How Do You Treat Minor Pressure Ulcers?

Patient Presentation
A 13-year-old female came to clinic with a complaint of recurrent wounds on her buttocks. These occurred over the past 3 months and had been getting worse during the summer. She and a friend had been training for a 7-day bike trip and had been increasing their mileage considerably over the past 2-3 weeks. She said that there had been several sore spots that changed in location over time but she now had two that were particularly painful and were not healing. She complained of general itching of the buttocks. She was also spending a great deal of time at the local pool sitting in wet bathing suits. She had put some lotion onto the area a few times without help. The past medical history showed a healthy female with no history of athletic injuries, but with mild atopic dermatitis.

The pertinent physical exam revealed a healthy female with normal growth and vital signs. Skin examination showed a tanned individual with keratosis pilaris of the upper outer arms and thighs. She had skin irritation under her breasts and in the axillary area. Her bilateral buttocks had multiple areas of discrete 1-2 mm erythematous macules or papules consistent with folliculitis particularly in the area where the buttocks meet the top of the thighs. There were two erythematous 13-15 mm round lesions without skin breakdown but the left buttock also had a 5-mm shallow crater to the dermis in the center that was dry. The lesions overlied the ischial tuberosities bilaterally. The buttocks appeared overall dry and irritated without discrete scratch marks. The genital area was normal.

The diagnosis of small pressure ulcers or saddle sores was made along with folliculitis of the buttocks and atopic dermatitis. The physician recommended several things to heal the current ulcers and prevent additional ones. First he discussed that the skin problems were due to a combination of pressure, friction and shearing forces along with moisture. He recommended using clean clothes for each practice that had no seams or few seams in the offending areas. Additionally he recommended that she use lubricants in the areas during practice and that specifically for biking many people used a chamois cloth to decrease friction. He also recommended that she go to the local bicycle shop and make sure that the bike and particularly the seat was fitted to her properly. To help heal the lesions he recommended regular bathing, especially after practice, with the use of iodine or alcohol to decrease bacteria in the area. He said that this could also cause drying so that an emollient should also be used afterwards and regularly to decrease irritation. Sitting in a wet bathing suit and sitting on hard surfaces was also not helping the situation and he recommended avoiding these activities, and moving as frequently as possible. At a health maintenance visit in the early fall, the patient reported that she still had some “small bumps” in the lower buttocks from time to time that coincided to when she wasn’t doing her skin care. The pressure ulcers had resolved on physical examination and she still had minor folliculitis.

Discussion
A pressure ulcer is defined as “a localized area of tissue damage developed when soft tissue (fat, muscle, arterial, and venous vasculature, etc.) is compressed between a bony prominence and any external surface for a prolonged period.” The ulcer forms when the compression cuts off the blood supply to an area resulting in tissue hypoxia, cellular death, and injury to the surrounding area. Some important risk factors include immobility or decreased mobility, poor nutrition, presence of infection, decreased oxygenation/perfusion, and underlying medical problems including sensory perception. Acutely ill patients such as trauma patients in an ICU setting are often thought of as being at risk, but patients with chronic problems such as neurological or orthopaedic problems also are at risk. The areas most affected in infants and small children are the head, sacral area, ear lobes and heels. Other areas include scapula and ankles. For hospitalized children, the Braden and Braden Q scoring systems aid in predicting pressure ulcer risk and help in planning preventive measures.

Learning Point
Skin care treatment revolves around treatment of moisture, pressure, friction and shearing forces. For patients with underlying medical problems, adequate nutrition is also a key determinant.

To decrease moisture, clothing that wicks moisture away is best. Close fitting (but not too tight) clothing can absorb the moisture and allow it to not gather or drain. Not tucking the ends of a shirt into the pants helps to decrease pooling of moisture in the pelvic area. For women use of feminine hygiene pads may help with leukorrhea, but they need to be regularly changed so they do not add to the moisture problem. Similarly, use of tampons instead of pads during menses can decrease moisture too. Changing clothing regularly (even during a practice) is important and clean, dry clothing should be used. People should shower or bathe regularly with good attention to drying.

Protection from repeated pressure or methods to spread out the pressure over a body part are an important part of a sport. Well-fitting equipment that is used properly is key. In bicycling, different seat types may fit different individuals better, but seat height, handle bar height and a bike that fits well overall are probably equally or even more important.

Friction and shearing forces may be obvious in the particular sport, such as bicycle seat friction. Padding and use of a lubricant are the usual treatment. For bicycling, using a soft chamois in the bicycling short along with a lubricant helps to prevent saddle sores. Sometimes the friction and shearing forces may not be so obvious such as seamlines in clothing, or breast tissue that is repeatedly moving. Well-fitting clothing and use of lubricants usually will improve the problem. Additionally, modification of the equipment or way the activity is performed may be necessary to accommodate the particular individual.

Once skin breakdown and/or ulcers begin they need to be treated promptly. Cleansing of the skin is needed to decrease bacterial counts but aggressive cleaning or rubbing can cause drying, friction and increased breakdown so a balance is needed. Topical or oral antibiotics may be needed. Moisture control measures should be instituted particularly with frequent dressing changes if dressings are used. Tapes and dressings themselves may cause friction so if they are used, care needs to be taken with them. Some dressings do not need tape and can be held in place by clothing or a loose gauze dressing. Decreasing friction can be aided by other dressings such as Tegaderm® to cover an area where friction frequently occurs. Pressure also needs to be relieved. This is best done by increasing mobility and frequent position changes.

Questions for Further Discussion
1. What types of positioning methods can be implemented for immobile children to decrease pressure ulcers?


2. What types of bedding can be used for immobile children to decrease pressure ulcers?


3. What types of dermatological problems can be anticipated for people involved in different sports such as weight lifting, running, rowing, swimming, hockey, etc.?

4. What are the grades of pressure ulcers?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Pressure Sores.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Butler CT. Pediatric skin care: guidelines for assessment, prevention, and treatment. Dermatol Nurs. 2007 Oct;19(5):471-2, 477-82, 485.

McCaskey MS, Kirk L, Gerdes C. Preventing skin breakdown in the immobile child in the home care setting. Home Healthc Nurse. 2011 Apr;29(4):248-55; quiz 256-7.

Bernabe KQ, Pressure ulcers in the pediatric patient. Current Opinion in Pediatrics. 2012;24(3):352-356.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • When Should a Child Start Toilet Training?

    Patient Presentation
    A 2-year-old female came to clinic for her well child check. The parents had no concerns and she was developing normally. The past medical history was non-contributory. The pertinent physical exam showed a healthy female with growth parameters in the 75-90%.

    The diagnosis of a healthy female was confirmed. The parents asked about when to begin toilet training. The pediatrician recommended to follow the child’s cue and when she seemed interested, could verbalize her toileting wants/needs, seemed to not like soiled or wet diapers, and could take care of at least part of her clothing, then they probably would have more success with trying to train her. The pediatrician warned that the child could be slow to toilet train while others did it quite quickly, and that staying dry at night would come much later.

    Discussion
    Toilet training is a normal developmental process but has very little research. In 1962 Dr. Barry Brazleton published the first standardized method using a “child readiness” approach that was unregimented and child-focused. The child had to be physiological and psychologically ready and the parent had to be psychologically ready to proceed with toilet training. Studies beginning at 18 months of age using this approach had a mean daytime continence achieved by 28 months. In 1973, Azrin and Foxx described a method that was structured and parent-focused. Again both the child had to be physically and psychologically ready and the parents had to be psychologically ready. In smaller studies this approach were trained in several hours.

    Readiness cues for toilet training from the literature have been looked at. Unfortunately which signs predict success are lacking. Part of this is due to the inconsistent definitions. For example does toilet training success mean being dry when while awake (i.e. still needs a diaper during naps) or is dry during all daylight hours? Does success mean recognizing that he/she needs to toilet and can wait until an adult helps with clothing, or does that mean that the child recognizes the urge, takes care of all clothing, successfully uses the toilet and performs all his/her own hygiene along with replacement of clothing? Developmental readiness also depends on which cue is used to determine the readiness. Below is a list developed from the literature and the range of ages in months when most children can perform them.

      Months Cue
      2-25 – Child imitates toileting behavior
      4-16 – Child is capable of sitting stable and without assistance on toilet/potty chair
      8-18 – Walks without help
      9-18 – Able to pick up small objects
      9-24 – Can say No as sign of independence
      9-24 – Has voluntary control over bladder and bowel reflex actions
      9-27 – Responds to directions and simple commands
      9-36 – Indicates need to toilet by non-verbal cues or by words
      10-22 – Enjoys putting things in containers
      12-24 – Awareness of bladder sensations and need to void
      12-27 – Understanding toilet-related words and has adequate vocabulary him/herself
      12-28 – Shows interest in toilet training
      12-32 – Has a larger bladder capacity
      12-36 – Insists on completing tasks him/herself and is proud of new skills
      12-36 – Asks for toilet/potty chair
      18-24 – Is distressed by wet/dirty diapers/clothing
      18-24 – Wants to wear grown-up clothing
      18-36 – Able to pull clothing up and down
      22-26 – Is Bowel movement-free overnight
      22-27 – Able to put items where they belong
      25-32 – Can sit still on toilet/potty chair for 5-10 minutes

    Learning Point
    When should children start toilet training depends and there is little data to support exact timing or the best method. Today most children start to train between 18-24 months with more intensive training starting at ~27 months. When asked, parents in one study said 20.6 +/- 7.6 months.

    A systematic review of 34 studies found “Both the Azrin and Foxx method and the child-oriented approach resulted in quick, successful toilet training, but there was limited information about the sustainability of the training. The two methods were not directly compared; thus, it is difficult to draw definitive conclusions regarding the superiority of one method over the other. In general, both programs may be used to teach toilet training to healthy children. The Azrin and Foxx method and operant conditioning methods were consistently effective for toilet training mentally handicapped children. Programs that were adapted to physically handicapped children also resulted in successful toilet training. A lack of data precluded conclusions regarding the development of adverse outcomes.”
    An author of this systematic review states that “Toilet training should be started when both the child and parent are willing to participate” and that, “[a] positive, consistent approach to toilet training is unlikely to cause long-term harm.”

    Questions for Further Discussion
    1. When do you recommend that children begin toilet training?
    2. Do you use any readiness cues and which ones?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Toilet Training

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Klassen TP, Kiddoo D, Lang ME, Friesen C, Russell K, Spooner C, Vandermeer B. The effectiveness of different methods of toilet training for bowel and bladder control. Evid Rep Technol Assess (Full Rep). 2006 Dec;(147):1-57.

    Vermandel A, Van Kampen M, Van Gorp C, Wyndaele JJ. How to toilet train healthy children? A review of the literature. Neurourol Urodyn. 2008;27(3):162-6.

    Kaerts N, Van Hal G, Vermandel A, Wyndaele JJ. Readiness signs used to define the proper moment to start toilet training: a review of the literature. Neurourol Urodyn. 2012 Apr;31(4):437-40.

    Kaerts N, Vermandel A, Lierman F, Van Gestel A, Wyndaele JJ. Observing signs of toilet readiness: results of two prospective studies. Scand J Urol Nephrol. 2012 Dec;46(6):424-30.

    Kiddoo DA. Toilet training children: when to start and how to train. CMAJ. 2012 Mar 20;184(5):511-2.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital