Pressure ulcers in diabetic old patients: a case report of two volunteer, the former smoker, the latter no-smoker

Piotr Brzeziński1, Lorenzo Martini2

1University of Siena, Department of Pharmaceutical Biotechnologies, Via A. Moro 2, 53100 Siena, Italy2C.R.I.S.M.A. Inter University Centre for Researched Advanced Medical Systems

Corresponding author: Prof. Lorenzo Martini, E-mail:

Submission: 25.10.2019; Acceptance: 19.11.2019

DOI: 10.7241/ourd.2019e.36

Cite this article: Brzeziński P, Martini L. Pressure ulcers in diabetic old patients: a case report of two volunteer, the former smoker, the latter no-smoker. Our Dermatol Online. 2019;10(e):e36.1-e36.4.

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Besides a rapid description of a new approach to the cure of bedsores in elder (4th stage) using hydrogels based on zinc-alginate nanospheres and kaolin, the AA have noticed surprisingly that smokers are more prone to a more rapid wound healing with regards to no-smokers. The AA have recruited two old diabetic women suffering from pressure lesions (4th stage) and have noticed that lack of ascorbic acid and zinc are the most responsible of the syndrome, and therefore they prescribed a diet rich of ascorbic acid and zinc. By the use of hydrogel based on nanospeheres of zinc-alginate and kaolin they have treated the patients and observed an excellent remission in two weeks.

Key words: Pressure lesions; Zinc alginate; Ascorbic acid;diabetes;Wound healing


Wound healing is a dynamic biological process in which the interaction between a big variety of cell types, extracellular matrix (ECM) molecules and growth factors acts to replace damaged tissues, through a series of interdependent stages. Development of wound dressings and devices, which encourages the different steps of healing and optimizes healing conditions, is a subject of great scientific interest. In an ideal condition, along to be non-antigenic and biocompatible, a good wound dressing should create and keep a moist environment, absorb wound fluids and exudate from the surface of wound, prevent both wound desiccation and maceration and, finally, protect lesion from infections [1,2].

Special attention has been paid to hydrogels because of their interesting properties. They have a very large intrinsic content of water, thus providing a moist environment to the lesion area. Moreover, hydrogels are easy to apply and replace, transparent to allow healing follow up, permeable to oxygen and able to absorb body fluids and prevent their loss [3].

Alginate is a naturally occurring polysaccharide, composed of b-d-mannuronic acid (M) and a-l-guluronic acid (G) units, in different proportions depending on the source. Soluble sodium alginate can form hydrogels in the presence of divalent cations (as Zinc, e.g.), through ionic interactions between carboxylate groups and chelating ion. Calcium cations, which are commonly used to crosslink sodium alginate, bind preferentially to the guluronic acid units of alginate in a planar two-dimensional manner, producing the well-known “egg-box” structure. Zinc-Alginate dressings provide a moist microenvironment and enhance healing by maintaining a physiological balance in wound site and thus promoting rapid granulation and reepithelialisation [4]. Furthermore, zinc-alginate hydrogels can be easily rinsed away by saline irrigation, as a consequence the removal of dressing does not interfere with tissue healing [5].

A controlled gelation of alginate was performed for the first time using ZnCO3 and GDL. Uniform and transparent gels were obtained and investigated as potential wound dressings. Homogeneity, water content, swelling capability, water evaporation rate, stability in normal saline solution, mechanical properties and antibacterial activity were assessed as a function of zinc concentration [6,7]. Gelation rate increased at increasing zinc content, while a decrease in water uptake and an improvement of stability were found. Release of zinc in physiological environments showed that concentration of zinc released in solution lies below the cytotoxicity level. Hydrogels showed antimicrobial activity against Escherichia coli. The hydrogel with highest zinc content was stabilized with calcium by immersion in a calcium chloride solution [8]. The resulting hydrogel preserved homogeneity and antibacterial activity. Furthermore, it showed even an improvement of stability and mechanical properties, which makes it suitable as long-lasting wound dressing.

  • Zinc alginate hydrogels were prepared via internal gelation for the first time.
  • Zinc alginates show swelling degrees higher than corresponding calcium alginates.
  • Zinc hydrogels show increasing antibacterial activity at increased Zn content.
  • Zinc alginate hydrogels stabilized by calcium preserve antibacterial activity.
  • Zinc alginates stabilized by calcium are stable for prolonged time.

Pressure ulcers, also known as bedsores, decubitus ulcers or pressure injuries, are localized areas of injury to the skin or the underlying tissue, or both pressure sores develop in four stages:

  1. The skin will look red and feel warm to the touch. It may be itchy.
  2. There may be a painful open sore or a blister, with discolored skin around it.
  3. A crater-like appearance develops, due to tissue damage below the skin’s surface.
  4. Severe damage to skin and tissue, possibly with infection. Muscles, bones, and tendons may be visible.

An infected sore takes longer to heal, and the infection can spread elsewhere in the body, affecting brain and heart.

Even with excellent medical and nursing care, bedsores can be hard to prevent, especially among vulnerable patients.

Some ways advisable to prevent bedsores are: moving the patient at least every 15 minutes for wheelchair users and at every 2 hours for people in bed; daily skin inspections; keeping the skin healthy and always dry; maintaining good nutrition, to enhance overall health and wound healing exercises, even if they must be carried out in bed, with assistance, as they improve circulation.

Anyone who stays in one place for a long time and who cannot change position without help is at risk of developing pressure sores. The ulcers can develop and progress rapidly, and they can be difficult to heal.

Sustained pressure can cut off circulation to vulnerable parts of the body. Without an adequate supply of blood, body tissues can die.

Pressure ulcers are usually caused by:

Continuous Pressure

If there is pressure on the skin on one side, and bone on the other, the skin and underlying tissue may not receive an adequate blood supply.


For some patients, especially those with thin, frail skin and poor circulation, turning and moving may damage the skin, raising the risk of bedsores.


If the skin moves one way while the underlying bone moves in the opposite direction, there is a risk of shearing. Cell walls and minute blood vessels may stretch and tear.

This can happen if a patient slides down a bed or a chair, or if the top half of the bed is raised too high.

Injured tissue can develop an infection. This can spread, leading to serious illness.

Pressure ulcers can affect patients who are unable to move because of paralysis, illness, or old age.

Patients who use a wheelchair have a higher risk of developing pressure sores on their: buttocks and tailbone; spine; shoulder blades; back of arms or legs.

Bed-bound patients are most at risk of developing bedsores on the bony parts of their body, such as the ankles, heels, shoulders, coccyx or tailbone, elbows, and the back of the head.

Pressure ulcers are more common among those who: are immobilized because of injury, illness, or sedation; have long-term spinal cord injuries.

Patients with long-term spinal cord injuries or neuropathic conditions, including have reduced sensation.

Diabetes is the most risky factor, followed by mental disease that let the patient not to feel the severity of the stage of the bedsores.

They may not feel a bedsore developing, so they continue to lie on it, making it worse, and this represents a real risk at all.

Patients who cannot move specific parts of their body unaided have a greater risk of developing pressure ulcers.

Factors that increase the risk include:

  • Older age as skin gets thinner and more vulnerable with age
  • Reduced pain perception, due, for example, to a spinal cord or other injury, as they may not notice the sore
  • Poor blood circulation, due to diabetes, vascular diseases, smoking, and compression
  • Poor diet, especially with a lack of protein, vitamin C, and zinc
  • Reduced mental awareness, due to a disease, injury, or medication, can reduce the patient’s ability to take preventive action
  • Incontinence of urine or feces can cause areas of permanently moist skin, increasing the risk of skin breakdown and damage

Share on Pinterest Cellulitis could be a possible complication of bed sores.

Without treatment, bed sores can lead to very serious complications.

Cellulitis is a potentially life-threatening bacterial infection of the skin, from the surface to the deepest layer of skin. Cellulitis can result in septicemia, or blood poisoning, and the infection can spread to other parts of the body.

Bone and joint infections can arise if a pressure ulcer spreads to the joints or bones. This can result in damage to cartilage and tissue, and a reduction in limb and joint function.

Sepsis, in which bacteria can enter through sores, especially advanced ones, and infect the bloodstream. This can lead to shock and organ failure, a life-threatening condition.

There is a higher risk of developing an aggressive Cancer in the skin›s squamous cells if the patient has bedsores.

Anyway our attention is focused on a topical treatment of bedsores, especially of the 4th stage in elder, because of the presence of blood and our interest is based on the fact the Zin ion can penetrate in the bloodstream.


As far as the preparation of microspheres of Zinc alginate we have followed the Chan-Jin’s method, where Calcium chloride and zinc sulphate were used to obtain cross-link alginate microspheres by a simplest emulsification method.

We have recruited two diabetic women (86 y. old) presenting pressure ulcers (4th degree), even if the former (Case A) is a greater smoker and the latter (Case B) has never smoked.

Their diet is equal: few carbohydrates, an avalanche of drinks, white meat.

Mushrooms; Beans; Quinoa; Garbanzo beans; Lentils; Beef; Chicken; Lamb; Liver; Eggs; Dairy products; And when they desire a snack; Pumpkin seeds; Sunflower seeds; Cashew tree seeds; Sesame seeds; Vit.C.

All this food is rich of zinc and Vit. C that are useful to reinforce the production of collagen and promote the rigeneretion of injured tissues and helps memory so that the patient should be always aware and conscious in order to perceive the diseases of the bedsores.

We have chosen the 4th degree of the syndrome because of the presence of blood in the pressure lesion.

Their weigh is in both case 68-70 kg.

The topical combinaison was create mixing mixing: Zinc alginate; Kaolin; Calendula officinalis glyceric extract; Omega 3 (AGE).

The treatment lasted weeks and an operator was prayed to observe the progress of the cicatrization three times/day photographing the development.


In the following scheme it is possible to observe how regeneration of the injured tissue of bedsores is more rapid in the Case A (the smoker volunteer) and it is an amazing and thrilling result.

We have tried to explain this odd issue knowing that smoking narrows blood vessels. The narrowed vessels have a hard time getting oxygen, nutrients, and healing factors to the wound. This does slow the wound healing process albeit the release of oxygen and nutrients is controlled and after three days one assists to an adjustment of the intake of these important and necessary elements to repair wounds. When smoking, carbon monoxide enters in blood cells it decisively lowers the level of oxygen in the blood. Smoking slows the healing process at the beginning of the treatment as less oxygen is delivered to the wound, for, the first three days it seems bedsores cannot repair, even if after the 4th day the right dose of oxygen in the bloodstream proceeds to a rapid recovery in order to accelerate the process of wound healing.

Here follow the examples:

In Case A from 1st day till 3rd day there is no sign of repair, from 4th day till 8th day one can behold quite good cicatrization, from 9yh day till 14th day excellent evident repair.

Case B from 1st day till 8th day quite good cicatrization, from 9th day till 14th day a good repair.

Statement of Human and Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.

Statement of Informed Consent

Informed consent was obtained from all patients for being included in the study.


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Source of Support: Nil

Conflict of Interest: None declared.

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