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A. Bánvölgyi Department of Dermatology, Venereology and Dermatooncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary

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A. Görög Department of Dermatology, Venereology and Dermatooncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary

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K. Gadó Department of Clinical Studies, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary

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P. Holló Department of Dermatology, Venereology and Dermatooncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary

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Abstract

The ageing processes, primarily after the age of 60, bring about a number of important changes that affect the skin’s protective function. These changes directly and indirectly increase its vulnerability and impair its ability to heal. Hence, the incidence of chronic wounds increases in the elderly population. Dry skin, often accompanied by itching and consequent scratching, can lead to the development of wounds. The skin’s ability to regenerate itself is also impaired by the atrophy that affects all the three layers of the skin, the epidermis, dermis, and subcutis. The deterioration of vascularisation and innervation increases the chance of ulcer formation and impaired healing of existing wounds. Together these lead to the development of chronic lower limb ulcers in elderly patients or decubitus in older bedridden patients. Bedsores are more likely to develop in older patients with reduced body weight due to their decreased amount of adipose tissue capable of pressure-relieving. This latter negative tendency may be exacerbated by the presence of reduced mobility, impaired muscle strength, and frequent incontinence. In all respects, the propensity to heal is worse than in younger age, thus in many cases a chronic process is expected, and in some cases halting the progression may be a significant outcome. Ulcers of rare aetiology can occur at any age, so pyoderma gangrenosum, vasculitis, and other ulcers with rare aetiology in the elderly population should also be considered.

Abstract

The ageing processes, primarily after the age of 60, bring about a number of important changes that affect the skin’s protective function. These changes directly and indirectly increase its vulnerability and impair its ability to heal. Hence, the incidence of chronic wounds increases in the elderly population. Dry skin, often accompanied by itching and consequent scratching, can lead to the development of wounds. The skin’s ability to regenerate itself is also impaired by the atrophy that affects all the three layers of the skin, the epidermis, dermis, and subcutis. The deterioration of vascularisation and innervation increases the chance of ulcer formation and impaired healing of existing wounds. Together these lead to the development of chronic lower limb ulcers in elderly patients or decubitus in older bedridden patients. Bedsores are more likely to develop in older patients with reduced body weight due to their decreased amount of adipose tissue capable of pressure-relieving. This latter negative tendency may be exacerbated by the presence of reduced mobility, impaired muscle strength, and frequent incontinence. In all respects, the propensity to heal is worse than in younger age, thus in many cases a chronic process is expected, and in some cases halting the progression may be a significant outcome. Ulcers of rare aetiology can occur at any age, so pyoderma gangrenosum, vasculitis, and other ulcers with rare aetiology in the elderly population should also be considered.

Introduction

In the general population, the prevalence of chronic ulcers is 0.2–2%, the most common of which are lower limb ulcers due to circulatory disorders, diabetes mellitus, and other factors [1, 2]. The prevalence of ulcers increases with age as the prevalence of underlying diseases increases. This can rise to 3.6% from the age of 60 years, and up to 6% of the population over 80 years may develop chronic ulcers, mainly leg ulcers [1–3]. In addition to general medical considerations, given that prevention is always of paramount importance, prevention is increasingly crucial in the case of ulcers in the elderly. Even with adequate therapy, the healing of established ulcers may be extremely slow due to frequent comorbidities. In addition to reduced vascularisation and impaired innervation, this is also explained by impaired skin barrier function and the closely related reduced turnover of the keratinocytes [4]. In the outpatient setting, the predominant causes of lower limb ulcers are venous, arterial, diabetes mellitus-related neuropathies, and rare aetiologies [5]. Patients in nursing homes and chronic care units of hospitals, especially immobile patients, are at high risk of developing decubitus ulcers, but also lower limb ulcers of the aforementioned aetiologies can develop [6, 7].

Smart dressings, modern disinfectants, negative-pressure wound therapy (NPWT), and caring for the surrounding skin: principles and practical advice

Due to the increasing cost and health burden of chronic ulcer management, there have been great advances in the field of smart dressings over the past decades. Smart dressings, which can help maintain optimal moisture, temperature, and wound surface oxygenation, prevent secondary infection, and allow atraumatic replacement of the bandage, are now a fundamental part of modern wound management [8].

The selection of the appropriate smart dressing is based on factors as the following: the depth and the shape of the ulcer, the features of the wound bed and the tissue covering the wound bed, and the degree of exudate [8, 9]. In case of deeper lower limb ulcers, but especially bedsores, special dressing with a combined innovative rinsing and absorption mechanism or alginate dressing are recommended [10]. Foam dressings can be selected for more superficial, shallower ulcers with moderate amount of exudate. Depending on the features of the tissue covering the wound bed and the degree of granulation, dressing containing silver or hydrogel may be chosen, the latter being excellent for enhancing granulation [10, 11]. If pronounced exudation occurs in case the lower limb ulcer is accompanied by lymphoedema or in case of decubitus, superabsorbent polymer dressings are preferable. These absorb the exudate, thus protecting the surrounding areas from maceration [12]. Regular moisturising of the skin reduces the possibility of onset of dry skin and consequent eczema on the surrounding skin of the wound. Externals containing talc can prevent the development of maceration by binding surplus exudate. Keeping the ulcer and its surrounding skin clean and properly disinfected is a prerequisite for the proper functioning of the smart dressing and also is the basis of wound management. For thorough and first-line washing, tap water is the medically appropriate choice. This should be followed by a first step of rinsing with physiological saline and then the application of a modern disinfectant [13]. As a first choice, products containing agents as octenidine dihydrochloride, poly-hexamethylene biguanide (PHMB), or a combination of sodium chloride, sodium hypochlorite, and hypochlorous acid are recommended. These are colourless, non-irritating and have anti-MRSA and anti-ESBL activity. They are compatible with most smart dressings, so no modification of the therapeutic protocol of the smart dressing is necessary when using them [14–16]. Povidone-iodine is also a suitable choice, with an excellent antimicrobial spectrum [17]. It should be noted, however, that due to its tendency to form complexes with silver, with dressings and externals which contain the latter, it is incompatible [18]. In recalcitrant cases that do not respond to other therapies, especially in case of deep, superinfected wounds, negative pressure wound therapy (NPWT) is a well-established and cost-effective treatment modality [19]. Though at first sight it may seem expensive, it has been shown to be cost-effective by shortening the length of overall need for treatment. It can be used primarily in active or chronic hospital wards but also in day hospitals or nursing homes [19–21]. In addition to direct wound care, it is crucial to treat the underlying conditions that contribute to the development and maintenance of chronic wounds. We can also help the healing process by providing special nutrients rich in amino acids and other supplements. These can increase the thickness of the subcutis and can thus directly reduce pressure, which can be particularly helpful in the case of bedsores [22]. In addition, targeted nutrients developed for this purpose can improve the rate of ulcer healing by increasing the amount of nutrients needed for granulation [23].

Decubitus: characteristics and treatment options

Decubitus or so-called bedsores, also known as pressure ulcers, are frequent and significant healthcare problems, especially in the nursing care of the elderly. Bedsores are most commonly seen in patients who are partially or totally disabled [21, 24, 25]. Nonetheless, it can also occur in older people who are less active and mobile due to other underlying conditions or a significant loss of muscle strength [25]. There are different stages in the disease process. In stage I, the effect of pressure compression on the vascular compartments acts on the venules. Here, erythema is clinically visible, which is still reversible and therefore no ulceration evolves. Because of the reversibility of the clinical changes, the process can still be halted and relatively easily reversed at this stage with appropriate therapy. Thereafter, from stage II onwards to stage IV with the stages being classified according to the depth of the ulcer [21, 24, 25], due to heavy and ongoing pressure compression forces it also inhibits capillary circulation. The severe damage to the circulation leads to ulceration, which progressively penetrates deeper and deeper, affecting the subcutaneous tissue and later even muscles and bones (Fig. 1).

Fig. 1.
Fig. 1.

Different wound depths are shown at different parts of a decubitus ulcer, according to the stage classification system

Citation: Developments in Health Sciences 4, 4; 10.1556/2066.2022.00054

Prevention is the most important thing in case of bedsores, as the resulting decubitus is a grave medical problem. The pressure load can be reduced or eliminated by regular and frequent changing of the patients’ position. Proper education of nursing staff, patients and relatives, the use of special mattresses and pillows can all help to decrease the pressure load [25, 26]. The treatment of already developed bedsores requires complex therapy with multiple points of attack. The elimination of risk factors and the strengthening of healing factors are needed simultaneously. Frequent comorbidity, as incontinence in older age and the consequent combined irritative and microbial dermatitis, so called “diaper dermatitis”, can be a serious risk factor, and its prevention and treatment are therefore also of paramount importance [27]. In case of an existing wound, the use of smart dressings is recommended according to the principles detailed above [28–30]. In some cases, particularly in the case of an especially deep decubitus, which extend to the muscles or even to the bone, the use of NPWT would be favourable to obtain excellent results.

Chronic leg ulcers: characteristics and treatment options

In the elderly population, both in hospitals and in nursing homes or outpatient care, the most common ulcers develop in the lower limbs, mainly in the leg, ankles, and soles. The primary cause of leg ulcer is chronic venous insufficiency (CVI) (Fig. 2).

Fig. 2.
Fig. 2.

Chronic venous leg ulcer is shown with the typical clinical signs of chronic venous insufficiency, as haemosiderosis and lipodermatosclerosis

Citation: Developments in Health Sciences 4, 4; 10.1556/2066.2022.00054

This is responsible for 50–80% of all lower limb ulcers, while the remaining ulcers are caused by peripheral arterial disease (PAD) and neuropathy, the latter generally occurring with diabetes. Other rare causes account for nearly 5% of chronic leg ulcers [1, 31]. Determining the aetiology is essential and in most cases the clinical picture of the ulcer and the surrounding skin helps to determine the type of the underlying disorder. However, all patients should be examined by a vascular surgeon or angiologist to verify or establish the aetiology [31, 32]. In the case of a CVI aetiology, appropriately applied compression therapy is fundamental, without that, no significant improvement in outcome can be expected [32]. This can rise considerable educational and nursing difficulties from a geriatric perspective. Many older patients are unable to use compression therapy appropriately for musculoskeletal or other reasons. The choice of smart dressings should follow the aforementioned principles. For venous ulcers, rheological treatment with sulodexide may help the ulcer to heal, and for an arterial aetiology prostacyclin and pentoxifylline may be effective, and the latter may have a beneficial effect on venous ulcers as well [32–35].

Chronic wounds of rare aetiology: characteristics and practical advice for early diagnosis

Chronic lower limb ulcers can be explained by rare aetiologies in about 5% of cases. These may be oncological or immunological processes. The role of the dermatologist is paramount in their recognition and investigation, and biopsy sampling and histopathology are often required in cases of suspected rare aetiology [36–38]. Of particular importance is pyoderma gangrenosum (Fig. 3), which can be associated with inflammatory bowel diseases such as Crohn’s disease, malignant haematological disorders, hepatitis C infection, or other autoimmune processes such as rheumatoid arthritis [38].

Fig. 3.
Fig. 3.

Pyoderma gangrenosum is shown as a deep and painful ulcer on the flexor surface of the shank

Citation: Developments in Health Sciences 4, 4; 10.1556/2066.2022.00054

The aforementioned comorbidities can often occur in older age and many cases of pyoderma gangrenosum also occur in the elderly [38]. Basal cell carcinoma, squamous cell carcinoma and, in even rarer cases, melanoma can cause bizarre ulcers that differ from the ones with vascular disorder origin [39]. The role of the dermatologist in identifying skin cancer ulcers is substantial. Here, the undoubtedly good vascularisation of the ulcers and the absence of healing despite a clear wound bed may arouse suspicion. In suspected cases, two punch biopsies of the ulcer edges are always necessary, and in these cases early diagnosis is crucial for adequate therapy and related long-term prognosis.

Conclusions

Chronic wounds in elder age affect a considerable proportion of the ageing population. Its social, healthcare, and health economic implications are significant, making prevention and appropriate treatment choices both crucial. In all cases, a multi-targeted therapy is needed, as the aetiology in elderly patients is most often combined and the skin’s regenerative capacity is significantly reduced. The use of smart dressings and other rheological or nutritional supportive therapies are essential parts of the treatment. Prompt and adequate therapy can lead to full recovery or can halt the progression of the process, so that the patient's quality of life can be maintained or improved.

Authors’ contribution

AB - writing original draft. Preparation, creation of the published work, specifically writing the initial draft. AG - preparation of the published work, contributed to the critical revision of the manuscript. KG - preparation of the published work, contributed to the critical revision of the manuscript. PH - Critical review, including pre- or post-publication stages, supervised the study and finalized the manuscript.

Ethical approval

N/A.

Conflicts of interest/Funding

The authors declare no conflict of interest. No financial support was received for preparing this manuscript.

Abbreviations

CVI

chronic venous insufficiency

NPWT

negative-pressure wound therapy

PAD

peripheral arterial disease

PHMB

poly-hexamethylene biguanide

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  • 2.

    Martinengo L , Olsson M , Bajpai R , et al. Prevalence of chronic wounds in the general population: systematic review and meta-analysis of observational studies. Ann Epidemiol. 2019;29:815. https://doi.org/10.1016/j.annepidem.2018.10.005.

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    • Search Google Scholar
    • Export Citation
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    Powers JG , Higham C , Broussard K , Phillips TJ . Wound healing and treating wounds: chronic wound care and management. J Am Acad Dermatol. 2016;74:607625; quiz 625–6. https://doi.org/10.1016/j.jaad.2015.08.070.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5.

    Morton LM , Phillips TJ . Wound healing and treating wounds: differential diagnosis and evaluation of chronic wounds. J Am Acad Dermatol. 2016;74:589605; quiz 605–6. https://doi.org/10.1016/j.jaad.2015.08.068.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6.

    Bergstrom N , Horn SD , Rapp M , et al. Preventing pressure ulcers: a multisite randomized controlled trial in nursing homes. Ont Health Technol Assess Ser. 2014;14:132.

    • Search Google Scholar
    • Export Citation
  • 7.

    Anrys C , Van Tiggelen H , Verhaeghe S , Van Hecke A , Beeckman D . Independent risk factors for pressure ulcer development in a high-risk nursing home population receiving evidence-based pressure ulcer prevention: results from a study in 26 nursing homes in Belgium. Int Wound J. 2019;16:325333. https://doi.org/10.1111/iwj.13032.

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    • Search Google Scholar
    • Export Citation
  • 8.

    Barros Almeida I , Garcez Barretto Teixeira L , Oliveira de Carvalho F , et al. Smart dressings for wound healing: a review. Adv Skin Wound Care 2021;34:18. https://doi.org/10.1097/01.ASW.0000725188.95109.68.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9.

    Gianino E , Miller C , Gilmore J . Smart wound dressings for diabetic chronic wounds. Bioengineering (Basel) 2018;5:51. https://doi.org/10.3390/bioengineering5030051.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10.

    Wasiak J , Cleland H . Burns: dressings. BMJ Clin Evid. 2015;2015:1903.

  • 11.

    Dumville JC , Stubbs N , Keogh SJ , Walker RM , Liu Z . Hydrogel dressings for treating pressure ulcers. Cochrane Database Syst Rev. 2015;17:CD011226. https://doi.org/10.1002/14651858.CD011226.pub2.

    • Search Google Scholar
    • Export Citation
  • 12.

    Atkin L , Barrett S , Chadwick P , et al. Evaluation of a superabsorbent wound dressing, patient and clinician perspective: a case series. J Wound Care 2020;29:174182. https://doi.org/10.12968/jowc.2020.29.3.174. Erratum in: J Wound Care. 2020;29:306.

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Senior Editors

Editor-in-Chief: Zoltán Zsolt NAGY
Vice Editors-in-Chief: Gabriella Bednárikné DÖRNYEI, Ákos KOLLER
Managing Editor: Johanna TAKÁCS

Editorial Board

  • Zoltán BALOGH (Department of Nursing, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Klára GADÓ (Department of Clinical Studies, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • István VINGENDER (Department of Social Sciences, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Attila DOROS (Department of Imaging and Medical Instrumentation, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Judit Helga FEITH (Department of Social Sciences, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Mónika HORVÁTH (Department of Physiotherapy, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Illés KOVÁCS (Department of Clinical Ophthalmology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Ildikó NAGYNÉ BAJI (Department of Applied Psychology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Tamás PÁNDICS (Department for Epidemiology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • József RÁCZ (Department of Addictology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Lajos A. RÉTHY (Department of Family Care Methodology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • János RIGÓ (Department of Clinical Studies in Obstetrics and Gynaecology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Andrea SZÉKELY (Department of Oxyology and Emergency Care, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Márta VERESNÉ BÁLINT (Department of Dietetics and Nutritional Sicences, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Gyula DOMJÁN (Department of Clinical Studies, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Péter KRAJCSI (Department of Morphology and Physiology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • György LÉVAY (Department of Morphology and Physiology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Csaba NYAKAS (Department of Morphology and Physiology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Vera POLGÁR (Department of Morphology and Physiology, InFaculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • László SZABÓ (Department of Family Care Methodology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Katalin TÁTRAI-NÉMETH (Department of Dietetics and Nutrition Sciences, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Katalin KOVÁCS ZÖLDI (Department of Social Sciences, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Gizella ÁNCSÁN (Library, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • András FALUS (Department of Genetics, Cell- and Immunbiology, Faculty of Medicine, Semmelweis University, Budapest, Hungary)
  • Zoltán UNGVÁRI (Department of Public Health, Faculty of medicine, Semmelweis University, Budapest, Hungary)
  • Romána ZELKÓ (Faculty of Pharmacy, Semmelweis University, Budapest, Hungary)
  • Mária BARNAI (Faculty of Health Sciences and Social Studies, University of Szeged, Szeged, Hungary)
  • László Péter KANIZSAI (Department of Emergency Medicine, Medical School, University of Pécs, Pécs, Hungary)
  • Bettina FŰZNÉ PIKÓ (Department of Behavioral Sciences, Faculty of Medicine, University of Szeged, Szeged, Hungary)
  • Imre SEMSEI (Faculty of Health, University of Debrecen, Debrecen, Hungary)
  • Teija-Kaisa AHOLAAKKO (Laurea Universities of Applied Sciences, Vantaa, Finland)
  • Ornella CORAZZA (University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom)
  • Oliver FINDL (Department of Ophthalmology, Hanusch Hospital, Vienna, Austria)
  • Tamás HACKI (University Hospital Regensburg, Phoniatrics and Pediatric Audiology, Regensburg, Germany)
  • Xu JIANGUANG (Shanghai University of Traditional Chinese Medicine, Shanghai, China)
  • Paul GM LUITEN (Department of Molecular Neurobiology, University of Groningen, Groningen, Netherlands)
  • Marie O'TOOLE (Rutgers School of Nursing, Camden, United States)
  • Evridiki PAPASTAVROU (School of Health Sciences, Cyprus University of Technology, Lemesos, Cyprus)
  • Pedro PARREIRA (The Nursing School of Coimbra, Coimbra, Portugal)
  • Jennifer LEWIS SMITH (Collage of Health and Social Care, University of Derby, Cohehre President, United Kingdom)
  • Yao SUYUAN (Heilongjiang University of Traditional Chinese Medicine, Heilongjiang, China)
  • Valérie TÓTHOVÁ (Faculty of Health and Social Sciences, University of South Bohemia, České Budějovice, Czech Republic)
  • Tibor VALYI-NAGY (Department of Pathology, University of Illonois of Chicago, Chicago, IL, United States)
  • Chen ZHEN (Central European TCM Association, European Chamber of Commerce for Traditional Chinese Medicine)

2020  

CrossRef
Documents

9
CrossRef Cites 8
CrossRef H-index 2
Days from submission to acceptance 219
Days from acceptance to publication 176
Acceptance
Rate
47%

 

 

2019  
CrossRef
Documents
13
Acceptance
Rate
83%

 

Developments in Health Sciences
Publication Model Online only Gold Open Access
Submission Fee none
Article Processing Charge none
Subscription Information Gold Open Access

Developments in Health Sciences
Language English
Size A4
Year of
Foundation
2018
Volumes
per Year
1
Issues
per Year
2
Founder Semmelweis Egyetem
Founder's
Address
H-1085 Budapest, Hungary Üllői út 26.
Publisher Akadémiai Kiadó
Publisher's
Address
H-1117 Budapest, Hungary 1516 Budapest, PO Box 245.
Responsible
Publisher
Chief Executive Officer, Akadémiai Kiadó
ISSN 2630-9378 (Print)
ISSN 2630-936X (Online)

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