*2.2.2. Treatment*

Offloading is the cornerstone of treatment of pressure ulcers. Ultrasound (low-frequency and nonthermal) may have a therapeutic role in intact skin ulcers. If the ulcer is superficial, foam dressing and collagenase may be used. For deep pressure ulcers, usually debridement and surgical intervention is needed. Osteomyelitis beneath the ulcer is so important and should be considered in treatment of deep ulcers [23]. In SCI patients, flap surgery may be needed to cover the place of debridement [25]. In Schryvers's study on large number of SCI patients with pressure ulcers during 20 years, a large number of patients needed surgical intervention. Pelvic area ulcers were the most common (468 of 598 pressure ulcers), of which 431 (92%) were treated surgically. Fasciocutaneous or cutaneous flaps, muscle or musculocutaneous flaps and primary closures were the most common surgical intervention. During the ulcer management, some bone intervention is unavoidable [29]. Medical honey has a substantial efficacy on wound management and control of infection of pressure ulcer, as shown by low bacterial growth, decreased wound size, and improved healing stage [30].

Electric stimulation therapy (EST) accelerates pressure ulcer healing in SCI patients. Pressure ulcer healing is determined by decrease in wound size and improvement in wound appearance after 3 months of treatment with EST [31]. Use of ultraviolet light C (light wavelength 200–290 nm) may be effective in treatment. It can be because of its potency in killing antibiotic-resistant microorganisms. *Staphylococcus aureus*, methicillin-resistant *Staphylococcus aureus* (MRSA) and *Pseudomonas aeruginosa* that may be resident on superficial layer of wound may be killed by ultraviolet light C [32]. Maggot therapy may also be used a subsidiary way to treat wound ulcer. Live blowfly larvae in wound dressings accelerate wound healing by increasing debridement. They can debride necrotic tissue within 1 week that is so rapid in nonsurgical wound management. It is safe, simple, and inexpensive, and it seems that it has no complications, so it can be used for treatment of pressure ulcers in SCI patients [33].

### *2.2.3. Prevention*

Pressure ulcers certainly have a great influence on daily activity and life of SCI patients [34]. The best position and the turning frequency are not clear, but avoiding the 90° lateral position is recommended. This position will bring about high pressure over the trochanters with the risk of pressure ulcer development. The risk of developing pressure ulcer is highly individualized and the SCI patient is at a significant risk. Prevention strategies in seating position and in bed are very important in this group to prevent pressure ulcer, and so, pressure relief maneuvers can be important [35]. Pressure relief, position changes, and regular and frequent observation of skin, especially on the pressure areas, that is, over the bony prominences can prevent pressure ulcer development [2]. Pressure ulcers can also be prevented by improvement of neurologic functions and reducing the time of hospitalization and rehabilitation stay [36]. Pressure ulcer prevention is strongly associated with lifestyle modification [35]. Frequent change of position and use of pressure-relieving devices have important roles in reducing the pressure ulcer development. Some risk factors other than pressure may be important in developing ulcer. In SCI patients who do not have vasomotor control below the level of the lesion, hypoxemia will develop, and it can be an important risk factor. So, pressure ulcers may be prevented not only by reducing external pressure by pressure relief, but also by increasing the patient's resistance to pressure, by increasing tissue oxygenation [37]. One of the important risk factors that may increase skin and soft tissue infections is resistant bacterial colonization. Some activities such as hand hygiene, contact precautions, and cultural changes are associated with significant declines in bacterial infection, especially MRSA colonization and infection [28].
