/dayof arginine until the pressure ulcers completely
healed. The rate of healing was then compared withthat of the control group consisting of patients who
had been treated in the past for spinal injuries. The
result indicated that the period required for total
healing of the pressure ulcers in the experimentalgroup was significantly shorter than that for thecontrol. However, because the control group used in
the study consisted of patients who had been involvedin a separate, past study, and because there wasinadequate information regarding nutritional status
and lack of uniformity in the conditions, we wereunable to assign a Recommendation Rating higher
than C1.
References
1）Stratton RJ, Ek AC, Engfer M, et al：Enteral nutritional support in prevention and treatment ofpressure ulcers：a systematic review and metaanalysis. Ageing Res Rev, 4（3）：422-450, 2005.（Level II）
2）Norris JR, Reynolds RE：The effect of oral zinc sulfate therapy on decubitus ulcer. J Am Geriatr Soc,
19：793-797, 1971.（Level II）
3 ）National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel：Prevention［Rating］C1［Analysis］A study of the economic viability of anutrition support team（ NST ）in pressure ulcer
management found that two years after deployment,
the incidence of pressure ulcers fell from 14. 9% to5.85%（roughly 1/3 of the original rate）in the study
population and that the cost of treating pressure
ulcers substantially fell in the second year of the NSTS
s operations. Two other studies have reported similarfindings with regard to the economic viability of the2, 3）
NST . Another study reported an improvement in
the patientsScondition as a result of intervention by
the NST, but because the number of cases was small,no statistical data were given.
The EPUAP nutritional guidelines recommend thatfor grade III and IV pressure ulcers, a multidisciplinary team assess the basic metabolic rate of
the patient and monitor the amount of exudates from5）
the wound .
All of the studies examined are unanimous inasserting the need for preventive intervention andrecommend appropriate nutritional assessment, as
well as intervention by the registered dietician or the
NST. However, none of the studies mentioned gives
specific data concerning the efficacy of this form ofintervention in promoting pressure ulcer healing.

and treatment of pressure ulcers：clinical practice

References

guideline. National Pressure Ulcer Advisory Panel,

1）Okude K, Higashiguchi T, Fukumura S, et al：Eco-

Washington DC, 2009.
4 ）Taylor TV, Rimmer S, Day B, et al：Ascorbic acidnomic effect of pressure ulcers management based on

supplementation in the treatment of pressure-sores.

nutrition therapy. J Jpn Soc Parenteral Enteral
Nutrition, 17（ 4 ）：29-33, 2002.（ Level V ）Lancet, 2（7880）：544-546, 1974.（Level II）（Jananese, English abstract）

5）Ter Riet G, Kessels AG, Knipschild PG：Randmized
clinical trial of ascorbic acid in the treatment of press-2）Onoki K, Isozaki T, Yonekawa O, et al：Medical eco-ure ulcers. J Clin Epidemiol, 48（ 12 ）：1453-1460,

nomic effect of nutrition support team（NST）in a

1995.（Level II）

general hospital in Japan. Med J Seirei Hamamatsu
General Hospital, 4（ 1 ）：23-27, 2004.（ Level V ）6）S Brewer, K Desneves, L Pearce, et al：Effect of an（Japanese）

arginine-containing nutritional supplement on pressure ulcer in community spinal patients. J Wound Care,

3）Toma T, Kitanishi M, Hasegawa K：Clinical outcomes of femoral neck fracture with nutrition support

19（7）：311-316, 2010.（Level III）

team. Central Japan J of Orthopaedic Surgery &CQ 4.11：Should a registered dietician or multidisciplinary nutritional team participate in the care ofpressure ulcer patients?
［ Recommendation ］Participation by a registereddietician or multidisciplinary nutrition support teamin the care of pressure ulcer patients may berecommended.

Traumatology, 48（ 4 ）：659-660, 2005.（ Level V ）（Japanese）
4）Ohara H, Kurihara Y, Dohi M：Improvement effect ofnutritional management on the long term hospitalized
patients. Jpn J National Med Service, 59（6）：300305, 2005.（Level V）（Japanese）
5）European Pressure Ulcer Advisory Panel：Nutrition-― G− 49 ―― 61 ―

Fig. 6 Algorithm illustrating preventive care options

Fig. 7 Algorithm illustrating care options after occurrence of pressure ulcer

al guidelines for pressure ulcer prevention andtreatment. Registered charity No：1066856, Euro-

group showed a significantly greater increase in bodyweight 12 weeks after commencement of the study
compared with the control group（p ＜ 0.001）,which1）
showed no change in body weight at all . Further, thepean Pressure Ulcer Advisory Panel, 2003.

CQ 4.12：Should body weight be used as a means ofassessing the efficacy of nutritional supplementationin pressure ulcer patients?
［Recommendation］Recommend using body weight
as a means of assessing the effectiveness of nutritional
supplementation if edema or dehydration can be ruledout.
［Rating］B［Analysis］A randomized controlled study examining the effectiveness of nutritional intervention inpressure ulcer patients found that the intervention

wound size in the intervention group decreased more
rapidly than in the control group（p ＜ 0.001）. The
results of this study have been deemed reliablebecause factors unrelated to nutrition but affecting
the pressure ulcers were controlled. Accordingly,
body weight is recommended as an index forassessing whether the patient has received adequate
nutrition.
2）
Further, the NPUAP/EPUAP guidelines recommend that, if the body weight of a pressure ulcer
patient decreases, the patient should be given― G− 50 ―― 62 ―

sufficient calories to restore body weight. However,edema and dehydration should first be ruled out as

stract）
3）Imai K, Kadowaki T, Aizawa Y：Standardized indi-potential causes of fluctuations in body weight.

ces of mortality among persons with spinal cord
injury：Accelerated aging process. Ind Health, 42

References（2）：213-218, 2004.（Level IV）

1 ）Ohura T, Nakajo T, Okada S , et al：Evaluation ofeffects of nutrition intervention on healing of pressure
ulcers and nutritional states：randomized controlled
trial. Wound Repair Regen, 19：330-336, 2011.
（Level II）
2 ）National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel：Prevention
and treatment of pressure ulcers：clinical practiceguideline. National Pressure Ulcer Advisory Panel,
Washington DC, 2009.

CQ 5 Rehabilitation
CQ 5.1：Which factors account for pressure ulcer
development in chronic spinal cord injury patients?
［Recommendation］For patients with a history ofpressure ulcers, vigilance is recommended to prevent
recurrence.
［Rating］B
1）［ Analysis ］A systematic review which has examined the factors leading to pressure ulcer development among chronic spinal cord injury patients foundgender（greater susceptibility of men）,length of time
following appearance of the wound, complete injury
rather than partial injury, the presence of deep veinthrombosis, presence of pneumonia, history of pressure ulcers, to be relevant factors. No relationship was
found between age and degree of injury. Among

CQ 5.2：Which methods are effective for preventing pressure ulcer development in spinal cord injury
patients?
［ Recommendation ］Conducting rehabilitation
while monitoring interface pressure may be considered.
［Rating］C1
1）［ Analysis ］Hirose et al . have compared thelength of time that elapsed between discharge from
hospital following treatment for pressure ulcers andreadmission for recurrence among patients who
received rehabilitation either with or without monitoring interface pressure. The results of the study
demonstrated a significantly lower incidence ofrecurrence among patients when their interfacepressure was monitored during rehabilitation（ p ＜2−4）0.02）.Further, three separate studies on pressure
ulcer prevention for spinal cord injury patients
performed at multiple rehabilitation facilities in Japan
reported that seat-type pressure measuring devices
are extremely useful in gauging pressure on the
buttocks and in providing feedback to the patient
during rehabilitation. On this basis, we have assigned
the recommendation rating of C1 to this section.
References

studies conducted in Japan, some have reported that2）
all pressure ulcers recur within 14 years , or that the3）recurrence may lead to sepsis or death . The

1）Hirose H, Niituma J, Iwasaki Y, et al：An approach to

Recommendation Rating of B is assigned to theseevidence sources in view of the apparently serious

118-125, 2010.（ Level IV ）（ Japanese, English ab-consequences of recurrence.

determine situations in which pressure ulcers occur
in patients with spinal cord injury. Jpn J PU, 12（2）：stract）
2）Morita T, Maeda J, Sakuma F, et al：A case study of aspinal cord injury（ SCI ）patient who developed aReferences

pressure ulcer after changing his wheelchair cushion

1）Gelis A, Dupeyron A, Legros P, et al：Pressure ulcer

and life-style-Physical therapy intervention of therisk factors in persons with spinal cord injury Part2：

treatment of pressure ulcer in SCI-. Physical Therapy

The chronic stage. Spinal Cord, 47：651-661, 2009.

Japan, 35（3）：104-109,2008.（Level V）（Japanese）（Level I）

3）Matsubara H, Hirose H, Hama Y：Fabrication of seat-2）Hirose H, Niituma J, Iwasaki Y, et al: An approach toing cushion for a person with spinal cord injury anddetermine situations in which pressure ulcers occur

hip disarticulation. J Jpn Acad Prosthetists Orthotists,in patients with spinal cord injury. Jpn J PU, 12（2）：12（1）：48-53, 2004.（Level V）（Japanese）

118-125, 2010.（ Level IV ）（ Japanese, English ab-4 ）Kaneko M, Nakashima M, Kurosaki S, et al：Indi-― G− 51 ―― 63 ―

vidually planned visits for self-care guidance andlivelihood support by co-medical staff could prevent
pressure ulcer recurrence in a patient with spinal
injury. Jpn J PU, 132-136, 2010.（ Level V ）［Rating］B［Analysis］A randomized controlled trial involving
57 patients in two orthopaedic wards examined theeffect of limiting the time patients could sit in chairs
1）placed near their beds . The study indicated that
limiting sitting time to two hours or less resulted in a

（Japanese, English abstract）

CQ 5.3：What type of cushion should be used withelderly patients in a seated position to prevent
pressure ulcers?
［Recommendation］A pressure-redistributing seatcushion for individuals with spinal cord injury is
recommended to prevent pressure ulcer development
while seated.
［Rating］B［Analysis］A randomized controlled trial comparing the efficacy of three types of pressureredistributing seat cushions designed for spinal cord
injury patients with that of a segmented foam cushion

significantly lower rate of pressure ulcer formationcompared to unlimited sitting time（p ＜ 0.001）. The
NPUAP/EPUAP guidelines, which cite the same
study, assign the data a recommendation rating of B
and endorse the view that seating time should be
limited, although they do offer specific recommenda2）
tions on the length of sitting time .
On the basis of these considerations, we have alsodecided to recommend only that seating time belimited without offering any specific recommendations regarding permissible seating time.
References1）（ 8cm in thickness ）in preventing pressure ulcers
found that while the rate of pressure ulcer development decreased significantly in the tissue overlying
the ischial bone as a result of the use of pressureredistributing seat cushions（p = 0.04）, there was no
measurable change in the rate of pressure ulcer
development in the coccyx and sacral areas. However,there is a case report published in Japan claiming thatthe application of a segmented air cushion 10 cm inthickness to the ischial area of three elderly patients2）
did not result in the development of pressure ulcers .
On the basis of these data, the methods discussed here
are assigned a recommendation rating of B.
References

1）Gebhardt K, Bliss MR：Preventing pressure sores inorthopedic patients is prolonged chair nursing
detrimental. J Tissue Viability, 4（ 2 ）：51-54, 1994.
（Level II）
2 ）National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel：Prevention
and treatment of pressure ulcers：clinical practiceguideline. National Pressure Ulcer Advisory Panel,
Washington DC, 2009.

CQ 5.5：At what intervals should the seated individual be repositioned?
［Recommendation］Repositioning every 15 min isrecommended for seated individuals who are capable1 ）Brienza D, Kelsey S, Karg P, et al：A randomized
clinical trial on preventing pressure ulcers withwheelchair seat cushions. J Am Geriatr Soc, 58：
2308-2314, 2010.（Level II）
2）Hirose H, Tanaka H, Mawaki A, et al: Case studies ofcoccygeal pressure ulcers caused by improper
wheelchair seating. Jpn J PU, 13（ 1 ）：54-60, 2011.
（Level V）（Japanese, English abstract）

CQ 5.4：Should limitations be set on the length oftime in which the individual remains continuously
seated?
［ Recommendation ］Limitations on sitting timeshould be set if the elderly individual is unable toreposition without assistance.

of changing their body position without assistance.
［Rating］C1［Analysis］There are no published studies to dateaddressing the question of optimal intervals for body
repositioning for wheelchair-bound individuals whoare capable of changing their body position without
1）
assistance. However, the WOCN guidelines , as well2）
as the Centers for Medicare and Medicaid , recommend an interval of 15 minutes.
On the basis of this information, we recommendthat wheelchair-bound individuals capable of repositioning on their own do so at regular 15 minuteintervals, although it should be noted that there is noclear evidence endorsing this recommendation.

― G− 52 ―― 64 ―

Washington DC, 2009.

References

3）AHCPR：AHCPR Supported clinical practice guide-1）Ratliff CR, Bryant DE：Wound, Ostomy, and Conti-

lines. 3. Pressure ulcers in adults：Prediction andnence Nurses Society（WOCN）：Guideline for pre-prevention, Clinical practice guideline Number 3,

vention and management of pressure ulcers. WOCNAHCPR Pub. No.92-0047.

clinical practice guideline No.2. WOCN, Glenview, IL,
2003.
2）CMS Manual System：Pub. 100-07 State Operations,
Provider Certification, Transmittal 4. Guidance toSurveyors for Long Term Care Facilities, 2004.

CQ 5. 6：Should the individual Ss posture while
seated be considered?
［Recommendation］The alignment and balance ofthe seated individualSs body should be considered.
［Rating］C1［Analysis］To date there exist only one case report
and two guidelines addressing the question of theeffect that prolonged sitting has on pressure ulcers.
1）
According to the case report , three patients at anursing home for elderly with shallow ulcers in thecoccygeal area underwent rehabilitation with theassistance of a trained physical therapist who chose
body positions and support surfaces according to
exercise physiological principles to lessen pressure on
the wounds. As a result of this treatment, the pressure
ulcers healed successfully even while the patientsremained in their wheelchair. The NPUAP/EPUAP
guidelines recommend\ selecting a posture that is
acceptable for the individual and minimizes theCQ 5.7：Should donut-type devices be used?
［ Recommendation ］Donut-type devices are notrecommended.
［Rating］D［Analysis］A case report investigating the effect ofvarious types of cushion on the development ofpressure ulcers in hospitalized elderly patients
indicated that donut-shaped devices either conduced
to the development of pressure ulcers or worsened1）existing cases . The NPUAP/EPUAP guidelines
similarly recommend,\Avoid use of synthetic sheepskin pads; cutout, ring, or donut type devices; and2）water-filled gloves S . The WOCN guidelines also
state,\Avoid foam rings, foam cutouts, or donut type3）
devicesS .
The preponderance of evidence suggests that
donut-shaped devices should be avoided; recommendation rating D.
References
1）Crewe RA：Problems of rubber ring nursing cushions
and a clinical survey of alternative cushions for illpatients. Care Sci Pract, 5（ 2 ）：9-11, 1987.（ Level
V）

pressures and shear exerted on the skin and soft2）
tissuesS . The WOCN guidelines also statehspecial

2 ）National Pressure Ulcer Advisory Panel and Euro-

attention to the individual's anatomy, postural align3）
ment, distribution of weighti .
On the basis of the above information, measures toprevent pressure ulcer development can be implemented even while the patient remains confined toa sitting position; recommendation rating C1.

and treatment of pressure ulcers：clinical practicepean Pressure Ulcer Advisory Panel：Prevention
guideline. National Pressure Ulcer Advisory Panel,
Washington DC, 2009.
3）AHCPR：AHCPR Supported clinical practice guidelines. 3. Pressure ulcers in adults：prediction andprevention, Clinical practice guideline Number 3,
AHCPR Pub. No.92-0047.

References
1）Hirose H, Tanaka H, Mawaki A, et al：Case studies of

CQ 5.8：What kind of physical modality can be usedcoccygeal pressure ulcers caused by improperand treatment of pressure ulcers：Clinical practiceto treat muscular atrophy?
［ Recommendation ］Consider using electric stimulation therapy.
［Rating］C1
1）［Analysis］Although there is a case report and a2）case series examining the use of neuromuscular

guideline. National Pressure Ulcer Advisory Panel,electric stimulation therapy to treat muscular atro-

wheelchair seating. Jpn J PU, 13（ 1 ）：54-60, 2011.
（Level V）（Japanese, English abstract）
2 ）National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel：Prevention― G− 53 ―― 65 ―

phy, these reports are concerned only with how tomaintain muscular layer thickness and what changes
to make in the daily activity of individuals, but do notaddress the issue of pressure ulcer prevention. The
review of the literature pertaining to this topic is of ageneral nature, discussing the effect on muscle crosssectional area, but omitting discussion of pressure
ulcers. Moreover, the two case reports cited earlier
focus on electric stimulation therapy using implanted
electrodes, while their remarks concerning surface
electrodes are based solely on expert opinion. For
these reasons, while the use of electric stimulation
therapy to treat muscular atrophy can have positiveeffects on the prevention of pressure ulcers, their use

movement and decreasing the size of pressure ulcers,
but fails to offer precautionary advice on how to
implement passive exercises, and recommends passive exercises involving the elbow and knee joints fortreatment of pressure ulcers in the sacral region.
These reports fail to clarify whether such exercises
are sufficient completely to prevent joint contracture.
However, because passive exercises are effective inmaintaining or improving range of movement, which
in turn can prevent joint contracture, they have been
assigned the recommendation rating of C1.
References
1）AM Moseley, RD Herbert, EJ Nightingale, et al：Pas-

merits a recommendation rating of no higher than C1
due to the lack of sufficient evidence.

sive stretching does not enhance outcomes in patientswith plantar flexion contracture after cast immobilization for ankle fracture：a randomized controlled trial.

References

Arch Phys Med Rehabil, 86（ 6 ）：1118-1126, 2005.

1）Bogie KM, Wang X, Triolo RJ：Long-term prevention（Level II）

of pressure ulcers in high-risk patients：A single case2）TM Steffen, LA Mollinger：Low-load, prolonged st-

study of use of gluteal neuromuscular electric

retch in the treatment of knee flexion contractures instimulation. Arch Phys Med Rehabil, 87（ 4 ）：585-

nursing home residents. Phys Ther, 75（ 10 ）：886-

591, 2006.（Level V）

897, 1995.（Level IV）

2 ）Sanjeev A, Triolo RJ, Kobetic R, et al：Long-term3）Harvey LA, Batty J, Crosbie J, et al：A randomized

user perceptions of an implanted neuroprosthesis fortrail assessing the effects of 4 weeks of daily

exercise, standing, and transfers after spinal cord

stretching on ankle mobility in patients with spinal

injury. J Rehab Res Develop, 40（3）：241-252, 2003.

cord injuries. Arch Phys Med Rehabil, 81（ 10 ）：（Level V）

1340-1347, 2000.（Level II）

3）Giangregorio L, McCartney N：Bone loss and muscle

4）Fox P, Richardson J, MCInners B, et al：Effectivenessatrophy in spinal cord injury：Epidemiology, fractureof a bed positioning program for treating older adults

prediction, and rehabilitation strategies. J Spinal Cordwith knee contractures who are institutionalized.

Med, 29（5）：489-500, 2006.（Level VI）

Phys Ther, 80（4）：363-372, 2000.（Level II）
5 ）Shimizu M, Shibata S：Effect of passive range of

CQ 5.9：What kind of therapeutic exercise can bemotion exercise for treatment of stage IV pressure

used to treat joint contracture?
［Recommendation］Consider using passive rangeof motion exercises.
［Rating］C1
1−3）［Analysis］Three randomized controlled studies
4）and one case report discuss the use of therapeutic
exercise to treat joint contracture in individuals at

ulcer in late-stage elderly. Nihon Kango Gakkai
Ronbunsyu Rounenkango, 38：155-157, 2007.（Level
V）（Japanese）

CQ 5.10：Should tissue overlying bony prominences be massaged?

risk of developing pressure ulcers. Neither reportfound therapeutic exercise to be effective in preventing joint contracture and in addition make no mention［Recommendation］Massaging areas covering bonyprominences is not recommended.
［Rating］D［Analysis］One systematic review and two rando-of pressure ulcers. In another case report, Shimizu
addresses the issue of joint contracture and therapeutic exercise and claims that the use of passive

mized controlled trials examine the use of massage inpressure ulcer care and management. In the systema1）
tic review , although claims are made regarding theexercises was effective in improving the range ofefficacy of massage therapy in improving skin― G− 54 ―― 66 ―

temperature and subcutaneous blood circulation, noneof these claims are supported by statistically signifi-

healed successfully even while the patients remained2）
in their wheelchair. The NPUAP/EPUAP guidelines

cant findings. Further, the same work indicates that alarge number of studies reviewed recommend avoiding massaging bony prominences. A randomized
2）
controlled trial involving 144 subjects scoring 20 orlower on the Braden Scale and at high risk of pressure

recommend re-evaluating the patients Spressure
ulcer state, and on the basis of the findings, selecting

ulcers examined the use of skin cream whenmassaging the individual. The study found that there
was no statistical difference in the rate of pressureusing the wheelchair. For these reasons, the methods
described above are assigned the recommendation
rating of C1.

ulcer development in relation to the use of skin cream3）
when massaging. The WOCN guidelines also statethat strong massaging should be avoided. In sum-

an appropriate cushion, limiting sitting time, anddetermining the effects of posture to avoid pressure
on the wound area to enable the patient to continue

References
1）Hirose H, Tanaka H, Mawaki A, et al：Case studies ofmary, the evidence given above generally indicatesthat massaging bony prominences should be avoided;
recommendation rating D.

coccygeal pressure ulcers caused by improper
wheelchair seating. Jpn J PU, 13（ 1 ）：54-60, 2011.
（Level V）（Japanese, English abstract）
2 ）National Pressure Ulcer Advisory Panel and Euro-

Referencespean Pressure Ulcer Advisory Panel：Prevention1）Duimel-Peeters IG, Halfens RJ, Berger MP, et al：Theand treatment of pressure ulcers：Clinical practiceeffects of massage as a method to prevent pressure

guideline. National Pressure Ulcer Advisory Panel,ulcers. A review of the literature. Ostomy Wound

Washington DC, 2009.

Manage, 51（4）：70-80, 2005.（Level I）
2）Duimel-Peeters IG, JG Halfens R, Ambergen AW, etal：The effective of massage with and without
dimethyl sulfoxide in preventing pressure ulcers：A
randomized, double-blind cross-over trial in patientsprone to pressure ulcers. Int J Nurs Stud, 44：12851295, 2007.（Level II）
3）Catherine R Ratliff：WOCNNs evidence based pressure ulcer guideline. Adv Skin Wound Care, 18（4）：204-208, 2005.

CQ 5.11：How can daily use of the wheelchair bypatients with shallow pressure ulcers be facilitated?
［ Recommendation ］A suitable sitting posture, anappropriate support cushion, and limitation on sitting
time may be considered.
［Rating］C1［Analysis］To date there exist only one case report
and two guidelines addressing the question of what
effect a sitting posture has on pressure ulcers.
1）
According to the case report , three patients at an

CQ 5. 12：What kind of physical modality can beused for patients with infected pressure ulcers?
［ Recommendation ］Hydrotherapy may be considered.
［Rating］C1［Analysis］The NPUAP/EPUAP guidelines state
considering a course of whirlpool for reducing
1）
bioburden and infection . Although hydrotherapy
providing agitation and turbulence to the water by
mixing air and water by turbines in a tank has notbeen found to effective in suppressing infection,2）
according to expert opinion it is effective in reducing
the bacterial load in wounds, thereby promoting
wound healing. For this reason this form of therapy
has been assigned the recommendation rating of C1.
References
1 ）National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel：Prevention
and treatment of pressure ulcers：clinical practiceelderly care facility with shallow ulcers in thecoccygeal area underwent rehabilitation with theguideline. National Pressure Ulcer Advisory Panel,assistance of a trained physical therapist who chose
body positions and support surfaces according tokinesiology to lessen pressure on the pressure ulcers.
As a result of this procedure, the pressure ulcers

2 ）Burke D, Ho C, Saucier M, et al：Effects of hydro-

Washington DC, 2009.

― G− 55 ―therapy on pressure ulcer healing. Am J Phys Med
Rehabil, 77（5）：394-398, 1998.（Level IV）

― 67 ―

CQ 5. 13：What kind of physical modality can beused for pressure ulcers containing necrotic tissue?
［Recommendation］Consider hydrotherapy or pulsatile lavage with or without suction.
［Rating］C1［Analysis］Based on expert opinion, the NPUAP/
1）
EPUAP guidelines state to consider a course ofwhirlpool as an adjunct for wound cleansing andfacilitating healing. The same guidelines further state
to consider a course of pulsatile lavage with suction
for wound cleansing and debridement. In Japan the
Hubbard tank is used in wound cleansing procedures,
but no studies assessing its efficacy have been
published to date. Given these considerations, themethods described here have been assigned therecommendation rating of C1.
References
1 ）National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel：Prevention
and treatment of pressure ulcers：clinical practiceguideline. National Pressure Ulcer Advisory Panel,
Washington DC, 2009.

CQ 5. 14：What kind of physical modality can beused to promote wound reduction?
［Recommendation］
1. Implementing electrical stimulation therapy isrecommended.
［Rating］B
2. Near infrared therapy, ultrasonic therapy, or
electromagnetic therapy may be considered.
［Rating］C1
1）［Analysis］One meta-analysis and one systematic
2）
review have compared the relative efficacy ofnear infrared therapy. These studies have found nearinfrared therapy to be effective in promoting wound
reduction. Although near infrared irradiation was
found to increase blood flow in the wound periphery7）
with significantly positive effects on wound healing ,the mechanism underlying this phenomenon has not
yet been explained and for this reason this technique
has been assigned a recommendation rating of C1.
Ultrasound/ultraviolet-C irradiation has been found to8）
reduce wound size , but the way in which eachintervention produces these results has not beenclarified. In addition, the one randomized controlled
12）
trial examining the efficacy of low-level laser irradiation on wound healing has not reported significant
8, 9）
improvement .
Although the systematic review of ultrasoundtherapy has reported less than adequate results for11）this form of therapy, in a case report, Maeshige et al.
state that ultrasound therapy had a positive effect on
reducing wound size. For this reason, ultrasoundtherapy has been assigned the recommendation
rating of C1.
12）
Non-thermal pulsed electromagnetic therapy
showed a positive effect on the reduction of wound
size, but this modality is assigned the recommendation rating of C1 due to the small size of randomized
clinical trial.
References
1）Gardner S, Frantz R, Schmidt F：Effect of electricalstimulation on chronic wound healing：A metaanalysis. Wound Repair Regen, 7（6）：495-503, 1999.
（Level I）
2）Regan MA, RWTeasell, DL Wolfe, et al：A systematic
review of therapeutic interventions for pressure

electrical stimulation therapy and conventional therapies for treating pressure ulcers, including chronic

ulcers after spinal cord injury. Arch Phys Med

ulcers. The recommended parameters for electricalstimulation therapy diverge widely in these studies,but the results reported for this form of treatment are
uniformly positive. Randomized controlled studies
3）
using both direct micro-current stimulation as well4）
as high-voltage current stimulation report wound
reduction. On these grounds these methods have been
assigned the recommendation rating of B.
Of the studies examining the effect of phototherapy3）Stefanovska A, Vodovnik L, Benko H, et al：Treat-

Rehabil, 90：213-231, 2009.（Level I）
ment of chronic wound by means of electric andelectromagnetic fields. Part2. Value of FES parameters for pressure sore treatment. Med Biol Eng
Comput, 31（3）：213-220, 1993.
4 ）Pamela E, Karen E, Campbell RN, et al：Electrical
Stimulation Therapy Increases Rate of Healing ofPressure Ulcers in Community-Dwelling People With
Spinal Cord Injury. Arch Phys Med Rehabil, 91（5）
：

5, 6）

on pressure ulcer, two randomized controlled trial
7）
and one case report specifically examine the use of669-678, 2010.
5 ）Schubert V：Effects of phototherapy on pressure― G− 56 ―― 68 ―

ulcer healing in elderly patients after a falling trauma.
A prospective, randomized, controlled study. Photodermatol Photoimmunol Photomed, 17（ 1 ）：32-38,
2001.
6 ）Dehlin O, Elmstahl S, Gottrup F：Monochromatic
phototherapy in elderly patients：A new way oftreating chronic pressure ulcers?. Aging Clin Exp
Res, 15（3）：259-263, 2003.

according to scale, rendering their relative utility forpredicting, and therefore preventing, pressure ulcer
occurrence unclear at best. On the other hand, theoccurrence of pressure ulcers can be reduced if theappropriate preventive interventions are conductedon the basis of information obtained from risk
assessment scales.
2）
Another systematic review assessing the Braden,

7）Kurokawa M, Yamada N, Hanemori Y, et al：Effect of

Norton, and Waterlow scales in terms of the para-

linear polarized near infrared therapy for pressure

meters of clinical judgment and predictive validity
subjected the odds ratio of the three scales（4.08, 2.16,
and 2.05, respectively）and the odds ratio of clinicalulcers. Geriat Med 40（ 8 ）：1165-1170, 2002.
（Japanese）
8）Nussbaum EL, Biemann I, Mustard B：Comparison ofultrasound/ ultraviolet-C and laser for treatment ofpressure ulcers in patients with spinal cord injury.
Phys Ther, 74（9）：812-823, 1994.
9 ）Lucas C, van Gemert MJ, de Haan RJ：Efficacy of
low-level laser therapy in the management of stage Ⅲ
decubitus ulcers：A prospective, observer-blindedjudgment（1.69）to meta-analysis and found that therisk assessment scale was effective in predicting theoccurrence of pressure ulcers.
In summary, the reports given above demonstratethat the use of risk assessment scales with theappropriate interventions can reduce the rate ofoccurrence of pressure ulcers significantly.

multicentre randomized clinical trial. Lasers Med Sci,

References18（2）：72-77, 2003.
10）Flemming K, Cullum N K, Cullum N, et al：Therapeu-

1）Deeks JJ：Pressure sore prevention: Using and evalu-

tic ultrasound for pressure ulcer. Cochrane Databaseating risk assessment tools. Br J Nurs, 5（ 5 ）：313-320, 1996.（Level I）

of Systematic Reviews. Issue 4, 2009.
11）Maeshige N, Terashi H, Sugimoto M, et al：Evalua-

2 ）Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-

tion of combined use of ultrasound irradiation andMedina IM, et al：Risk assessment scales forwound dressing on pressure ulcer. J Wound Care, 19

pressure ulcer prevention: a systematic review. J Adv（2）：63-68, 2010.

Nurs, 54（1）：94-110, 2006.（Level I）

12）Salzberg CA, Stephanie A, Frnncisco JP, et al：The

injured patients：A randomized, double-blind study.

CQ 6.2：Which risk assessment scale should generally be used?
［ Recommendation ］Use of the Braden Scale is

Wounds, 7（1）：11-16, 1995.

recommended for most situations.

effects of non-thermal pulsed electromagnetic energy
on wound healing of pressure ulcers in spinal cord-

CQ 6 Risk assessment
CQ 6.1：Is risk assessment effective in predicting
the development of pressure ulcers?
［Recommendation］Use of risk assessment scales
is recommended for predicting pressure ulcer development.
［Rating］B
1）［Analysis］Deeks published a systematic review［Rating］B［ Analysis ］The efficacy of the Braden Scale andthe Norton Scale for predicting pressure ulcer
occurrence was examined in a cohort study using two
randomly assigned groups, the\ turning group Sin
which subjectsSbody position was rotated, and the1）\non-turning groupS . The results showed that the
subjects in the non-turning group developed Grade II

in which the validity of seven risk assessment scales,
namely, the Norton, Gosnell, Knoll, Braden, Waterlow,

or higher pressure ulcers at a significantly higher rate
than the turning group. Further, a comparison of thesensitivity, specificity, and the odds ratio of both

PSPS, and Andersen scales, were evaluated in termsof the parameters of sensitivity, specificity, andpressure sore incidence rates. However, differences insample size and target population varied widely

scales, when applied to the non-turning group,
demonstrated the equivalence of these two scales.
An Internet search using\ Braden Scale Sas the2）
key word produced a systematic review of nine

― G− 57 ―― 69 ―

studies dealing with the predictive validity of theBraden Scale. However, due to the fact that the cut-off
value varied widely from 14〜20 points, no agreement
could be found among these studies.
3）
Another article dealing with a cohort study using
the Braden Scale found that use of this scale enabled a

References
1）Kaigawa K, Moriguchi T, Oka H, et al：Analysis of
the pressure ulcer risk in bedridden patients, Jpn
JPU, 8（ 1 ）：54-57, 2006.（ Level IV ）（ Japanese,
English abstract）

50〜60% reduction in the incidence of pressure ulcers,
as well as reductions in costs associated with specialty
bed rentals and pressure reduction mattress overlays.

CQ 6. 4：Which risk assessment scale is recommended for use with the elderly?

In summary, the Braden Scale has proved effective
in both predicting pressure ulcer occurrence as well
as reducing costs associated with pressure ulcer care.

［Recommendation］
1. The OH Scale may be used with bedridden
elderly patients.

As such, the adoption of this scale is recommended aspart of a prevention program.

［Rating］C1［Recommendation］
2. The K Scale may be used with bedridden elderly

References
1）Defllor T, Grydonck MFH：Pressure Ulcers: validation of two risk assessment scales. J Clin Nurs, 14（3）：373-382, 2005.（Level IV）
2 ）Brown SJ：The Braden Scale. A review of the research evidence. Orthop Nurs, 23（1）：30-38, 2004.
（Level I）
3 ）Bergstrom N, Braden B, Boynton P, et al：Using a
research-based assessment scale in clinical practice.
Nurs Clin North Am, 30（3）：539-551, 1995.（Level
IV）

CQ 6. 3：What method of assessment used forelderly patients?
［Recommendation］Assessing the risk factors forpressure ulcer development may be considered.
［Rating］C1
1）［ Analysis ］A retrospective cohort study of six
risk factors（basic mobility, morbid bony prominence,
articular contraction, malnutrition, skin moisture,edema）stipulated by the Ministry of Health, Labor,and Welfare in Supplement No. 4 of the Clinical
Practice for Pressure Ulcer Development（March 6,
2006）studied the odds ratio of two groups, the nonpressure ulcer group and the pressure ulcer group.
The study found the odds ratio of the 173 bedridden
subjects enrolled in the study to be 4. 0 for morbid
bony prominence, 15.9 for articular contraction, 3.8 formalnutrition, and 3.1 for edema. Logistic regression

patients in hospital.
［Rating］C1
1）［Analysis］A case control report using the Ohura
Risk Assessment Scale to evaluate four risk factors,
namely, the state of consciousness, degree of sacralbony prominence, edema, and articular contracture in
95 pressure ulcer patients and 318 non-pressure ulcer
patients found a significant difference between the
total average score for the pressure ulcer group（6.7）
and that of the non-pressure ulcer group（3.4）. The
Ohura Risk Assessment Scale has since been revised
and is now accepted as an highly accurate OH scale.
The reliability and predictive validity of the K Scale
have been examined in a prospective cohort study of2）
hospitalized bedridden elderly patients . The study
found that in terms of reliability, the K Scale did not
require as high a level of experience or skill in the user
as the Braden Scale. Further, an assessment of thepredictive validity of the K Scale found the specificityof the underlying subscales to be 29.0% whereas thatof the trigger subscales was 74. 2%. These results
demonstrated the clinical significance of the K Scaleas an effective tool for predicting the development ofpressure ulcers by observing the changes in interfacepressure, moisture, and shear within a short period oftime.
References
1）Fujioka M, Hamada Y：Usefulness of the Ohura risk

found the odds ratio for articular contraction to be
11.2, the largest figure obtained, indicating theseriousness of this risk factor.

assessment scale for predicting pressure ulcer
development, Jpn J PU, 6（ 1 ）：68-74, 2004.（ Level
IV）（Japanese, English abstract）
2）Okuwa M, Sanada H, Sugama J, et al：The Reliability― G− 58 ―― 70 ―and Validity of the K Scale for Predicting Pressure
Ulcer Development for the Elderly. Jpn J PU, 3（1）：7-13, 2001.（Level IV）（Japanese, English abstract）

CQ 6. 5：Which risk assessment scale is recommended for pediatric patients?
［ Recommendation ］The Braden Q Scale may beconsidered for risk assessment in pediatric patients.
［Rating］C1
1）［Analysis］A prospective cohort study was conducted with 332 pediatric in-patients with acute1）rit（ hemoglobin ）. A retrospective cohort study ofthe efficacy of this scale for pressure ulcer risk
assessment in spinal cord injury patients reported ahigh degree of reliability and validity. However, it
should be borne in mind that as no similar study has
been conducted in Japan, results may vary when thescale is used with Japanese subjects.
References1）Salzberg CA, Byrne DW, Cayten CG, et al：A newpressure ulcer risk assessment scale for individuals

diseases（21 days old to 8 years old）to determine thepredictive validity and cut-off value for the Braden Q
Scale. For a cut-off point of 16 or lower, the sensitivity
was 88%, the specificity was 58%, the positive
predictive value was 15%, the negative predictive
value was 98%, and the likelihood ratio was 2.11. This
study supports the efficacy of the Braden Q Scale asequivalent to that of the Braden Scale used with adultsubjects.
The Braden Q Scale is used by the WOCN Clinical2）
Practice Guideline as a pediatric risk assessment
scale.
References
1）Curley MAQ, Razmus IS, Roberts KE, et al：Predicting pressure ulcer risk in pediatric patients : The
Braden Q Scale. Nurs Res, 52（ 1 ）：22-33, 2003.
（Level IV）
2 ）Wound Ostomy and Continence Nurses Society：with spinal cord injury. Am J Phys Med Rehabil, 75（2）：96-104, 1996.（Level IV）

CQ 6. 7：Which risk assessment scale is recommended for subjects in a home-care setting?
［ Recommendation ］A pressure ulcer risk assessment scale specifically designed for patients in a homecare setting may be used.
［Rating］C1［ Analysis ］The Pressure Ulcer Risk Assessment
Scale for the Home Care Setting（home care setting
version of the K Scale ）combines the K Scale withcare capacity assessment. A prospective cohort
1）study using this scale rated its predictive validity
very highly. However, as this study was conducted ina medium-sized city, differences in results may be
expected due to variations in family structure andcare capacity. These considerations need to be bornein mind before using this scale.

Guideline for Prevention and Management of Press-

References

ure Ulcers, 4 , WOCN Society, Mount Laurel, NJ,2010.

1）Murayama S, Kitayama Y, Okuwa M, et al：Develop-

CQ 6. 6：Which risk assessment scale is recommended for spinal cord injury patients?
［Recommendation］The SCIPUS scale may be considered for risk assessment in spinal cord injury
patients.
［Rating］C1［Analysis］The Spinal Cord Injury Pressure Ulcer
Scale（ SCIPUS ）comprises 15 parameters: level ofactivity, mobility, complete spinal cord injury, urine
incontinence or constantly moist, autonomic dysreflexia or severe spasticity, age, tobacco use/smoking,pulmonary disease, cardiac disease or abnormal ECG,
diabetes or hyperglycemia, renal disease, impaired
cognitive function, internment in a nursing home or
hospitalization, albumin or total protein, and hematoc-

ment of a pressure ulcer risk assessment scale for thehome-care setting. Jpn J PU, 9（ 1 ）：28-37, 2007.
（Level IV）（Japanese, English abstract）

CQ 7 Skin assessment
CQ 7.1：How can the depth of pressure ulcers be
predicted?
［Recommendation］
1. The prediction of d1 pressure ulcer prognosis
may be based on the presence of double erythema（graduated redness）away from a bony prominence.
［Rating］C1［Recommendation］
2. Ultrasonography may be used.
［Rating］C1― G− 59 ―― 71 ―

［Recommendation］
3. The ABI（ankle brachial index）may be used to2 ）Aoi N, Yoshimura K, Kadono T, et al：Ultrasoundpredict the depth of pressure ulcers in the heel region.
［Rating］C1
1）［ Analysis ］Sato, et al. have examined the development of non-blanchable erythema characterizing

Possible prediction of pressure ulcer progression.

assessment of deep tissue injury in pressure ulcers:
Plast Reconstr Surg, 124（2）：540-550, 2009.（Level
V）3）Okuwa M, Sanada H, Sugama J, et al：RelationshipStage I pressure ulcers（NPUAP）in order to determine the utility of clinical signs for pressure ulcer
prognosis. From their observations, they concluded

between heel pressure ulcer severity and the ankle

that the presence of double erythema（ graduatedredness ）, non-blanchable erythema confirmed byglass plate compression, erythema away from a bony

English abstract）

prominence, or expanding erythema predicted thedevelopment of tissue defects penetrating to thedermis or even to underlying tissue. In particular, theprognostic value of double erythema and erythema
away from a bony prominence for Stage I pressure
ulcers was extremely high, and helpful in predicting
the deterioration of d1 pressure ulcers.
In their study of 12 cases, Aoi, et al. determined thatthe level of deep tissue injury could be predicted on
the basis of an initial macroscopic observation of the2）patient and ultrasound findings . The study relied onfour types of images, among which those of the
discontinuous fascia and heterogeneous hypoechoic
areas had greatest diagnostic value. Further, ultrasonography proved useful for predicting tissue loss incases where the depth of the pressure ulcer wasotherwise unclear.
Another study of 27 cases of pressure ulcer in theheel region examined the relationship between ABI（ Ankle Brachial Index ）findings at the initial examination and the final stage of pressure ulcer
3）
development . The ABI value for d1 and d2 pressure
ulcers in the heel region was 0.87, and 0.48 for woundsof level D3 or deeper in the heel region. The ROC
analysis yielded an ABI outlier value of 0.6. The ABI
can be used to predict the depth of pressure ulcers in
the heel region.
In conclusion, the accuracy of the prognosis ofpressure ulcer progression can be increased throughclose observation of erythema and the use of methods
such as ultrasonography and ABI.
Referencesbrachial index among bedfast elderly patient. Jpn J P
U，9（ 2 ）：177-182，2007.（ Level V ）（ Japanese,

CQ 7.2：How can redness/d1 stage pressure ulcer
be identified?
［Recommendation］The transparent disk methodor the finger method may be considered.
［Rating］C1［Analysis］A controlled study by Vanderwee et al.
examined the reliability and diagnostic accuracy of
the transparent disk methed and the finger method1）
for identifying Stage I pressure ulcers（ EPUAP ） .
The concordance rate of the two methods was higher
than 90%, and CohenSs k co-efficient was higher than 0.
6, both indicating a high level of agreement. In termsof diagnostic accuracy as well, these methods yieldeda very high degree of agreement irrespective of theattending nursesSlength of experience.
Although at present there are no further highevidence-level reports on the topic, both of themethods discussed here, namely the transparent disk
method and the finger method, as well as palpation,
can be considered for use in identifying redness/d1
pressure ulcer because of the ease with which they
can be performed in a clinical setting.
References
1）Vanderwee K, Grypdonck M, De Bacquer D, et al：
The reliability of two observation methods ofnonblanchable erythema, Grade 1 pressure ulcer.
Appl Nurs Res, 19（3）：156-162, 2006.（Level V）

CQ 7. 3：Which methods can be used to identify
deep tissue injury（DTI）?
［Recommendation］
1. Palpate the area to see whether pain, induration,
edema, or changes in skin temperature（ warm orpressure ulcers and related factors. Int Wound J, 3

cool ）are present in comparison with the adjacenttissue.

（4）：355-362, 2006.（Level V）［Rating］C11）Sato M, Sanada H, Konya C, et al：Prognosis of stage I― G− 60 ―― 72 ―

［Recommendation］
2. Consider using ultrasonography.
［Rating］C1［Analysis］According to the NPUAP classification,a suspected DTI is categorized as a\ purple ormaroon localized area of discolored intact skin or
blood-filled blister due to damage of underlying soft
tissue from pressure and/or shear. The area may be
preceded by tissue that is painful, firm, mushy, boggy,
warmer or cooler as compared to adjacent tissue. S
Although the NPUAP advisory panel states that theextent of deep soft tissue damage may be difficult to
detect from skin surface appearance, they discusschanges in skin sensation and assessment by palpa1）
tion as valid clinical findings . The clinical findings
from palpation may provide useful information for
identifying DTI.
Ultrasonography can be used as an objective means
2）of assessing DTI, according to one case report . The
use of the CT scan, MRI, or ultrasonography, in
addition to macroscopic observation and palpation, is
recommended for an objective assessment of thecondition. Of these various methods, only ultrasonography is mentioned in connection with pressure
ulcer assessment.
References
1）Black J, Baharestani MM, Cuddigan J, et al：National

occurrence of superficial pressure ulcers（ partial
thickness wounds）. One randomized controlled study
compared the severity of pressure ulcers in incontinent patients following the use of soap or a mildly1）
acidic cleansing agent . The results of this study
indicated a significant reduction in the occurrence ofGrade I pressure ulcers（pressure ulcers without skindefect）following the use of the mildly acidic cleans2, 3）
ing agent. Two non-randomized clinical trials and4）
one historical control study examined the incidenceof pressure ulcers after cleansing only, or after theapplication of skin emollients to the anal and genitalareas and to the peripheral skin. In both groups theincidence of pressure ulcers declined; in one study,
however, no statistically significant difference was3）reported . A before-and-after comparison of 136
subjects interned in a long-term care facility foundthat the number of cases of skin trouble declined from68 to 40 subjects, while the rate of occurrence of StageI and II pressure ulcers declined from 19.9% to 8.1%
5）
（ p ＜ 0. 01 ） . Some of the skin care products mentioned in the sources cited are unavailable here in
Japan although comparable products can be obtained.
On the basis of the above data, the application ofskin emollients to the anal/ genitalia area to theperipheral skin after cleansing with an appropriate
cleansing agent is assigned a recommendation ratingof C1.

Pressure Ulcer Advisory Panel. National Pressure

References

Ulcer Advisory PanelSs update pressure ulcer staging
system. Adv Skin Wound Care, 20（ 5 ）：269-274,

1 ）Cooper P, Gray D：Comparison of two skin careregimes for incontinence. Br J Nurs, 10：S6, S8, S102007.

passim 2001.（Level II）

2）Nagase T, Koshima I, Maekawa T, et al：Ultrasonographic evaluation of an unusual peri-anal induration: a2 ）Thompson P, Langemo D, Anderson J, et al：Skinpossible case of deep tissue injury. J Wound Care, 16

care protocols for pressure ulcers and incontinence in（8）：365-367, 2007.（Level V）

long-term care : A quasi-experimental study. Adv
Skin Wound Care, 18：422-429, 2005.（Level III）

CQ 8 Skin care
Preventive CareCQ 8.1：What kind of skin care is recommended forpatients suffering from urinary and/or fecal incontinence in order to prevent development of pressure
ulcers?
［Recommendation］After cleansing with an appropriate cleansing agent, skin emollients can be applied
to the anal/genital area and to the peripheral skin.
［Rating］C13）Clever K, Smith G, Bowser C, et al：Evaluating theefficacy of a uniquely delivered skin protectant and its
effect on the formation of sacral/buttock pressure
ulcer. Ostomy Wound Manage, 48（12）：60-67, 2002.
（Level III）
4）Dealey C：Pressure sores and incontinence : a study
evaluating the use of topical agents in skin care. J
Wound Care, 4：103-105, 1995.（Level III）
5）Hunter S, Anderson J, Hanson D, et al : Clinical Traial［ Analysis ］Incontinence is associated with the― G− 61 ―of a prevention and treatment protocol for skinbreakdown in two nursing homes. J Wound Ostomy

― 73 ―

Continence Nurs, 30（5）：250-258, 2003.（Level III）

CQ 8. 2：What type of preventive skin care isrecommended for use on bony prominences in elderly
patients?
［ Recommendation ］Transparent film dressingsand other dressings with a low-friction externalsurface are recommended.
［Rating］B［ Analysis ］According to one study, transparent

recommended for application to the sacral area inpatients who will undergo surgery in a supine
position; Rating C1. However, it should be noted that
this form of treatment is not covered by Japanese
National Health Insurance.
References
1）Imanishi K, Morita K, Matsuoka M, et al：Preventionof postoperative pressure ulcer by a polyurethane
film patch. J Dermatol, 33（ 3 ）：236-237, 2006.

film dressings applied to the sacral area resulted in asignificant decrease in the rate of occurrence of1）pressure ulcers . Another study using both smoothsurface dressings and transparent film dressings on

CQ 8.4：What kind of skin care is recommended for
non-invasive ventilation patients to prevent pressure

the left and right sides of the greater trochanter found
an absence of pressure ulcer formation in both groups,
and a significantly lower incidence of non-blanchable

ulcer formation at the face mask contact site?
［Recommendation］A transparent film dressing or
a hydrocolloid dressing may be used for this purpose.

erythema in the low-friction external surface dressing
2）group .

［Rating］C1［ Analysis ］Weng examined the rate of pressure
ulcer occurrence in 90 non-invasive ventilation
1）
patients . The subjects were divided into threegroups, namely the control group and the transparent
film and hydrocolloid dressing groups and the rate ofoccurrence of Stage I pressure ulcers among themwas compared. The rate of pressure ulcer occurrence
was 96. 7% in the control group, 53. 3% in thetransparent film dressing group, and 40% in thehydrocolloid dressing group, showing a significant
difference with the control group（p ＜ 0.01）.
In Japan also, one case report examined the use ofhydrocolloid dressings with patients placed on a noninvasive respirator and found evidence of pressure2）
ulcer formation in only two of the 30 cases examined .
Pressure ulcers resulting from the use of medical
devices have previously been cited as a matter ofconcern. The present guidelines have therefore

References
1 ）Ito Y, Yasuda M, Yone J, et al：Polyurethane film
dressing applied to the sacral area for prevention ofpressure ulcers. Jpn J PU, 9（1）：38-42, 2007.（Level
IV）（Japanese English abstract）
2） Nakagami G, Sanada H, Konya C, et al：Evaluation ofa new pressure ulcer preventive dressing containing
ceramide 2 with low frictional outer layer. J Adv Nurs,
59（5）：520-529, 2007.（Level III）

CQ 8.3：What kind of skin care is recommended forpatients undergoing surgery in a supine position?
［ Recommendation ］A transparent film dressing
can be applied to the sacral area.
［Rating］C1［ Analysis ］In a randomized controlled trial, Imanishi et al. compared the rate of occurrence of postoperative pressure ulcers in supine patients with and1）without transparent film dressings . Of the 103
subjects without the dressings, 22 developed pressure
ulcers, whereas in the 98 subjects with dressings, only
10 developed pressure ulcers, demonstrating astatistically significant difference between the twogroups（p = 0.049）.However, in view of the fact that

（Level II）

included discussion of this topic as well.
References
1 ）Weng MH：The effect of protective treatment in
reducing pressure ulcers for non-invasive ventilation
patients. Intensive Crit Care Nurs, 24（5）：295-299,
2008.（Level III）
2）Tanaka M, Sakaki Y：Prevention of pressure ulcer inthe BMI of all of the subjects was within the normal
range, the relevance of these results to patients withpronounced bony prominences cannot be ascertained.
In summary, the transparent film dressing is― G− 62 ―the nose/cheeks due to mask application in noninvasive positive pressure ventilation -Effects of theuse of a skin barrier-. Jpn J PU, 10（1）：35-38, 2008.
（Level V）

― 74 ―

Care after occurrence
CQ 8.5：How should the skin surrounding a press-

3）Ishikawa S, Togashi H, Tamura S, et al：Influence ofure ulcer be cleansed in order to promote pressure
ulcer healing?
［Recommendation］Cleansing with a mildly acidic

ceramide on the surrounding skin of pressure ulcers.

cleansing agent may be considered.
［Rating］C1［Analysis］Skin surrounding a pressure ulcer con-

CQ 8.6：In cases with urinary and/or fecal incontinence, what kind of skin care is recommended totains insoluble proteins, lipids and other contaminants,
and therefore requires cleansing in the same manner1）
as healthy skin . One study comparing the rate ofhealing in pressure ulcers before and after a regimenof cleansing peripheral skin using either a sterile
saline solution or a mildly acidic cleansing agent foundthat the latter shortened the healing time of pressure2）
ulcers at any stage . Further, the rate of healing
among cases of Stage II pressure ulcers cleansed withnew skin cleanser containing synthetic pseudoJpn J PU, 5（3）：508-514, 2003.

promote pressure ulcer healing?
［Recommendation］Skin emollients can be applied
to the peripheral skin after cleansing with anappropriate cleansing agent.
［Rating］C1［Analysis］Two non-randomized controlled studies
comparing healing time between a control groupwhose skin was cleansed using a cleansing agent only
and an experimental group whose skin was covered
with a protective cream after cleansing found thatthe mildly acidic cleansing agent was 1.79 times fasterthan the sterile saline solution group.
As yet there are no reports as to the specific typesof cleansing agents that promote healing in pressure
ulcers. However, one study comparing the effect of amildly acidic cleansing agent and a mildly acidic
ceramide-containing cleansing agent reported a
reduction in the quantity of scales and microbes aswell as an increase in the amount of ceramide after
use of the mildly acidic ceramide-containing cleansing
3）
agent . Accordingly, if maintaining the normal
physiological function of the skin is sufficient toprevent epithelialization of the skin surrounding thewound, a mildly acidic cleansing agent containing

healing time shortened and the healing rate improved
1, 2）
significantly in the latter group .
On the basis of these data, in order to promotepressure ulcer healing, the application of skinemollients on the peripheral skin is recommended incases of fecal and/or urinary incontinence, as withprevention of pressure ulcers, following cleansing
with an appropriate cleansing agent.

skin-protective agents is the best option. Absent thisoption, a mildly acidic cleansing agent is preferred to2）Dealey C：Pressure sores and incontinence : a study

conventional soap. In summary, a mildly acidic
cleansing agent is the preferred option for cleansing
the skin surrounding a pressure ulcer wound in orderto promote wound healing; Rating C1.
References
1）Konya C, Sanada H, Sugama J, et al：Skin debris andmicro-organisms on the periwound skin of pressure
ulcers and the influence of periwound cleansing on
microbial flora. Ostomy Wound Manage, 51（1）：5059, 2005.

References
1 ）Thompson P, Langemo D, Anderson J, et al：Skincare protocols for pressure ulcers and incontinence inlong-term care : a quasi-experimental study. Adv Skin
Wound Care, 18（8）：422-429, 2005.
evaluating the use of topical agents in skin care. J
Wound Care, 4（3）：103-105, 1995.
3 ）Bale S, Tebble N, Jones V, et al：The benefits ofimplementing a new skin care protocol in nursing
homes. J Tissue Viability, 14（2）：44-50, 2004.

CQ 9 Repositioning
CQ 9. 1：How frequently should the bed boundpatient be repositioned to prevent pressure ulcer?
［Recommendation］Consider repositioning the patient at least every two hours.
［Rating］C1

people healing?. J wound care, 14（4）：169-171, 2005.

［Analysis］One systematic review dealing with thefrequency of body repositioning demonstrated that
under optimal conditions provided by the use of a

（Level III）

support surface, body repositioning performed every2）Konya C, Sanada H, Sugama J, et al：Dose the use of acleanser on skin surrounding pressure ulcer in order― G− 63 ―― 75 ―

four hours was equally effective for preventingpressure ulcer formation as repositioning every two
1）hours . Further, the NPUAP/EPUAP guidelines
state that,\ Repositioning frequency will be determined by the individual Ss tissue tolerance, his/herlevel of activity and mobility, his/her general medical
condition, the overall treatment objectives, and2）assessments of the individualSs skin conditionS . The
WOCN guidelines recommend to schedule regularbeen published to date dealing with body reposition1, 2）
ing for nursing home residents . The subjects weredivided into the 2-hour and 3-hour repositioning
groups using a standard hospital mattress and a 4hour and 6-hour repositioning group using a support
surface（ visco-elastic foam mattress 15cm in thickness ）, and the rates of pressure ulcer development
1）
among them was assessed . As a result, the 4-hour
repositioning group showed a significantly lower rate

repositioning and turning for bed and chair bound3）
individuals . Neither guidelines state specific intervals at which the patient Ss body should be reposi-of Grade II pressure ulcer development（p = 0.002）.
Further, a study comparing pressure ulcer formation
rates between a control group（comprised of subjects

tioned; nor are there any studies conducted in Japanto date which address this question with respect topatients at high risk of developing pressure ulcers. In

laterally positioned for 2 hours and supinely positioned for 4 hours ）and the experimental group（comprised of subjects laterally positioned for 4 hours

view of the fact that the present guidelines aim toaddress issues relating to pressure ulcer care andmanagement in a diversity of care settings, such as
home, institution, and hospital, we recommend thatthe patient be repositioned at least every two hours.

Guideline for prevention and management of press-

and supinely positioned for 4 hours ）using a viscoelastic mattress 7cm in thickness failed to demonstrate a significant difference in pressure ulcer2）
development rate among these groups . The subject
enrolled in these studies, however, differ in respect totheir body size, weight, and other factors, from theircounterparts in Japan, and for this reason theapplication of the methods outlined in the aforementioned studies to patients in Japan may entail somerisk, and offer no guarantee of yielding similar results.
On the other hand, a case controlled study dealing
with patients in a convalescent hospital assessed thedevelopment of erythema among patients supinely
positioned on a double-layer air-cell mattress3）
overlay . The patients were repositioned at intervalsof two hours or greater, and their skin was observed
at 2, 4, and 5 hours from commencement of theure ulcers. WOCN clinical practice guidelines no. 2

experiment for indications of erythema. As a result, 4Glenview, IL, 2003.

hours was found to be the upper limit at which
patients could be maintained in one position without
the development of erythema. After 5 hours, 50% of
patients were found to have developed indications oferythema.

References
1）Krapfl LA, Gray M：Does regular repositioning prevent pressure ulcers?. J Wound Ostomy Continence
Nurs, 35（6）：571-577, 2008.（Level I）
2）National Pressure Ulcer and Advisory Panel and European Pressure Ulcer Advisory Panel：Prevention
and treatment of pressure ulcers, clinical practiceguideline, National Pressure Ulcer Advisory Panel,
Washington DC, 2009.
3 ）Wound, Ostmy and Continence Nurses Society：

CQ 9.2：How frequently should bed bound patient
be repositioned when a support surface is being used?
［Recommendation］
1. When a visco-elastic foam mattress is being used,consider repositioning the patient at least every fourhours.
［Rating］C1［Recommendation］
2. When a double-layer air-cell mattress overlay is
being used, consider repositioning the patient at least
every four hours.
［Rating］C1

The NPUAP/EPUAP guidelines state that,h Frequency of repositioning will be influenced by variables
concerning the individual and support surface in4）
usei .
Because both evidence sources involve a specificgroup of subjects using a specific type of support
surface, and therefore provide findings with limited
applicability, they are assigned the recommendation
rating of C1.

［Analysis］Two randomized controlled trials have― G− 64 ―― 76 ―

wishes of the patient or the physical stature of theReferences
1）Defloor T, De Bacquer D, Grypdonck MH, et al：The

patient, rather than adhering strictly to the 30-degreetilted side-lying position; recommendation rating C1.

effect of various combinations of turning and pressure

References

reducing devices on the incidence of pressure ulcers.

1）Young T：The 30°tilt position vs the 90°lateral and

Int J Nurs Stud, 42（1）：37-46, 2005.（Level II）
2）Vanderwee K, Grypdonck MH, De Bacquer D, et al：supine position in reducing the incidence of non-Effectiveness of turning with unequal time intervals

blanching erythema in a hospital inpatient population:on the incidence of pressure ulcer lesions. J Adv Nurs,

A randomized controlled trial. J Tissue Viability, 1457（1）：59-68, 2007.（Level II）（3）：88-96, 2004.（Level II）

3）Nakashima F, Toyoda T：Evaluation of pressure ulcer
development in patients who underwent positionalchanges at intervals of 2 hours or more. Jpn J P U, 5
（ 1 ）：37-41, 2003.（ Level IV ）（ Japanese English
abstract）
4）National Pressure Ulcer and Advisory Panel and European Pressure Ulcer Advisory Panel：Prevention
and treatment of pressure ulcers, clinical practiceguideline, National Pressure Ulcer Advisory Panel,
Washington DC, 2009.

CQ 9. 3：When repositioning bed bound patients,
what positions should be undertaken to avoid
pressure ulcer formation?
［Recommendation］A 30- and 90-degree angle forthe laterally recumbent position may be considered.
［Rating］C1［Analysis］A randomized controlled trial involving
elderly patients interned in an acute phase care
hospital compared the rate of pressure ulcer development between the experimental group, comprised ofpatients in a 30-degree tilted side-lying position andtwo control groups, one comprised of patients in asupine position plus 90-degree side-lying position, andthe other, comprised of patients in only a supine
position. The study found no significant difference inthe rate of pressure ulcer development among thesegroups. However, more than 80% of subjects in the 30degree tilted side-lying position group complained of
discomfort.
The 30-degree tilted side-lying position requires
patients to support their body weight with their

CQ 9.4：How can patients in intensive care be repositioned in order to prevent pressure ulcer formation?
［ Recommendation ］The patient may be repositioned in an electric rolling hospital bed.
［Rating］C1［Analysis］Patients in intensive care with unstable
vital signs pose a greater difficulty to the attending
nurse who must periodically reposition the patient. A
1）
historical cohort study conducted at a cardiac
treatment center examined the rate of pressure ulcer
development among cardiac patients during theperiod in which they were repositioned manually at 2hour intervals by nursing staff compared to the period
in which they were repositioned in an electric rolling
hospital bed. The results indicated that the rate ofpressure ulcer development in the period during
which the electric rolling hospital bed was used wassignificantly lower（p ＜ 0.001）. Because the electricrolling hospital bed featured in the study were
equipped with various functions, it is difficult toestablish the efficacy of any single one of thesefunctions for the prevention of pressure ulcers. In
Japan, due to cost considerations and the difficulty oftechnical maintenance, few health care institutions areequipped with high-tech rolling hospital beds. For theabove reasons, the use of electric rolling hospital bed
is assigned the recommendation rating of C1.
References1）Gregor S, Kerstin F, Enrico Z, et al：Kinetic therapy
reduces complications and shortens hospital stay ingluteal muscles. However, due to the decline in
nutritional health as well as muscular atrophy

patients with cardiac shock, a retrospective analysis.

resulting from inactivity, bed bound patients in Japantend to show more prominent bony prominences inthe buttock region. For this reason, the body positionof the patient should be chosen in accordance with theIV）

Eur J Cardiovasc Nurs, 6（ 1 ）：40-45, 2007.（ Level

CQ 9. 5：What positions should be undertaken to
promote healing in patients with pressure ulcers in― G− 65 ―― 77 ―

the gluteal region?
［ Recommendation ］Any position besides the 30-

pressure applied to the skin surrounding pressure

degree tilted side-lying position or head-of-bed elevated position may be undertaken.
［Rating］C1

Tissue Viability, 15（1）：3-8, 2005.（Level III）

［ Analysis ］Two non-randomized self-controlled
studies conducted in Japan have addressed thequestion of which body positions are best for patients1）with pressure ulcers in the gluteal region. One study
compared the shape of the wounds after a period in
30- and 90-degree side-lying positions and found that a

total of 5 wounds demonstrated a change in shape,
while 4 did not（changes in cross-sectional area of thewound in the\ changed Sgroup; 72. 3: in the\ nonchangedSgroup; 8.2, p = 0.04）. Similar results were
found with the 30-degree head-of-bed elevated position group. The ratio of change in the cross-sectional

ulcers while patients are nursed in the 30°position. J

CQ 10 Support surfaces
CQ 10.1：Should support surfaces be used to lower
the incidence of pressure ulcers?
［ Recommendation ］Use of support surfaces isstrongly recommended in order to lower the incidence of pressure ulcers.
［Rating］A［Analysis］There are five systematic reviews andmeta-analyses which compare the use of standard
hospital mattresses with other types of support
1−5）
surface . All of these studies found that support
surfaces are significantly superior to standard hospitalmattresses in preventing pressure ulcers. On thebasis of this evidence, the use of support surfaces has
area of the wounds was statistically significant, at 0.16
been assigned a recommendation rating of A.
for the\changed,Sand 1.36 for the\non-changed,S
2）
6）
Furthermore, the NPUAP/EPUAP guidelines state,groups（ p = 0. 02 ）. In a separate study measuring
pressure on healthy skin and the thickened tissue of hDo not base the selection of support surfaces solely
the wound periphery in patients in a 30-degree tilted
on the perceived level of risk for pressure ulcer
side-lying position and 30-degree head-of-bed elevateddevelopment or the category/stage of any existing
position demonstrated significantly higher maximalpressure ulcersiand,hChoose a support surface thatpressure（p = 0.01, p = 0.05）as well as significantly
is compatible with the care settingiunderscoring thehigher average pressure（p = 0.01, p = 0.03）on theneed to consider pressure ulcer risk, patients S
thickened tissue. Both above-mentioned studies expreferences, and care settings when choosing aamined pressure ulcers among bed bound elderly
support surface.
patients.
References
The so-called 30-degree rule was become widespread as a means of preventing pressure ulcers, andhas also been applied to the management of existingpressure ulcers. However, it should be borne in mind
that this rule may have the effect of prolonging

1 ）Cullum N：Support surface for pressure ulcer pre-recovery if applied in all cases regardless of thephysical stature of the patient. We recommend that aulcers, a systematic review. JAMA, 296（ 8 ）：974-

body position most suitable to the physical stature andwound condition of the patient be chosen, rather thanadhering strictly to the 30-degree rule. On the basis ofthese considerations, we have assigned these evi-3）Whittemore R：Pressure-reduction support surfaces：

vention. EBM reviews Cochrane Database Syst Rev,
3：CD001735, 2004.（Level I）
2）Reddy M, Gill SS, Rochon PA：Preventing pressure984, 2006.（Level I）
A review of the literature. J Wound Ostomy
Continence Nurs, 25（1）：6-25, 1998.（Level I）
4）Nicosia G：The effect of pressure-relieving surfaces

dence sources a recommendation rating of C1.

on the prevention of heel ulcers in a variety ofsettings：a meta-analysis. Int Wound J, 4（3）：197-

References

207, 2007.（Level I）

1 ）Kitagawa A, Konya C, Omote S, et al：Effects of5 ）McInnes E, Jammali-Blasi A, Bell-Syer SE, et al：changing body position on pressure ulcer morphology

Support surfaces for pressure ulcer prevention.

and blood circulation. Jpn J P U, 5（ 3 ）：494-502,

Cochrane Database Syst Rev, 13（ 4 ）：CD001735.

2003.（Level III）
（Japanese English abstract）

2011.（Level I）

2）Okuwa M, Sugama J, Sanada H, et al：Measuring the6）National Pressure Ulcer and Advisory Panel and Eu-― G− 66 ―― 78 ―

ropean Pressure Ulcer Advisory Panel：Prevention
and treatment of pressure ulcers, clinical practiceguideline. National Pressure Ulcer Advisory Panel,
Washington DC, 2009.

CQ 10.2：Which support surface is recommended
for completely immobile patients?
［Recommendation］
1. Recommend using an alternating-pressure air
mattress overlay/ replacement.
［Rating］B［Recommendation］
2. Consider using a foam mattress replacement.

for prevention of pressure ulcers in elderly individuals?
［Recommendation］
1. Recommend using a double-layer air-cell mattress.
［Rating］B［Recommendation］
2. An alternating-pressure air mattress overlay/
replacement, air-filled mattress overlay, or foam
mattress may also be used.
［Rating］C1［Analysis］Six randomized controlled studies pub1−6）

lished outside Japan［Rating］C1［Analysis］The NPUAP/EPUAP guidelines endorse the use of alternating pressure air mattresses
overlays/replacement for patients who cannot be
repositioned frequently, adding that this method is
1）
endorsed by the highest evidence rating . Two
randomized controlled studies which examined theincidence of pressure ulcer development among
completely immobile patients found that, althoughfoam mattress replacements were more effective thanfoam mattress overlay , the incidence of pressure
ulcers was still high at 25%, indicating generally poor
2）
efficacy . Berthe et al. have also reported that no
significant difference was found between standard
hospital mattresses and foam mattress replacements
3）in the incidence of pressure ulcer development . On
the basis of these data, the use of foam mattressreplacements earns a recommendation rating of C1.
References1）National Pressure Ulcer and Advisory Panel and European Pressure Ulcer Advisory Panel：Prevention
and treatment of pressure ulcers, clinical practiceguideline. National Pressure Ulcer Advisory Panel,
Washington DC, 2009.

, and one randomized control7）
led study published in Japan , have examined therelationship between various types of support surfaces and the incidence of pressure ulcer development
among elderly patients.
The studies published outside Japan examined theefficacy of alternating-pressure large-cell ripple
1, 2）
3）
mattresses , air-filled mattress overlays , visco4, 6）
elastic foam mattresses , and convoluted foam
5）
mattresses and found that alternating-pressurelarge-cell ripple mattresses and visco-elastic foam
mattresses showed no difference in their efficacy inpreventing pressure ulcers, citing differences insupport surface types and the condition of theindividual patients as the reason. A comparison of airfilled mattress overlay and other control mattresses
showed no significant difference in efficacy. On theother hand, convoluted foam mattresses showedsignificantly higher efficacy than other control mattresses in preventing pressure ulcers. Nonetheless,the pressure ulcer development incidence was 26.6%,
indicating that convoluted foam mattresses weregenerally ineffective at prevention and could not berecommended for use; recommendation rating C1. In arandomized controlled trial involving Japanese subjects, double-layer air-cell mattress, single-layer air-Acta Chir Belg, 107（2）：155-161, 2007.（Level II）

cell mattress overlay, and standard hospital mattresswere associated with a pressure ulcer development
incidence of 3.4%, 19.2%, and 37.0%, respectively, withdouble-layer air-cell mattress showing a significantly
7）
lower incidence than the others（ p ＜ 0. 01 ） . The
same study found that the double-layer air-cellmattress was similarly effective in a 45-degree headof-bed elevated position. On the basis of these results,

CQ 10.3：Which support surface is recommended

the use of the double-layered air-cell mattress has
been assigned a recommendation rating of B.

2）Vyhidal SK, Moxness D, Bosak KS, et al：Mattressreplacement or foam overlay? A prospective study on
the incidence of pressure ulcers. Appl Nurs Res, 10（3）：111-120, 1997.（Level II）
3）Berthe JV, Bustillo A, Melot C, et al：Does a foamyblock mattress system prevent pressure sores? A
prospective randomized clinical trial in 1729 patients.

― G− 67 ―― 79 ―For elderly patients, the risk of pressure ulcers,
especially in areas with bony prominences, and theparticular care setting should also be considered whenchoosing the most appropriate support surfaces.
References
1）Bliss MR：Preventing pressure sores in elderly patients：a comparison of seven mattress overlays. Age
Ageing, 24（4）：297-302, 1995.（Level II）
2）Exton-Smith AN, Overstall PW, Wedgwood J, et al：Use of\air wave systemSto prevent pressure sores
in hospital. Lancet, 1（ 8284 ）：1288-1290, 1982.
（Level II）
3）Lazzara DJ, Buschmann MT：Prevention of pressure
ulcers in elderly nursing home residents-：Arespecial support surfaces the answer?. Decubitus, 4（4）：42-48, 1991.（Level II）
4）Russell LJ, Reynolds TM, Park C, et al：Randomized
clinical trial comparing 2 support surfaces：Results ofthe prevention of pressure ulcers study. Adv Skin
Wound Care, 16（6）：317-327, 2003.（Level II）
5）Kemp MG, Kopanke D, Tordecilla L, et al：The role ofsupport surfaces and patient attributes in preventingpressure ulcers in elderly patients. Res Nurs Health,16（2）：89-96, 1993.（Level II）
6）Gunningberg L, Lindholm C, Carlsson M, et al：Effectof visco-elastic foam mattresses on the developmentof pressure ulcers in patients with hip fractures. J
Wound Care, 9（10）：455-460, 2000.（Level II）
7 ）Sanada H, Sugama J, Matsui Y, et al：Randomized
controlled trial to evaluate a new double-layer air-cell
overlay for elderly patients requiring head elevation.
J Tissue Viability, 13（3）：112-121, 2003.（Level II）

CQ 10. 4：Which support surfaces are recommended for prevention of pressure ulcers in intensive
care patients?
［Recommendation］
1. Recommend using a low air pressure mattress.
［Rating］B［Recommendation］

examining the incidence of pressure ulcer among
6−9）patients admitted to the ICU or CCU .
The studies conducted outside Japan examined theefficacy of low air-loss beds, alternating-pressure air
mattress overlays, air-filled mattress overlays, water
mattresses, and air-filled mattress replacement inpressure ulcer prevention. The efficacy of low air-loss
1, 2）
while air-filled
beds varied according to study
mattress overlays and water mattresses showed nosignificant difference when compared with other4）
control mattresses . Although the air-filled mattressreplacements were associated with a significantly
lower incidence of pressure ulcer development than5）
the controls , these results could not be corroborated
6）
by any studies done in Japan . On the basis of theevidence presented above, the recommendation
rating of C1 has been assigned to the items discussed
here. A number of controlled trials examining theincidence of pressure ulcers among Japanese subjects
endorsed the use of alternating-pressure air mattressoverlays as an effective means of lowering the7−9）incidence of pressure ulcers . Subsequently, aclinical controlled trial compared the efficacy ofalternating-pressure air mattress overlays, foam
mattress overlays/ replacements and control mattresses found that low air pressure mattresses wereassociated with a significantly lower rate of pressure
ulcer development（6%）than the control mattresses7）（ 28%; p ＜ 0. 05 ） . On the basis of the evidence
presented above, these items have been assigned therecommendation rating of B.
Owing to advances in medical treatments, theseverity of the condition of patients admitted into the
ICU and CCU has been increasing yearly along withthe risk of pressure ulcer development. Accordingly,
differences in care settings should be among theissues considered when selecting an appropriate
support surface.
References
1）Inmann KJ, Sibbald WJ, Rutledge FS, et al：Clinical

2. A low-air-loss bed, an alternating-pressure air
mattress overlay, or an air-filled mattress replacement

utility and cost-effectiveness of an air suspension bed

may also be considered.
［Rating］C1［ Analysis ］There are five randomized controlled
1−5）
trials conducted outside Japan , and four rando-（9）：1139-1143, 1993.（Level II）

in the prevention of pressure ulcers. JAMA, 269
2）Theaker C, Kuper M, Soni N：Pressure ulcer preven-mized controlled trials conducted within Japan― G− 68 ―tion in intensive care- a randomized control trial of
two pressure reliving devices. Anaesthesia, 60（4）：395-399, 2005.（Level II）

― 80 ―

relieving supports in an ICU. J Wound Care, 5（3）：used.
［Rating］C1116-121, 1996.（Level II）［Recommendation］

3）Gebhardt KS, Bliss MR, Winwright PL, et al：Pressure-5）Takala J, Varmavuo S, Soppi E：Prevention of press-

4. The bead bed system may be used during
surgery for patients undergoing surgery to repair
femoral-neck fracture.
［Rating］C1［Recommendation］

ure sores in acute respiratory failure：a randomized

5. Thermoactive viscoelastic foam overlay may becontrolled trial. Clin Intensive Care, 7：228-235, 1996.

used for patients who will undergo cardiac surgery.
［Rating］C1
1）［Analysis］There are one systematic review one4）Sideranko S, Quinn A, Burns K, et al：Effects of position and mattress overlay on sacral and heel pressure
in a clinical population. Res Nurs Health, 15（ 4 ）：245-251, 1992.（Level II）（Level II）
6）Fujioka A, Taneike M, Tanaka T, et al：Comparisonof two support surfaces from the point of theincidence of pressure ulcers and QOL of ICU patients.
Jpn J Nurs Soc: Adult Nursing I：149-151, 1998.
（Level II）（Japanese）
7）Fujikawa Y, Terashi H, Sanada H：The assessmentof low air pressure mattress for ICU Patients;
Incidence of pressure ulcers and total cost. JpnJ P U, 3（1）：44-49, 2001.（Level II）（Japanese English abstract）
8）Sugama J, Sanada H, Taneike M, et al：Differences in
the pressure distribution between static and alternating air mattresses. Emergency Nursing, 8（ 8 ）：42-47, 1995.（Level II）（Japanese）
9）Sugama J, Sanada H, Taneike M, et al：Prevention ofpressure sores for patients in intensive care unit −Incidence of pressure sores using two types ofmattres −, ICU and CCU, 19（ 2 ）：147-152, 1995.
（Level II）（Japanese）

CQ 10.5：Which tools, including support surfaces,
are effective in preventing the development ofpressure ulcers during perioperative periods?
［Recommendation］
1. Support surfaces on the operating table arerecommended for patients at risk of developingpressure ulcers.

2）

meta-analysis and six randomized controlled
3−8）which compare pressure ulcer development
trialsincidence among perioperative patients.
The systematic reviews reported that the use of
support surfaces on the operating table had a positiveeffect on lowering the incidence of pressure ulcers,
but failed to mention which support surfaces weremost effective in achieving this result.
The studies published outside Japan were chiefly
concerned with assessing the efficacy of gel or viscoelastic pad, alternating-pressure air mattress overlays/ replacement, bead bed system, and thermoactive viscoelastic foam overlay. The gel or visco-elastic
pad were associated with a significantly lower
incidence of pressure ulcer development than the3, 4）
control mattresses . The results of using thealternating-pressure air mattress overlays/ replacement during surgery, however, varied according tostudy and no clear conclusion could be reachedregarding its efficacy in preventing pressure
5, 6）
ulcers . Although a significantly lower incidence ofpressure ulcer occurrence（ 15. 6% ）was associatedwith the use of the bead bed system than with thecontrols, the bead bed system cannot be considered as［Rating］B［Recommendation］

an effect means of reducing pressure ulcer development due to the high rate of pressure ulcer
7）
occurrence . Fechtinger et al. have reported that
there was no significant difference in efficacy between

2. In addition to using support surfaces, viscoelastic pads or gel applied to the heel area, cubital
region, and other areas with bony prominences isrecommended during operations.

thermoactive viscoelastic foam overlay and the8）control group . No randomized controlled studies
examining these support surfaces have been conducted in Japan. On the basis of these data, the use of［Rating］B［Recommendation］

gel or visco-elastic pad has been given a recommendation rating of B, while the other types of support
surface have been assigned a rating of C1.
The use of this evidence in Japan should be

3. During and after operations, an alternatingpressure air mattress overlays/replacement may be― G− 69 ―― 81 ―

preceded by a careful consideration of the surgicalprocedure involved, the surgical environment, andrisk to the patient. The surgical procedures discussed
in the above-mentioned studies involved maintaining
the lithotomy position or supine position for threecontinuous hours in general, vascular, gynecological,
cardiac, or femoral surgical procedures for treating
femoral neck fractures.
References
1 ）Cullum N：Support surface for pressure ulcer prevention. EBM reviews Cochrane Database Syst Rev,
3：CD001735, 2004.（Level I）
2 ）McInnes E, Jammali-Blasi A, Bell-Syer SE, et al：
Support surfaces for pressure ulcer prevention.
Cochrane Database Syst Rev, 13（ 4 ）：CD001735,
2011.（Level I）
3 ）Schultz A, Bien M, Dumond K, et al：Etiology andincidence of pressure ulcers in surgical patients.
AORN J, 70（3）：434-449, 1999.（Level II）
4）Nixon J, McElvenny D, Mason S, et al：A sequential
randomized controlled trial comparing a dry viscoelastic polymer pad and standard operating table
mattress in the prevention of post-operative pressure
ulcers. Int J Nurs Stud, 35（ 4 ）：193-203, 1998.

facilitate care for convalescent patients in a homecare setting?
［Recommendation］An automatic turning air mattress may be used.
［Rating］C1［Analysis］In one self-controlled trial by Melland etal., patients in a home-care setting and a long-termcare facility reported no difference in comfort levels
when using an automatic turning air mattress thanwhen using conventional bedding. The same subjects
also reported experiencing very good quality of sleep（ p = 0. 024 ）. Furthermore, one in 17 subjects developed pressure ulcers in the four-week period
during which the automatic turning air mattress wasused. A self-controlled trial conducted in Japan
reported that the caregiver S
s burden was lessened
and no pressure ulcers reported during a two-week2）
period in which this mattress was used .
The automatic turning air mattress may be used inorder to facilitate the activity of caregivers in a homecare setting and to improve the patientSs quality ofsleep, but the basic purpose of this device is to assist
the work of the caregiver. The caregiver still needs toensure that the patient Ss body is repositioned on aregular basis.

（Level II）

References

5 ）Aronovitch SA, Wilber M, Slezak S, et al：A comparative study of an alternating air mattress for

1 ）Melland HI, Langemo D, Hanson D, et al：Clinicalprevention of pressure ulcers in surgical patients.

evaluation of an automated turning bed. Orthop Nurs,

Ostomy Wound Manage, 45（ 3 ）：34-44, 1999.

18（4）：65-70, 1999.（Level III）
2 ）Futamura M, Sugama J, Sanada H, et al: A clinical（Level II）
6 ）Russel LJ, Lichtenstein SL：Randomized controlled

evaluation of automatic turning function of column-

trial to determine the safety and efficacy of a multi-

type air-cell mattress − Effect on pressure distribu-

cell pulsating dynamic mattress system in thetion and caregiverSs burden in home cared elderly −.

prevention of pressure ulcers in patients undergoing

Jpn J Acad Gerontol Nurs, 10（ 2 ）：62-69，2006．

cardiovascular surgery. Ostomy Wound Manage, 46（Level III）（Japanese）（2）：46-55, 2000.（Level II）
7）Goldstone LA, Norris M, OS
Reilly M, et al：A clinical
trial of a bead bed system for the prevention ofpressure sores in elderly orthopaedic patints. J Adv
Nurs, 7（6）：545-548, 1982.（Level II）
8 ）Fechtinger J, de Bie R, Dassen T, et al：A 4-cm
thermoactive viscoelastic foam pad on the operating
room table to prevent pressure ulcer during cardiac
surgery. J Clin Nurs, 15（2）：162-167, 2006.（LevelII）

CQ 10. 6：Which support surfaces can be used to

CQ 10.7：Which support surfaces provide the greatest comfort both while awake and sleeping?
［Recommendation］
1. Using an alternating-pressure air mattressreplacement is recommended.
［Rating］B［Recommendation］
2. For terminally ill patients, an alternatingpressure air mattress with automatic adjustment to
the patient's weight and position may be considered.
［Rating］C1― G− 70 ―― 82 ―
1）［Analysis］One systematic review and two rando2, 3）
conducted outside Japan
mized controlled trials
have examined the quality of sleep and comfort levels
experienced by patients who were used analternating-pressure air mattress replacement. The
systematic review found that the comfort levels
reported by the patients were significantly higher forthe alternating-pressure air mattress overlays/replacement than for the control group. Furthermore, thetwo- and four-cell types were considered more
1）
comfortable . In addition, 18. 9% of patients complained about the alternating-pressure air mattressreplacement while 23. 3% complained about thealternating-pressure air mattress overlay, indicating asignificantly lower number of complaints for the2）former（p ＜ 0.05） . Grindley et al. surveyed terminal patients about their preferences and found that 62.
5% preferred the alternating-pressure air mattresswith automatic adjustment to the patientSs weight andposition, 12.5% preferred the alternating-pressure air
mattress overlay, and 25.0% preferred the standard
3）
mattress（p ＜ 0.05） .
When choosing a mattress, consider the patientsSpreferences as well as pressure ulcer development
risk and pressure ulcer stage.

passage of time. One of the causes of the degradationof quality is fatigue. Fatigue is seen when distortionsin the contours of the mattress remain even after theweight or source of pressure has been removed. Twoanalytical epidemiological studies have examined the
1, 2）
problem of fatigue in urethane foam mattresses .
These studies found that 66 urethane foam mattresses 5〜10 years after their purchase had compressed
an average of 10.7 ± 6.0 mm（range 0-30 mm）from
fatigue. Use of urethane foam mattresses which hadcompressed an average of 11mm as a result of fatigue
significantly increased interface pressure values
1）
compared with new mattresses（p ＜ 0.05） . Further, the study examined the degree of fatigue
according to contact points on the body including the
buttocks, knees, shoulder joints, head, and heel, foundthat fatigue was most visible in the area of themattress in direct contact with the buttocks（ p ＜2）0.05） .
On the basis of these data, urethane mattresses
should be checked periodically for signs of fatigue,
especially in the areas that come into frequent or
prolonged contact with the buttocks.
References
1 ）Matsubara Y：Fatigue of foam mattress and inter-

References

face pressure in healthy volunteers. Nursing, 271）Vanderwee K, Grypdonck M, Defloor T：Alternating（11）：88-93, 2007.（Level IV）（Japanese）

pressure air mattresses as prevention for pressure2 ）Heule EJ, Goossens RH, Mugge R, et al：Using anulcers：a literature review. Int J Nurs Stud, 45（5）：indentation measurement device to assess foam

784-801, 2008.（Level I）

mattress quality. Ostomy Wound Manage, 53（11）：2 ）Nixon J, Cranny G, Iglesias C, et al：Randomized,

56-62, 2007.（Level I）（Level IV）

controlled trial of alternating pressure mattresses
compared with alternating pressure overlays for the

CQ 10. 9：Which support surfaces are recommen-

prevention of pressure ulcers：PRESSURE（ press-ded for promoting healing in d1, d2, and D3〜D5
pressure ulcers?
［Recommendation］
1. Use of an air-fluidized bed or low-air-loss bed isstrongly recommended to promote healing in D3〜D5

ure relieving support surfaces ）trial. BMJ, 332（7555）：1413, 2006.（Level II）
3）Grindley A, Acres J：Alternating pressure mattresses： comfort and quality of sleep. Br J Nurs（MarkAllen Publishing ）, 5（ 21 ）：1303-1310, 1996.（ LevelII）

CQ 10.8：What precautions should be taken whenusing foam mattresses?
［ Recommendation ］Monitor the deterioration of
the foam due to fatigue.
［Rating］C1［Analysis］Foam mattresses will degrade with thepressure ulcers or pressure ulcers in multiple sites.
［Rating］A［Recommendation］
2. Use of an alternating-pressure air mattress with
automatic adjustment for the patient S
s position andweight, an alternating-pressure large-cell ripple mattress, a double-layer air-cell mattress, or a low airpressure mattress may be considered to promotehealing in d2 or deeper pressure ulcers.

― G− 71 ―― 83 ―

［Rating］C1［Recommendation］

air-fluidized beds and low-air-loss beds is strongly
recommended for patients diagnosed with stage III or

3. Use of an air-filled mattress overlay may beconsidered to promote healing in d1/2 pressure ulcers.
［Rating］C1

IV, or D3〜D5 pressure ulcers or with pressure ulcers
in multiple sites. However, in Japan the use of airfluidized beds, low-air-loss beds and other equipment［Recommendation］
4. Use of an alternating-pressure air mattress with
automatic adjustment to the patient S
s weight andof this nature is limited by cost and difficulty ofmaintenance to very few health care institutions.
Furthermore, as with prevention measures, the choice

position may be considered after flap reconstruction
for pressure ulcers.
［Rating］C1
1）
2）［Analysis］The NPUAP/EPUAP , WOCN , and3）
the Wound Healing Society guidelines recommend
the use of special beds. The basis for their recom-of support surface involves not only the condition of
the patient S
s pressure ulcers but also a variety ofother factors, each of which requires due considera-

mendation is found in five randomized controlled
4−6, 8, 9）
which found that the use of low-air-loss
trialsbeds and air-fluidized beds was more effective for1）National Pressure Ulcer and Advisory Panel and Eu-

wound healing and contraction rates. The efficacy ofalternating-pressure air mattress with automatic
adjustment to the patient S
s position and weightfunction replacement was examined in a randomized
controlled trial involving patients who had received
flap surgery for pressure ulcers involing fascia,
7）
muscle and bone as well as in a randomized
controlled trial involving stage II〜IV pressure ulcer
11）
patients . Neither study found a significant difference in effect between the bed type in question andthe controls. Bliss examined the efficacy ofalternating-pressure large cell ripple mattresses in arandomized controlled trial involving stage II〜IV
pressure ulcers and found that they were significantly

guideline, National Pressure Ulcer Advisory Panel,more effective than the controls in promoting
10）
healing . On the other hand, Lazzara and Bushmann
conducted a randomized controlled trial involving
state I and II pressure ulcer patients to examine theefficacy of air-filled mattress overlays in promoting

tion.
References
ropean Pressure Ulcer Advisory Panel：Prevention
and treatment of pressure ulcers, clinical practice
Washington DC, 2009.
2）Wound Ostomy and Continence Nurses Society：Guideline for prevention and management of pressure
ulcers. WOCN clinical practice guideline；no. 2,
Glenview, IL, 2003.
3）Whitney J, Phillips L, Aslam R, et al：Guidelines forthe treatment of pressure ulcers. Wound Repair
Regen, 14（6）：663-679, 2006.
4）Day A, Leonard F：Seeking quality care for patientswith pressure ulcers. Decubitus, 6（1）：32-43, 1993.
（Level II）
5）Ferrell BA, Keeler E, Siu AL, et al：A randomized
trial of low-air loss for treatment of pressure ulcers.
JAMA, 269（4）：494-497, 1993.（Level II）
6）Branom R, Rappl LM：
hConstant force technologyi
versus low-air-loss therapy in the treatment ofpressure ulcers. Ostomy Wound Manage, 47（ 9 ）：38-46, 2001.（Level II）

wound healing, and found no statistically significant
12）
difference with the control groups .
13）
One historical controlled trial and one non14）
controlled intervention study conducted in Japan
using stage II〜IV pressure ulcer patients found that

7）Finnegan MJ, Gazzerro L, Finnegan JO, et al：Com-

use of double-layer air-cell mattresses was more
conducive to wound reduction than single-layer air13）
cell mattresses（p ＜ 0.05） . The low air pressure
mattresses were also found to be more effective instudy. J Tissue Viability, 17（1）：2-9, 2008.（Level

wound reduction and skin regeneration than air-filled
14）mattress overlays（p ＜ 0.05） .
On the basis of the data presented above, the use ofparing the effectiveness of a specialized alternating
air pressure mattress replacement system and an airfluidized integrated bed in the management of postoperative flap patients：a randomized controlled pilot
II）8）Munro BH, Brown L, Heitman BB：Pressure ulcers,
one bed or another?. Geriatr Nurs, 10（4）：190-192,
1989.（Level II）
9）Allman RM, Walker JM, Hart MK, et al：Air-fluidized― G− 72 ―beds or conventional therapy for pressure sores. A

― 84 ―

randomized trial. Ann Int Med, 107（ 5 ）：641-648,［ Analysis ］There are one randomized controlled

1987.（Level II）

trials, one non-randomized controlled trial, one cohort
study, and numerous case reports pertaining topatient education.
Instructions in repositioning including positioning,
posture in using the wheelchair, and maintaining10）Bliss MR：Preventing pressure sores in elderly patients：a comparison of seven mattress overlays. Age
Ageing, 24（4）：297-302, 1995.（Level II）
11）Evans D, Land L, Geary A, et al：A clinical evaluationof the Ninbus 3 alternating pressure mattressreplacement system. J Wound Care, 9（4）：181-186,
2000.（Level II）
12）Lazzara DJ, Buschmann MT：Prevention of pressure
ulcers in elderly nursing home residents：Are special
support surfaces the answer?. Decubitus, 4（ 4 ）：correct sitting posture can be carried out to preventthe development of pressure ulcers. Further, themeasurement of pressure on various points of the
body in turn leads to a better understanding of
prevention as well as risk assessment, as reported in a
1−3）
number of published case studies .
With regard to the efficacy of consultations with

42-48, 1991.（Level II）
13）Sato A, Sanada H, Sugama J, et al：The cost-effectivenessof double-layer air-cell mattress for treating pressure
ulcers. Jpn J PU, 8（2）：140-147, 2006.（Level III）
（Japanese, English abstract）
14）Sanada H, Sugama J, Inagaki M, et al：Evaluation of a
newly-developed overlaying low pressure airmattress. Memoirs Health Sci Med Kanazawa Univ,
21：45-49, 1997.（ Level V ）（ Japanese, English abstract）

CQ 11 Patient education
CQ 11. 1：How can patients and their family or
caregivers be educated to prevent the development
or recurrence of pressure ulcers?
［Recommendation］
1. Education/training in repositioning and using
support surfaces can be carried out .
［Rating］C1［Recommendation］
2. Periodic telephone consultations with a healthcare professional and/or remote assessment of thepatientSs skin condition using electronic visual media
may be done.
［Rating］C1［Recommendation］
3. Education by an e-learning system led by thehealth care professional may be given.
［Rating］C1［Recommendation］
4. Education/training in any or all of the following
may be given: the etiology of ulcers, risk factors,
staging, principles of wound healing, nutritional
support, program of skincare and skin inspection, andmanagement of incontinence.
［Rating］C1

health care professionals, one randomized controlled
trial has reported that knowledge of pressure ulcer
prevention among the consultation group was higher
than among the control group as a result of monthly
telephone contact after discharge in addition toenhanced education given to the participants prior to4）discharge from hospital . However, the content of the
instruction was not specified nor was the statisticalsignificance documented. A non-randomized control5）
led trial comparing the efficacy of periodic intervention using video images as an educational tool, periodic
telephone intervention, and telephone counseling as
freely chosen by the patient, found that reports ofpressure ulcers were highest among the video groupalthough the differences among the groups were notstatistically significant. The larger number of reports
among the video group is thought be due to the higher
rate of detection resulting from the increased
opportunities for visual contact with health care
professionals. Further, the fact that pressure ulcers
detected among the video group were generally lessadvanced suggests that this mode of education/consultation was effective for early detection as well.
However, the remote video and telephone consultations featured in these two foreign studies are notcovered by the National Health Insurance in Japan.
On the other hand, the viability of these methods isbeing considered within the context of home nursing
care in Japan.
According to one cohort study, e-learning implemented as a form of visual educational method
succeeded in raising awareness about pressure ulcers
among the participants, as demonstrated by test
6）
results . Although such methods do not directly
affect the rates of occurrence or healing of pressure― G− 73 ―― 85 ―

ulcers among the participants, they have proved
effective as educational tools.
7）
The WOCN Clinical Practice Guidelines has asection on education on the topics including the
etiology of ulcers, risk factors, staging, principles ofwound healing, nutritional support, program ofskincare and skin inspection, and management ofincontinence; however, these are based on expert
opinion.
In summary, education of the patient/family/caregiver, while succeeding in raising knowledge ofpressure ulcers, failed directly to affect the rates ofoccurrence or recurrence of pressure ulcers.
References
1）Sato M, Shimobatake Y, Nakahara K, et al：Case ofspinal cord injury recovered pressure ulcer ofhipbone. Leaving hospital adjustment for recurrence

CQ 11. 2：How should patients/family/caregivers
be educated/trained in the care of existing pressure
ulcers?
［Recommendation］Consider informing patient/family/caregiver how to contact an appropriate medical
center for help in the event the pressure ulcers
worsen.
［Rating］C1［Analysis］A search of the currently existing sources
under\ education Sfailed to produce any reports
based on clinical trials. The WOCN Practice Guideline
recommends contacting a health care professional in
the event of any complications, but this, too, is basedon expert opinion.
At present, there are no clinical trials endorsing themethods described above. For this reason, educational
and/or training methods endorsed only by expert
opinion can be considered.

prevention. Jpn Adn Ⅱ, 36：390-391, 2005.（ Level

References

V）（Japanese）
2）Hori M, Kakuya K, Orikasa H, et al：Management of a1 ）Wound Ostomy and Continence Nurses Society：paraplegic patient who suffers from repeated ischial

Guideline for Prevention and Management of Press-

pressure ulcers. Jpn J PU, 3（ 3 ）：351-354, 2001.

ure Ulcers, 24, WOCN Society, IL, 2003.

（level V）（Japanese English abstract）
3 ）Ogawa N, Tanaka H, Toyoda M, et al：Improving
curative environment through mental relationship −For a bedsore patient with spinal cord injury −．Jpn
J WOCN, 5（2）：26-30, 2002.（Level V）（Japanese
English abstract）
4）Garber SL, Rintala DH, Holmes SA, et al：A structured
educational model to improve pressure ulcer prevention knowledge in veterans with spinal cord dysfunction. J Rehabil Res Dev, 39（ 5 ）：575-588, 2002.
（Level II）
5）Phillips VL, Temkin A, Vesmarovich S, et al：Using
telehealth interventions to prevent pressure ulcers in
newly injured spinal cord injury patients postdischarge. Results from a pilot study. Int J Technol
Assess Health Care, 15（ 4 ）：749-755, 1999.（ Level
III）6 ）Jacalyn A, Jane R：A prospective evaluation of apressure ulcer prevention and management E-

CQ 12 Outcome management
CQ 12.1：Which measures should be undertaken ina hospital care setting to prevent pressure ulcers?
［Recommendation］
1. Choice of support surface based on the Braden
Scale is strongly recommended.
［Rating］A［Recommendation］
2. Choice of support surface based on the OH Scale
may be considered.
［Rating］C1［Recommendation］
3. Deployment of a multidisciplinary wound careteam may be considered.
［Rating］C1［Recommendation］
4. Assignment of wound ostomy and continence
nurse may be considered.

Guideline for Prevention and Management of Press-［Rating］C1［Recommendation］
5. Introduction of reimbursement system forpressure ulcer high risk patient care may beconsidered.

ure Ulcers, 24, WOCN Society, IL, 2003．

［Rating］C1

Learning program for adults with spinal cord injury.
Ostomy Wound Manage, 56（ 8 ）：40-50, 2010.
（Level V）
7 ）Wound Ostomy and Continence Nurses Society：― G− 74 ―― 86 ―

［Recommendation］
6. Implementation of comprehensive programs andpreventing pressure ulcers.
An historical controlled study conducted by Sobue

protocols may be considered.
［Rating］C1［Recommendation］

et al. examined the prevalence of pressure ulcers in
hospital before and after group training by a wound4）

1）［ Analysis ］Comfort Ss meta-analysis of nine studies found after a search using the key words,\ Braden Sand\ support surface, Sexamines the
choice of support surfaces based on risk assessment
conducted with the Braden Scale at acute treatment
facilities and university hospitals. Comfort S
s studyfound that the odds ratio of pressure ulcer development in the group using support surfaces chosen on
the basis of risk assessment using the Braden Scale
was 0.335（95% CI = 0.220〜0.508）. This report demonstrates a high level of efficacy in using Braden
Scale risk assessment as a basis for choosing a support
surface for pressure ulcer prevention, and is therefore
strongly recommended.
An historical controlled study by Takagi et al.
evaluated the criteria for selecting support surfaces
based on the OH scale, using as the experimentalgroup, 445 patients, and as the control group, 354
patients, hospitalized in a general hospital with 198
2）beds . The results of the study indicated that the rateof pressure ulcer development in the experimentalgroup was significantly lower（ p ＜ 0. 05 ）, thus demonstrating the utility of the algorithm based on the
OH Scale for choosing appropriate support surfaces
for pressure ulcer prevention.
A longitudinal study by Granick et al. examined theefficacy of prophylactic treatment administered to 690
patients at an university hospital by an interdisciplin3）
ary wound care team . The results of the study

ostomy and continence nurse . The results of thestudy indicated that the rate of pressure ulcer
development was significantly lower（ p ＜ 0. 05 ）three years after, compared to six months before,
commencement of training. These data suggest that
employing a wound ostomy and continence nurse may
have a significantly positive effect on the preventionof pressure ulcers.
One prospective cohort study involving 190 woundostomy and continence nurses（ 111 nurses who
introduced the afore-mentioned reimbursement system（see item 5 above）, and 79 who did not）foundthat the estimated incidence of pressure ulcer
development in reimbursement system-introduced
hospital was significantly lower than that in non5）
introduced hospitals（ p = 0. 008 ） . These results
indicate that the reimbursement system can produce
a significant decrease in the incidence of pressure
ulcer development.
A meta-analysis examining the effect of utilizing
clinical paths on the formation of pressure ulcers in6）
post-operative femoral neck fracture patients foundthe odds ratio for pressure ulcer development to be
0.48（95% CI = 0.30〜0.75）in 2935 subjects across
six comparative studies. An historical controlled
study by de Laat et al. involving 399 adult patients in
an intensive care unit of an university hospital（ 28beds ）examined the efficacy of a care regimen forprevention of pressure ulcer based on the Dutch
7）
AHCPR/EPUAP guidelines . The three-month markdemonstrated that the prevalence of pressure ulcers
declined steadily from the first, through the second
and third years of intervention（p ＜ 0.05）. A comparison of the number of new cases of pressure ulcers
in the first and third years shows a significant decline

was established as a baseline, and changes in patientsS
condition were monitored from months 3 to 6 andmonths 12 to15 after implementation of the protocol.
The results indicated a significant reduction in therate of pressure ulcer development（ p = 0. 04 ）. In

（p ＜ 0.005）. In addition, several cohort studies havereported a decrease in the number of both existing

addition, there are a number of cohort studies whichhave examined the efficacy of comprehensive press-

pressure ulcer cases and new cases following intervention by a multidisciplinary wound care teamconsisting of physicians, nurses, dietitians, occupational therapists, pharmacologists, registered dieticians,

ure ulcer prevention regimens. As can be seen,
measures utilizing clinical paths, guidelines, andcomprehensive programs have proved to be effective
in preventing pressure ulcer development. However,

and administrative staff at general and acute phasetreatment facilities. These data demonstrate theas the source of evidence is based only on the metaanalysis of clinical paths in post-operative femoral

efficacy of multidisciplinary wound care team inneck fracture patients and on some cohort studies, the― G− 75 ―― 87 ―

methods reviewed here have been assigned arecommendation rating of C1.
References

consultation with WOC nurses and similar comprehensive care for pressure ulcers at two long-term carefacilities（ facility A, 150 beds; facility B, 110 beds ）1）have been examined in a longitudinal study . The

1 ）Comfort EH：Reducing pressure ulcer incidence

results indicated that there was a significant decrease

through Braden Scale risk assessment and support

in the rate of pressure ulcer development four months
after commencement of the program（ P = 0. 02 ）,suggesting that the adoption of comprehensive

surface use. Adv Skin Wound Care, 21（7）：330-334,
2008.（Level I）
2）Takaki Y, Toyohara T：Use of criteria for the selection support surfaces and changes in the incidence ofpressure ulcer. Jpn J PU, 10（ 1 ）：39-43, 2008.
（Level IV）（Japanese English abstract）
3）Granick MS, McGowan E, Long CD：Outcome assessment of an in-hospital cross-functional wound careteam. Plast Reconstr Surg, 101（5）：1243-1247, 1998.
（Level IV）
4）Sobue M, Tanahashi S, Hori S, et al：The effects ofcaring for pressure ulcers by the skin care committee.
Jpn J PU, 7（1）：43-52, 2005.（Level IV）（Japanese
English abstract）

programs and protocols at long-term care facilities iseffective in preventing pressure ulcer development.
An historical controlled study of the efficacy of aBraden Scale-based pressure ulcer prevention algorithm employed at a special elderly care facility（120beds）found a marked decrease in the prevalence ofpressure ulcer nine months after the implementationof the algorithm as compared to nine months prior to2）
implementation（P ＜ 0.01） . This evidence suggeststhat the use of algorithms based on the Braden Scaleat long-term care facilities is effective for pressure
ulcers prevention.

5）Sanada H, Mizokami Y, Minami Y, et al：The impact

Referencesof reimbursement system for pressure ulcer high risk
patient care on the pressure ulcer incidence and1 ）Lyder CH, Shannon R, Empleo-Frazier O, et al：A

medical cost. Jpn J WOCN, 11（ 2 ）：59-62, 2007.

comprehensive program to prevent pressure ulcers（Level IV）（Japanese English abstract）

in long-term care：exploring costs and outcomes.
Ostomy Wound Manage, 48（ 4 ）：52-62, 2002.

6 ）Neuman MD, Archan S, Karlawish JH, et al：The（Level IV）

relationship between short-term mortality and quality of care for hip fracture：a meta-analysis of clinical2）Sanada H, Sugama J, Sugimura S, et al：The effec-

pathways for hip fracture. J Am Geriatr Soc, 57

tiveness of care algorithm for prevention of pressure（11）：2046-2054, 2009.（Level I）

ulcer in a long term care facility. Jpn J Nursing
Society, elderly 25, 170-173, 1994.（ Level IV ）7）de Laat EH, Pickkers P, Schoonhoven L, et al：Guide-（Japanese）

line implementation results in a decrease of pressure
ulcer incidence in critically ill patients. Crit Care Med,CQ 12. 3：Which measures are recommended to35（3）：815-820, 2007.（Level IV）

CQ 12. 2：Which measures are recommended forpressure ulcer prevention in long-term care facilities?
［Recommendation］
1. Implementation of comprehensive programs andprotocols may be considered.
［Rating］C1
2. Use of an algorithm incorporating the Braden
Scale to implement preventive care may be considered.
［Rating］C1［Analysis］The efficacy of pressure ulcer prediction based on the Braden Scale, prevention programs,skin care regimens, nutritional supplementation, skinpromote healing of pressure ulcers in a hospital caresetting?
［Recommendation］
1. Deployment of a multidisciplinary wound careteam may be considered.
［Rating］C1［Recommendation］
2. Introduction of reimbursement system forpressure ulcer high risk patient care may beconsidered.
［Rating］C1［Recommendation］
3. Assignment of wound ostomy and continence
nurse may be recommended.

― G− 76 ―― 88 ―

［Rating］C1［ Analysis ］A longitudinal study conducted by

References

Ogawa et al. involving 48 patients with pressure
ulcers at a general ward and a nursing ward
examined the efficacy of a multidisciplinary wound1）
management team in pressure ulcer healing rate .
The study reported a significant improvement in the1 ）Ogawa R, Kikuchi M, Kato K, et al：Prevention

DESIGN scores six months after the start of the teamSsactivities as compared to scores obtained six months
prior to the commencement of their activities（p ＜2）Sanada H, Nakagami G, Mizokami Y, et al：Evaluat-

0.05）, strongly indicating the positive effect of such
multidisciplinary teams on wound healing.
A prospective cohort study examined the impact ofeffectiveness：A cohort study. Int J Nurs Stud, 47

introducing reimbursement system for high risk
patients on pressure ulcer healing at a total of 59
health care facilities, including advanced treatment
facilities, regional central hospital, and general2）
hospitals . The study reported that the DESIGN
scores for patients in facilities that introduced
reimbursement system had decreased during three
weeks significantly more compared to those patientsin facilities that had no billable services（p = 0.002）.
Further, multiple regression analysis using thedecrease in the DESIGN score as a dependent variable
found a significant correlation between pressure ulcer
healing and the implementation of the aforementioned care（p ＜ 0.001）.This data suggests thatthe introduction of reimbursement system for highrisk patient care has a positive impact on the healingof pressure ulcer.
Two case reports examined the impact of careprovided by wound ostomy and continence nurse at a3）
nursing ward in a coloproctological facility . In thefirst of these reports, improvement was seen inpatientsSpressure ulcers as a result of the selection ofproper support surface by wound ostomy andcontinence nurse. The second study failed to assess
the effect of care administered by wound ostomy andcontinence nurse on cases of prolonged recovery
caused by contamination of the wounds by urine. In
the former, the deployment of wound ostomy andcontinence nurse as one of the conditions stipulated in
the introduction of reimbursement system for highrisk patient care can be seen as a major contributing
factor in the success of these services. Taken as awhole, these data suggest that the care administeredby wound ostomy and continence nurse has a positive
impact on the healing of pressure ulcers.

effects and therapeutic outcomes of pressure ulcer
based on a creation of committee. Jpn J PU, 7（2）：184-189, 2005.（ Level IV ）（ Japanese English abstract）
ing effect of new incentive system for high-riskpressure ulcer patients on wound healing and cost（3）：279-286, 2010.（Level IV）
3）Takaki Y, Shirayama C, Masutomi T, et al：Practicereport of a WOC-certified expert nurse S
s pressure
ulcer care in a long team care unit. Jpn J WOCN, 6（2）：20-24, 2003.（Level V）（Japanese English abstract）

CQ 12. 4：Which measures are recommended topromote healing of pressure ulcers in a long-term carefacility?
［Recommendation］
1. Deployment of a multidisciplinary wound careteam is recommended.
［Rating］B［Recommendation］
2. Implementation of comprehensive programs andprotocols may be considered.
［Rating］C1［Analysis］A randomized controlled trial involving
44 nursing homes（ intervention group, 21; control
group, 23）assessed the efficacy of a multifunctional
wound care team in promoting pressure ulcer healing
and found that the intervention group showed ahigher healing rate than the control group（P = 0.07）
1）
with a hazard ratio of 1.73（P = 0.003） . This data
indicate that the deployment of a multifunctional
wound care team at a long-term care facility is likely
to have a positive impact on the healing rates ofpressure ulcer. However, it should be noted that only
80% of the enrolled patients suffered from pressure
ulcers, while 20% had leg ulcers.
A historical controlled study compared healing timeof pressure ulcers among patients at a long-term carefacility（ 77 beds ）who were either administered acare protocol based on guidelines or treated according2）
to conventional methods . The subjects were divided
into three groups based on three time frames: before― G− 77 ―― 89 ―

intervention, immediately after intervention, andthree years after intervention. Using healing ofpain in home care pressure ulcer patients（ p = 0.
2）042） . Further, a descriptive and transversal studypressure ulcer in each group as the end-point, thesurvival curve was assessed by the Log rank test. The
results of this assessment found a significant differ-conducted by Blanes et al. reported that among out-ence between each of the three groups in terms of theduration required for pressure ulcer healing（ Logrank = 9. 49, P ＜. 01 ）. These data suggest that the
adoption of comprehensive programs such as
guideline-based protocols at long-term care facilities
has a positive effect on promoting healing of pressure
ulcers.
References
1）Vu T, Harris A, Duncan G, et al：Cost-effectiveness ofmultidisciplinary wound care in nursing homes：apseudo-randomized pragmatic cluster trial. Fam
Pract, 24（4）：372-379, 2007.（Level II）
2）Xakellis GC, Frantz RA, Lewis A, et al：Translatingpressure ulcer guidelines into practice：It S
s harderthan it sounds. Adv Skin Wound Care, 14（ 5 ）：249-256, 258, 2001.（Level IV）

CQ 13 QOL/ Pain
CQ 13. 1：How can the quality of life（ QOL ）ofpressure ulcer patients be assessed?
［Recommendation］The QOL of the patients may
be assessed along physiological, psychological, andsocial parameters.
［Rating］C1［ Analysis ］A longitudinal multivariate analysis
was conducted on the basis of reports filed every six
months by nursing home residents in which theparticipants reported the relationship betweenchanges in their QOL and the prevalence of theirpressure ulcers. The results of the study indicated anpatients with traumatic spinal cord injuries, theaverage mental health scores for those patients
suffering from pressure ulcers were significantly
lower in comparison with those of who did not suffer
3）
from pressure ulcers（p = 0.001） . Clearly, the factthat the QOL of patients is influenced significantly by
the presence of pressure ulcers, makes a carefulassessment of patientsSQOL imperative.
According to ten quantitative studies and 21
qualitative studies selected through systematic review, there are 11 factors which are thought toinfluence the health-related QOL of pressure ulcer
4）
patients . These are: physical impact and limitation,
impact of pressure ulcer symptoms, need versus
impact of interventions, impact on general health andconsequences, psychological impact, perceived etiology（ anger felt by patients who associated theirdevelopment of pressure ulcers with perceived
inadequacies in health care ）, need for knowledge,
social impact, healthcare provider-patient relationships, impact on others, and financial impact. It should
be noted that although this article is a systematic
review, its scope is restricted to a compilation ofquantitative and qualitative studies. For this reason,
the study has been assigned the recommendation
rating of C1.
References
1）Degenholtz HB, Rosen J, Castle N, et al：The association between changes in health status and nursing
home resident quality of life. Gerontologist, 48（5）：584-592, 2008.（Level IV）
2）Franks PJ, Winterberg H, Moffatt CJ：Health-related

inverse relationship between the prevalence ofpressure ulcers（Stage II or higher）and the sense of
autonomy, security, and psychological well-being
1）reported by the patients at six-month intervals .
TM
Another cross-sectional study using the SF-36 （ awidely accepted scale used to assess\Health Related
Quality of LifeS）to examine the physical functionality（p ＜ 0.001）, social functionality（p ＜ 0.001）, selfcare（p = 0.010）, and mobility（p = 0.001）of press-

quality of life and pressure ulceration assessment inpatients treated in the community. Wound Repair
Regen, 10（3）：133-140, 2002.（Level V）
3）Blanes L, Carmagnani MI, Ferreira LM：Quality oflife and self-esteem of persons with paraplegia livingin São Paulo, Brazil. Qual Life Res, 18（ 1 ）：15-21,
2009.（Level V）
4 ）Gorecki C, Brown JM, Nelson EA, et al：Impact ofure ulcer patients confined to their home reported
significantly lower scores in these categories. A crosssectional study has reported high scores for bodily― G− 78 ―pressure ulcers on quality of life in older patients: asystematic review. J Am Geriatr Soc, 57（ 7 ）：1175-1183, 2009.（Level I）

― 90 ―CQ 13.2：For which stage of pressure ulcer is pain
assessment recommended?
［ Recommendation ］Pain may be assessed at any
stage of pressure ulcer.
［Rating］C1［ Analysis ］A cross-sectional study of 32 patients
recruited from acute care settings, extended caresettings, and home care settings with stage II, III, andof the patients reported continuous pain. These data
indicate the need to assess pain levels in pressure
ulcer patients not only when treatment is administered but also when the patients are at rest.
References
1 ）Szor JK, Bourguignon C：Description of pressure
ulcer pain at rest and at dressing change. J Wound

IV pressure ulcers found that 75% reported mild pain,1）
while 18% reported excruciating pain . Anothercross-sectional study based on an interview of 44
patients in an acute care setting reported a correlation
between the VAS（visual analog scale）and stage ofpressure ulcer（r = 0.37, P ＜ 0.01）, with a positive
correlation between the depth of the wound and the2）intensity of pain . However, pain has reportedly1）
accompanied even relatively shallow wounds .Accordingly, pain assessment is necessary at every stage ofpressure ulcer for the accurate assessment ofpatientsSQOL.
References
1）Szor JK, Bourguignon C: Description of pressure ulcer
pain at rest and at dressing change. J Wound Ostomy
Continence Nurs, 26（3）：115-120, 1999.（Level V）
2）Dallam L, Smyth C, Jackson BS, et al: Pressure ulcer
pain: assessment and quantification. J Wound Ostomy
Continence Nurs, 22（5）：211-218, 1995.（Level V）

CQ 13. 3：When should pain assessment be conducted?
［Recommendation］Pain assessment may be conducted at any time（ regardless of whether topicalintervention is being administered）.
［Rating］C1［ Analysis ］According to a cross-sectional study
conducted on 32 patients with stage II, III, or IV
pressure ulcers interned at acute care, extended care,and home care settings using the MPQ（McGill pain
questionnaire ）, 87. 5% reported feeling pain when

Ostomy Continence Nurs, 26（ 3 ）：115-120, 1999.
（Level V）

CQ 13.4：Which tools can be used to assess pressureulcer-related pain?
［Recommendation］Pain may be assessed using avalidated scale.
［Rating］C1［Analysis］A cross-sectional study based on interviews of 44 patients with Stage I~IV pressure ulcers
interned in an acute care facility found that the degreeof pain reported by the patients in the interviews
correlated with the VAS（visual analog scale; r = 0.59,
P ＜ 0.1）as well as with the FRS（faces pain rating
1）
Ssle; r = 0.53, P ＜ 0.1） .
Another cross-sectional study of 47 patients with
Stage II~IV pressure ulcers found that 94. 6% of
patients who reported pressure-ulcer-related pain
showed a correlation between their FRS and MPQ（McGill pain questionnaire）scores（r = 0.90, P ＜ 0.
2）001） . These data indicate that the VAS, FRS, andMPQ subjective rating systems are able accurately tomeasure the degree of pain felt by pressure ulcer
patients and are therefore appropriate tools for theassessment of pressure-ulcer-related pain.
References
1）Dallam L, Smyth C, Jackson BS, et al：Pressure ulcer
pain: assessment and quantification. J Wound Ostomy
Continence Nurs, 22（5）：211-218, 1995.（Level V）
2 ）Günes UY：A descriptive study of pressure ulcer

their dressings were changed, and 84. 4% reported
1）
similar sensations when at rest . Furthermore, 42%― G− 79 ―pain. Ostomy Wound Manage, 54（ 2 ）：56-61, 2008.
（Level V）