Key messages
The uncertainty of the evidence we identified means that we do not know whether dressings or topical agents (including various creams, lotions, and oils) make any difference to the number of pressure ulcers that develop in at-risk people.
What is a pressure ulcer?
Pressure ulcers, also known as pressure injuries, bed sores, or pressure sores, happen when the skin or tissue beneath it gets injured due to prolonged pressure on bony areas of the body. They are common amongst elderly and less mobile individuals. They can be challenging and costly to treat.
How can pressure ulcers be prevented?
Prevention options for pressure ulcers include: moving and repositioning while lying or seated; using the right type of surface to lie and sit on; and having a good intake of nutritious food and fluids. More recently, various dressings and creams are also used to prevent the development of pressure ulcers.
What did we want to find out?
We wanted to know if specific dressings or creams could effectively prevent pressure ulcers in at-risk individuals. Additionally, we aimed to assess factors such as pain, quality of life, and treatment costs when these dressings and creams were used.
What did we do?
We updated the review from 2018, and it now includes 51 studies. The studies included 13,303 at-risk people. The studies tested products such as fatty acids and creams, and dressings made from different materials.
What did we find?
We cannot be sure if dressings or creams made a difference in preventing pressure ulcers, or in preventing unwanted effects, due to inadequate research methods employed in the studies we examined. As a result, our confidence in these results remains limited.
Main results
We conducted a total of 20 different comparisons related to dressings and creams. This means we looked at how different types of dressings and creams performed in various situations to prevent pressure ulcers. There is an important amount of uncertainty in the evidence within the studies we included. Therefore, we do not know whether the dressings or creams included in this review have an impact on preventing new pressure ulcers or in preventing unwanted effects from developing. There was limited evidence both about the cost of treatment and whether people in the studies experienced any pain. Only one study reported on participants' quality of life.
What are the limitations of the evidence?
We are not confident in the evidence for three main reasons. First, it is possible that people in the studies were aware of which treatment they were getting. Second, results were very inconsistent across the different studies. Finally, some studies were very small.
How current is this evidence?
We conducted our search for studies up to November 2022, ensuring that this review includes the most recent research available.
The included studies tested a wide variety of dressings and topical agents. The evidence for all interventions is uncertain or very uncertain; thus, it is unclear whether any of the dressings or topical agents studied make any difference to pressure ulcer development. Future studies should engage with stakeholders to determine priority interventions.
Pressure ulcers occur when people cannot reposition themselves to relieve pressure over bony prominences. They are difficult to heal, costly, and reduce quality of life. Dressings and topical agents (lotions, creams, and oils) for pressure ulcer prevention are widely used. However, their effectiveness is unclear. This is the third update of this review.
To evaluate the effects of dressings and topical agents on pressure ulcer prevention, in people of any age without existing pressure ulcers, but at risk of developing one, in any healthcare setting.
We used the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, two other databases, and two trial registers, together with reference checking, citation searching, and contact with study authors to identify the studies that are included in the review. The latest search date was November 2022. We imposed no restrictions on language, publication date, or setting.
We included randomised controlled trials that enroled people at risk of developing a pressure ulcer.
We used standard Cochrane methodological procedures.
In this update, we added 33 new studies, resulting in a total of 51 trials (13,303 participants). Of these, 31 studies involved dressings, 16 topical agents, and four included both dressings and topical agents. All trials reported the primary outcome of pressure ulcer incidence.
Dressings
Pressure ulcer incidence
We made a total of 13 comparisons with 9027 participants. We present seven prioritised comparisons in the summary of findings (SoF) tables, as follows: silicone foam dressing versus no dressing (18 trials, 5903 participants; risk ratio (RR) 0.50, 95% confidence interval (CI) 0.33 to 0.77); foam dressing versus film dressing (3 trials, 569 participants; RR 0.72, 95% CI 0.20 to 2.67); hydrocellular foam dressing versus hydrocolloid dressing (1 trial, 80 participants; RR not estimable); silicone foam dressing type 1 versus silicone foam dressing type 2 (2 trials, 376 participants; RR 0.80, 95% CI 0.56 to 1.15); foam dressing versus fatty acid (2 trials, 300 participants; RR 1.67, 95% CI 0.49 to 5.72); polyurethane film versus hydrocolloid dressing (1 trial, 160 participants; RR 0.58, 95% CI 0.24 to 1.41); and hydrocolloid dressing versus no dressing (2 trials, 230 participants; RR 0.60, 95% CI 0.46 to 0.78). All low or very low-certainty evidence. The evidence is very uncertain about the effect of dressings on pressure ulcer development.
Pressure ulcer stage
Three comparisons reported pressure ulcer (PU) stage. Silicone foam dressing versus no dressing: PU stage 1 (8 trials, 1823 participants; RR 0.32, 95% CI 0.13 to 0.79); PU stage 2 (10 trials, 2873 participants; RR 0.47, 95% CI 0.30 to 0.73); PU stage 3 (3 trials, 718 participants; RR 0.45, 95% CI 0.06 to 3.21); PU stage 4 (2 trials, 610 participants; RR 0.21, 95% CI 0.02 to 1.77); unstageable PU (1 trial, 366 participants; RR 0.20, 95% CI 0.01 to 4.09); deep tissue injury (3 trials, 840 participants; RR 0.32, 95% CI 0.09 to 1.08). Foam dressing versus film dressing: PU stage 1 (1 trial, 270 participants; RR 0.56, 95% CI 0.39 to 0.80); PU stage 2 (1 trial, 270 participants; RR 1.00, 95% CI 0.06 to 15.82); deep tissue injury (1 trial, 270 participants; RR 0.67, 95% CI 0.11 to 3.93). Hydrocolloid dressing versus no dressing: PU stage 1 (1 trial, 108 participants; RR 0.54, 95% CI 0.31 to 0.94); PU stage 2 (1 trial, 108 participants; RR 0.86, 95% CI 0.28 to 2.66). All low or very low-certainty evidence. The evidence is very uncertain about the effect of dressings on different stages of pressure ulcer development.
Adverse events
One comparison reported adverse events: silicone foam dressing versus no dressing (3 trials, 2317 participants; RR not estimable; very low-certainty evidence). Silicone foam dressings may have little to no effect on the incidence of adverse events, but the evidence is very uncertain.
Topical agents
Pressure ulcer incidence
We evaluated seven comparisons with 4276 participants. We present five prioritised comparisons in the SoF tables as follows: fatty acid versus placebo (6 trials, 2201 participants; RR 0.86, 95% CI 0.54 to 1.36); fatty acid versus usual care (7 trials, 1058 participants; RR 0.64, 95% CI 0.46 to 0.84); cream versus fatty acid (1 trial, 120 participants; RR 3.00, 95% CI 0.32 to 28.03); cream versus placebo (3 trials, 513 participants; RR 1.18, 95% CI 0.59 to 2.36); and cream versus usual care (1 trial, 47 participants; RR 1.60, 95% CI 0.84 to 3.04). All very low-certainty evidence. It is very uncertain whether they make any difference to PU development.
Pressure ulcer stage
Two comparisons reported PU stage. Fatty acid versus usual care: PU stage 1 (2 trials, 180 participants; RR 1.00, 95% CI 0.49 to 2.03); PU stage 2 (2 trials, 180 participants; RR 0.19, 95% CI 0.07 to 0.53). Cream versus placebo: PU stage 3 (1 trial, 258 participants; RR 1.25, 95% CI 0.34 to 4.55); PU stage 4 (1 trial, 258 participants; RR 0.33, 95% CI 0.01 to 8.11). Both low or very low-certainty evidence. It is uncertain whether they make any difference to the stage of PU development.
Adverse events
One comparison reported adverse events: fatty acid versus placebo (3 trials, 967 participants; RR 4.38, 95% CI 0.50 to 38.30; very low-certainty evidence). Fatty acid may have little to no effect on the incidence of adverse events compared to placebo, but the evidence is very uncertain.
Risk of bias and imprecision were the main reasons for downgrading the certainty of the evidence.