title: Cross-linked hyaluronic acid in pressure ulcer prevention.
abstract: OBJECTIVE
  Long-term bedridden patients are at high risk of acquring pressure ulcers (PUs). In this group of patients, prevention is necessary to cut the health costs, improve quality of life and reduce the mortality. Here, we evaluated the effectiveness of a cross-linked hyaluronic acid (HA) as plastic bulking-agent filling and remodelling the deep dermis and subcutaneous space of the skin areas exposed to the risk of necrosis. Our work hypothesis has been to inflate a sub-dermal elastic cushion, filled with a natural ECM component, with the aim to induce a stronger tissue background resistant to the ulcerative process.
  
  
  METHODS
  All the patients had an increased risk of PUs, at the sacral, ileum or heel skin. Patients were being nursed accordingly to the standard orthopaedic ward management with a pressure relieveing air mattress. The standard protocol consisted in body mobilisation every 3 hours, 24 hours a day and accurate cleaning of the skin with liquid soap and water without any towel friction and without adding any cream or lotion for the skin protection. Our filling protocol enclosed: accurate disinfection of the skin to be injected with povidone-iodine solution, followed by a local anaesthesia with 28G 13 mm needle, injecting 1.5 ml of 1% xylocaine. Then slow, deep, subcutaneous injection of cross-linked HA was performed with a 18G long needle, in order to deliver a homogeneous, soft gel layer underneath and around the whitish erythematous skin edges at risk of ulceration. Patients' tolerability of the compound and adverse events were also recorded.
  
  
  RESULTS
  There were 15 patients (78-94 years old) who participated in the study. All tolerated the procedure very well and no serious side effects were declared. No skin pressure ulceration was detected in the four weeks follow-up Conclusion: We have demonstrated the safety and tolerability of a cross-linked HA subdermal injection in PUs prevention. The compound stratifies in a soft, elastic, interstitial bulk into the deep dermis, thus reducing the exogenous pressure stress: thus, the induction of a thick hydrophilic substrate supports adequate mesenchymal and blood cells traffic to immediately restore any early or impending damage to the skin.
  
  
  BACKGROUND
  The authors certify that there is no conflict of interest with any financial organisation regarding the material discussed in the manuscript.
authors.affiliation: Surgical, Medical, Dental and Morphological Sciences Departments with interest in Transplants, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy.|Network del Secondo Parere, Modena, Italy 98505.
authors.forename: P
authors.initials: P
authors.lastname: Beniamino
authors.affiliation: Surgical, Medical, Dental and Morphological Sciences Departments with interest in Transplants, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy.|Network del Secondo Parere, Modena, Italy 98505.
authors.forename: M
authors.initials: M
authors.lastname: Vadalà
authors.affiliation: Surgical, Medical, Dental and Morphological Sciences Departments with interest in Transplants, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy.|Network del Secondo Parere, Modena, Italy 98505.
authors.forename: C
authors.initials: C
authors.lastname: Laurino
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001513:Beds; D005260:Female; D006801:Humans; D006820:Hyaluronic Acid / Q000627:therapeutic use*; D008297:Male; D055805:Moving and Lifting Patients / Q000379:methods / Q000451:nursing*; D009336:Necrosis / Q000517:prevention & control*; D003668:Pressure Ulcer / Q000451:nursing / Q000517:prevention & control*; D017592:Skin Care / Q000379:methods* / Q000451:nursing; D014945:Wound Healing / Q000502:physiology*
chemical_list: D006820:Hyaluronic Acid
keywords: healing; hyaluronic acid; prevention; tolerability; ulcers