Commentary
THE DECUBITUS ULCER
LAWRENCE CHARLES PARISH, M.D. AND )OSEPH A WITKOWSKI, M.D.
The decubitus ulcer, also known as a pressure or bed sore, represents a loss of skin often occurring over bony prominences. The plural of decubitus is decubitus and 1 not decubitii, as commonly thought. The tissue destruction may extend to subcutaneous fat, fascia and even muscle. Decubitus ulcers are nota new disease, as ulcerations of this nature have been known for centuries. The incidence of decubitus ulcers is not known because many physicians refuse to acknowledge the presence of the l es i~n. They are often so preoccupied with blammg the nurses for not turning the patient every two hours that they fail to observe the morphology of the evolving lesion. Nurses, on the other hand, are often besides themselves and usually transfer the blame to the family, who are generally bewildered by the present of the oderiferous oozing cuta~e ous catastrophy. Once the hospital or nurs1~g home has been implicated, there is a full Clrcle of guilt and nothing positive is accomplished.2 Although few contemporary textbooks of medicine or nursing include a description of · Supported in part by the Herman and Ruth Goodman Foundation, lnc., New York. Address for reprints: Lawrence Charles Parish, M .D ., Hospital of lhe Universi ty of Pennsylvan1a, 34th and Spruce Slreets, Philadelphia, PA 19104. 0011-9059/ 79 /0400/0211 / $00.60
From the D epartment of D ermatology, University of Pennsy/vania School of M edicine, Philadelphi a, Penns ylvania
the decubitus ulcer, a perfectly lucid morphologic picture was described a century ago. 3 First, there is a decubital dermatitis, aptly named by Shelley 4 and is characterized by blanching erythema. This progresses lo nonblanching redness with microscopic vesiculation and finally bullous formation . The first sign of ulteration may be marked by a black eschar. With further extension, there is a massive necrosis of tissue and deep ulceration. There is a generai lack of information in pathology textbooks concerning decubitus ulcers. The overall picture represenTs an anemie infarct. Microscopic examination of tissue removed from the decubital dermatitis shows eosinophilic staining of the epidermis and dermis. There is a loss of cellular definition of the epidermis and subepidermal blister. The dermis usually appears necrobiotic. Examination of skin adjacent to a developing ulcer reveals similar c hanges. Tissue from near a healing ulcer shows a thin epidermis with loss of rete ridges. The dermis is fibrotic and relatively avascular. Scar-like changes
© lnternational 211
Society of Tropical Dermatology, In c.
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INTERNATIONAL JOURNAL OF DERMATOLOGY
are seen in tissue removed from the base of a stable ulcer. Pressure has been implicated in the cause of the decubitus ulcer. Although pressure exceeding 100m m mercury may act as a trigger factor, ali of the damage cannot be ascribed to this factor alone. Moreover, there is no evidence that moisture, urinary or fecal incontinence, increase in local temperature or diet cause the skin breakdown. This has led us to question whether there could be something about the blood vessels of patients who develop decubitus ulcers. Are their blood vessel walls more sensitive to anoxia? Perhaps, a previous immunologie insult or an alterati o n of the fibrinolysin-fibrin equilibrium is playing a predisposing role. No obvious chemical or hematologic abnormalities have been discovered thus far in patients with pressure ulcers. The decubitus ulcer has been treated with a multitude of physical and chemical agents. These range from the sublime to the absurd: red dyes to brown stains, saw-dust to water, and chalky lotions to black ointments. The rationale, always justified, reaches incredulousness when antacids used to treat peptic ulcers have been advocated as a treatment far the decubitus ulcer. The most rational of available medicai therapies consists of antibiotic powders, astringent compresses and enzymatic debriding agents. Recently this has been simplified. Most open decubitus ulcers can now be managed by simply lavaging the ulcer, covering the base
Aprii 1979
Vol. 18
with dextranomer powder and applying a simple dry dressing. 5 Surgical therapy is stili a necessary component of decubitus ulcer care. Eschars and debris-filled ulcers stili require cold steel debridement. Grafts and flap procedures remain vital measures when large defects require coverage. Dextranomer has also been found useful in preparing the ulcer bed far these reconstructive procedures. We do not pròpose to know how to prevent this scourge of the bed or chair-ridden patient. Water beds, ai r mattresses, polyethylene mesh, etc., may be helpful, but the major problem is to identify the susceptible patient. lf nursing personnel would report the appearance of that initial patch of nonblanching erythema, the dermatologist or other interested physicians could institute preventative measures and more could be learned about the disease. Keeping the decubitus ulcer hidden, and making it a shameful diagnosis, will only perpetuate ignorance.
Drug Name dextranomer: Debrisan
References 1. Arnold, H. L., jr.: Personal communication. 2. Adams, G.: Essentials of Geriatric Medicine, Oxford, Oxford Univ. Press, 1978, p. 64 . 3. Shaw, T. C. : On so-called bed-sores in the insane. St. Bartholomew's Hosp. Rep. 8:130, 1872 . 4. Schlappner, O . L. A., and Shelley, W . B.: Polyethylene mesh: a new treatm ent for decubital dermatitis. JAMA 223:430, 1973. S. Parish, L. C., and Collins, E.: Decubitus ulcers: a comparative study. Cutis 23 : 106, 1979.
Decubital Dermatitis Perhaps no dermatitis is more common than that which ensues from confinement to bed or to chair. Such a dermatitis results from a variety of causes. Without question, moisture, pressure, friction, irritation, sensitization, and indeed, infection each play a contributory role in varying degrees. This type of dermatitis seen in the clinica! setting is often not readily classifiable as a si.mple folliculitis, or a miliaria, or a contact dermatitis, but rather, it is a dermatologie potpourri.-Schlappner, O. L. A., and Shelley, W. 8 .: Polyethylene mesh: a new treatment far decubital dermatitis: }AMA 223:430, 1973.
THE DECUBITUS ULCER
LAWRENCE CHARLES PARISH, M.D. AND )OSEPH A WITKOWSKI, M.D.
The decubitus ulcer, also known as a pressure or bed sore, represents a loss of skin often occurring over bony prominences. The plural of decubitus is decubitus and 1 not decubitii, as commonly thought. The tissue destruction may extend to subcutaneous fat, fascia and even muscle. Decubitus ulcers are nota new disease, as ulcerations of this nature have been known for centuries. The incidence of decubitus ulcers is not known because many physicians refuse to acknowledge the presence of the l es i~n. They are often so preoccupied with blammg the nurses for not turning the patient every two hours that they fail to observe the morphology of the evolving lesion. Nurses, on the other hand, are often besides themselves and usually transfer the blame to the family, who are generally bewildered by the present of the oderiferous oozing cuta~e ous catastrophy. Once the hospital or nurs1~g home has been implicated, there is a full Clrcle of guilt and nothing positive is accomplished.2 Although few contemporary textbooks of medicine or nursing include a description of · Supported in part by the Herman and Ruth Goodman Foundation, lnc., New York. Address for reprints: Lawrence Charles Parish, M .D ., Hospital of lhe Universi ty of Pennsylvan1a, 34th and Spruce Slreets, Philadelphia, PA 19104. 0011-9059/ 79 /0400/0211 / $00.60
From the D epartment of D ermatology, University of Pennsy/vania School of M edicine, Philadelphi a, Penns ylvania
the decubitus ulcer, a perfectly lucid morphologic picture was described a century ago. 3 First, there is a decubital dermatitis, aptly named by Shelley 4 and is characterized by blanching erythema. This progresses lo nonblanching redness with microscopic vesiculation and finally bullous formation . The first sign of ulteration may be marked by a black eschar. With further extension, there is a massive necrosis of tissue and deep ulceration. There is a generai lack of information in pathology textbooks concerning decubitus ulcers. The overall picture represenTs an anemie infarct. Microscopic examination of tissue removed from the decubital dermatitis shows eosinophilic staining of the epidermis and dermis. There is a loss of cellular definition of the epidermis and subepidermal blister. The dermis usually appears necrobiotic. Examination of skin adjacent to a developing ulcer reveals similar c hanges. Tissue from near a healing ulcer shows a thin epidermis with loss of rete ridges. The dermis is fibrotic and relatively avascular. Scar-like changes
© lnternational 211
Society of Tropical Dermatology, In c.
212
INTERNATIONAL JOURNAL OF DERMATOLOGY
are seen in tissue removed from the base of a stable ulcer. Pressure has been implicated in the cause of the decubitus ulcer. Although pressure exceeding 100m m mercury may act as a trigger factor, ali of the damage cannot be ascribed to this factor alone. Moreover, there is no evidence that moisture, urinary or fecal incontinence, increase in local temperature or diet cause the skin breakdown. This has led us to question whether there could be something about the blood vessels of patients who develop decubitus ulcers. Are their blood vessel walls more sensitive to anoxia? Perhaps, a previous immunologie insult or an alterati o n of the fibrinolysin-fibrin equilibrium is playing a predisposing role. No obvious chemical or hematologic abnormalities have been discovered thus far in patients with pressure ulcers. The decubitus ulcer has been treated with a multitude of physical and chemical agents. These range from the sublime to the absurd: red dyes to brown stains, saw-dust to water, and chalky lotions to black ointments. The rationale, always justified, reaches incredulousness when antacids used to treat peptic ulcers have been advocated as a treatment far the decubitus ulcer. The most rational of available medicai therapies consists of antibiotic powders, astringent compresses and enzymatic debriding agents. Recently this has been simplified. Most open decubitus ulcers can now be managed by simply lavaging the ulcer, covering the base
Aprii 1979
Vol. 18
with dextranomer powder and applying a simple dry dressing. 5 Surgical therapy is stili a necessary component of decubitus ulcer care. Eschars and debris-filled ulcers stili require cold steel debridement. Grafts and flap procedures remain vital measures when large defects require coverage. Dextranomer has also been found useful in preparing the ulcer bed far these reconstructive procedures. We do not pròpose to know how to prevent this scourge of the bed or chair-ridden patient. Water beds, ai r mattresses, polyethylene mesh, etc., may be helpful, but the major problem is to identify the susceptible patient. lf nursing personnel would report the appearance of that initial patch of nonblanching erythema, the dermatologist or other interested physicians could institute preventative measures and more could be learned about the disease. Keeping the decubitus ulcer hidden, and making it a shameful diagnosis, will only perpetuate ignorance.
Drug Name dextranomer: Debrisan
References 1. Arnold, H. L., jr.: Personal communication. 2. Adams, G.: Essentials of Geriatric Medicine, Oxford, Oxford Univ. Press, 1978, p. 64 . 3. Shaw, T. C. : On so-called bed-sores in the insane. St. Bartholomew's Hosp. Rep. 8:130, 1872 . 4. Schlappner, O . L. A., and Shelley, W . B.: Polyethylene mesh: a new treatm ent for decubital dermatitis. JAMA 223:430, 1973. S. Parish, L. C., and Collins, E.: Decubitus ulcers: a comparative study. Cutis 23 : 106, 1979.
Decubital Dermatitis Perhaps no dermatitis is more common than that which ensues from confinement to bed or to chair. Such a dermatitis results from a variety of causes. Without question, moisture, pressure, friction, irritation, sensitization, and indeed, infection each play a contributory role in varying degrees. This type of dermatitis seen in the clinica! setting is often not readily classifiable as a si.mple folliculitis, or a miliaria, or a contact dermatitis, but rather, it is a dermatologie potpourri.-Schlappner, O. L. A., and Shelley, W. 8 .: Polyethylene mesh: a new treatment far decubital dermatitis: }AMA 223:430, 1973.
