Clinical question
Should a low friction fabric product versus no low friction fabric product be used to prevent PI occurrence in individuals at risk?
Context
Population:
Intervention:
Comparison:
Main Outcomes:
Setting:
Conflicts on Interest:
Background:
People at risk of pressure injuries
Leave-on topical product
Usual care with no leave-on topical product
Any clinical setting
Pressure injury (PI) occurrence
None
Descriptions of leave-on topical products are varied and may not accurately characterize the product. For example, products described as hyperoxygenated fatty acid based preparations consist of esters from glycerol and fatty acids; although present, the fatty acid is not a defining product characteristic. The descriptor ‘cream’ is an unclear characterization on products, because the preparations can be mixtures of many ingredients. As a pragmatic approach, all topical leave-on products (different oils, ‘creams’, emulsions etc) were combined.
Evidence to Decision Framework
(Click on the individual judgements for more information)
Summary of Judgements
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Yes
Moderate
Small
Very low
No important uncertainty or variability
Probably favors the intervention
Varies
Very low
No included studies
Probably no impact
Probably yes
Probably yes
1. Problem:
Is the problem (pressure injuries) a priority?
JUDGEMENT
No
Probably No
Probably Yes
Yes
Varies
Don’t Know
RESEARCH EVIDENCE
The problem of preventing pressure injuries is a significant priority to healthcare in most clinical settings. In a stakeholder survey conducted by the Guideline Governance Group in 2021, the target audiences for the guideline, including individuals with or at risk of PIs, their informal carers and health professionals, all identified that receiving clinical guidance on local interventions to prevent promote skin integrity (e.g. interventions that manage moisture or friction) as being the highest priority (median ranking 5/5, where 5 is the highest priority).
In an earlier survey conducted by the previous Guideline Governance Group in 2018(Haesler, Pittman et al. 2022), 90.10% (304/337) of individuals with or at risk of PIs and 87.52% (603/689) of informal carers rated receiving information on skin care as important or very important.
2. Desirable Effects:
How substantial are the desirable anticipated effects?
JUDGEMENT
Trivial
Small
Moderate
Large
Varies
Don’t Know
RESEARCH EVIDENCE
| Outcome | Leave on topical product |
No leave on topical product (usual care) |
Difference | Relative effect |
|---|---|---|---|---|
| PI occurrence | 116/695 (16.7%) | 152/652 (23.3%) | 112 fewer per 1,000 (from 138 fewer to 79 fewer) |
RR 0.52 (0.41-0.66) |
Outcome 1: PI Occurrence
The meta-analysis included nine randomized trial (RCTs) (Houwing, van der Zwet et al. 2008, Chiew, Liu et al. 2010, Madadi, Zeighami et al. 2015, Aloweni, Lim et al. 2017, Chang, Tay et al. 2017, Babamohamadi, Ansari et al. 2019, Borzou, Amiri et al. 2020, Sönmez and Yapucu Güneş 2020, Fallahi, Soroush et al. 2022) that compared a leave topical product to no leave on topical product (usual care) for preventing PIs. The studies explored a range of products including:
A product consisting of hyperoxygenated fatty acids (HOFAs, sunflower seed oil), aloe vera and centella asiática extracts (Aloweni, Lim et al. 2017)
Medical-grade sweet almond oil(Borzou, Amiri et al. 2020)
A product consisting of HOFAs (linoleic acid 60%, linolenic acid, tocopherol, and vitamin E) and aniseed perfume(Chiew, Liu et al. 2010)
Olive oil preparations(Madadi, Zeighami et al. 2015, Sönmez and Yapucu Güneş 2020, Fallahi, Soroush et al. 2022)
Aloe vera gel(Fallahi, Soroush et al. 2022)
Aloe vera gel combined with olive oil(Fallahi, Soroush et al. 2022)
A product containing hexyl nicotinate, zinc stearate, isopropyl myristate, dimethicone 350, cetrimide and glycol(Houwing, van der Zwet et al. 2008).
The products were applied to anatomical areas at risk of PIs on different regimens ranging from every two hours to 1-3 times daily. The products were tested for 7-14 days (or unstated durations). Control groups all received usual care that did not include any topical product. The meta-analysis showed that using topical leave-on product was associated with a significantly lower rate of PIs (16.7% versus 23.3%, RR 0.52, 95% CI 0.41 to 0.66, p<0.00001), translating to a difference of 112 fewer per 1,000 experiencing a PI when a fatty acid topical product is used. However, it is very uncertain if the result represents a true effect; the true effect lies between 138 fewer people and 79 fewer people.
3. Undesirable Effects:
How substantial are the undesirable anticipated effects?
JUDGEMENT
Trivial
Small
Moderate
Large
Varies
Don’t Know
RESEARCH EVIDENCE
| Outcome | Fatty acid topical product |
No leave on topical product (usual care) |
Difference | Relative effect |
|---|---|---|---|---|
| Adverse events (rash and itching) |
3/481 (0.6%) | 0/486 (0%) | 1 more per 1,000 (from 0 fewer to 8 more) |
RR 4.38 (0.50-38.30) |
In a meta-analysis(Patton, Moore et al. 2024) of studies exploring different leave-on topical products to placebo topical products for preventing PIs, adverse events occurred at a higher rate with a leave-on topical product, but the difference was not statistically significant (0.6% vs 0%, RR 4.38, 95% CI 0.50-38.30, p=0.18). There was very low certainty that this represented a true effect. The adverse events (e.g. rash and itching) resolved with cessation of treatment.(Díaz-Valenzuela, García-Fernández et al. 2019) The studies reported in a second systematic review also experienced very low rates of adverse events.(Lin, Yang et al. 2025)
There is large body of evidence that is not specific to PI prevention suggesting that vegetable oils (including olive oils) should not be used in people with skin barrier impairments, because of disruption to the stratum corneum (e.g. from free fatty acids) can lead to skin irritation and other adverse events.(Moore, Wagner et al. 2020)
4. Overall certainty of evidence: What is the overall certainty of the evidence of effects?
JUDGEMENT
Very low
Low
Moderate
High
No included studies
RESEARCH EVIDENCE
| Outcome | Relative Importance | Certainty of Evidence |
|---|---|---|
| PI occurrence | CRITICAL | VERY LOW |
In a Delphi survey (Lechner, Coleman et al. 2022) that developed a core outcomes et for PI prevention trials, the outcome of PI occurrence was rated as being of critical importance (score of 7-9).
Outcome 1: PI occurrence
The certainty of evidence is very low. The evidence was downgraded twice for risk of bias due to high risk of bias across all domains. The evidence was also downgraded for inconsistency because of variation in point estimates.
5. Values:
Is there important uncertainty about or variability in how much people value the main outcomes?
JUDGEMENT
Important uncertainty or variability
Possibly important uncertainty or variability
Probably no important uncertainty or variability
No important uncertainty or variability
RESEARCH EVIDENCE
In a Delphi survey (Lechner, Coleman et al. 2022) that developed a core outcomes et for PI prevention trials, the outcome of PI occurrence was rated as being of critical important (score of 7-9) by all types of stakeholders (health professionals, people with or at risk of a PI and their informal carers, industry representatives and researchers). Greater than 90% of the 158 participants rated this outcome measure as critically important (Lechner, Coleman et al. 2022).
6. Balance of Effects:
Does the balance between desirable and undesirable effects favour the intervention or the comparison?
JUDGEMENT
Favors the comparison
Probably favors the comparison
Does not favor either the intervention or the comparison
Probably favors the intervention
Favors the intervention
Varies
Don’t know
RESEARCH EVIDENCE
Based on moderate desirable effects and small undesirable effects the balance probably favors the intervention.
7. Resources Required:
How large are resource requirements (costs) of the intervention?
JUDGEMENT
Large costs
Moderate costs
Negligible costs and savings
Moderate savings
Large savings
Varies
Don’t know
RESEARCH EVIDENCE
Cost of using a leave-on topical product is highly variable depending on the product, how often it is applied and the geographic location. Most studies do not report costs, but indicate that using a leave-on topical is not expensive. The following indicative costs are reported in the literature:
Cost using generic protective barrier product applied twice daily cost an average of $0.42/day for the product, with an additional $3.44/day cost for nursing time (US dollars in 2009).(Shannon, Coombs et al. 2009)
A leave-on product designed to nourish skin cost $0.36/day, with an additional $3.44/day cost for nursing time (US dollars in 2009).(Shannon, Coombs et al. 2009)
Cost of treatment using sweet almond oil at approximately $6 per person (currency unclear, Iran)(Borzou, Amiri et al. 2020)
Cost for 16 weeks treatment with a hyperoxygenated fatty acid product for as approximately €50 per person(Spain in 2017) (Lupiañez-Pérez, Morilla-Herrera et al. 2017)
Cost for 16 weeks treatment with olive oil product as approximately €21 per person(Spain in 2017)(Lupiañez-Pérez, Morilla-Herrera et al. 2017)
Cost of using a hyperoxygenated fatty acid product as approximately €7.74 (Spain in 2005)(Torra i Bou, Segovia Gómez et al. 2005)
8. Certainty of evidence of required resources:
What is the certainty of evidence of resource requirements (costs) of the intervention?
JUDGEMENT
Very low
Low
Moderate
High
No included studies
RESEARCH EVIDENCE
The GGG considered the evidence on cost effectiveness to be of low certainty.
9. Cost Effectiveness: Does the cost-effectiveness of the intervention favour the intervention or the comparison?
JUDGEMENT
Favors the comparison
Probably favors the comparison
Does not favor either the intervention or the comparison
Probably favors the intervention
Varies
No included studies
RESEARCH EVIDENCE
There are no cost effectiveness analyses.
10. Inequity:
What would be the impact of recommending the intervention on health inequity?
JUDGEMENT
Reduced
Probably reduced
Probably no impact
Probably increased
Increased
Varies
Don’t know
RESEARCH EVIDENCE
Many studies on leave-on topical products are conducted in geographic areas with low resource communities.
11. Acceptability:
Is the intervention acceptable to key stakeholders?
JUDGEMENT
No
Probably no
Probably yes
Yes
Varies
Don’t know
RESEARCH EVIDENCE
There is no evidence, but a leave-on product is likely to be acceptable to most people if they do not experience adverse effects.
12. Feasibility:
Is the intervention feasible to implement?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
In one study, the application of the product was reported to take less than one minute/day.(Borzou, Amiri et al. 2020)
References
Aloweni, F., M. L. Lim, T. L. Chua, S. B. Tan, S. B. Lian and S. Y. Ang (2017). "A randomised controlled trial to evaluate the incremental effectiveness of a prophylactic dressing and fatty acids oil in the prevention of pressure injuries." Wound Practice & Research 25(1): 24-34.
Babamohamadi, H., Z. Ansari, M. Nobahar and M. l. Mirmohammadkhani (2019). "The effects of peppermint gel on prevention of pressure injury in hospitalized patients with head trauma in neurosurgical ICU: A double-blind randomized controlled trial." Complementary Therapies in Medicine 47: 102223.
Borzou, S. R., S. Amiri, A. Azizi, L. Tapak, F. Rahimi Bashar and S. Moradkhani (2020). "Topical almond oil for prevention of pressure injuries: A single-blinded comparison study." J Wound Ostomy Cont Nurs 47(4): 336-342.
Chang, Y. Y., A. C. Tay, M. L. Lim, S. B. Lian and F. A. B. Aloweni (2017). "Preliminary findings of a randomized controlled trial to evaluate the effectiveness of prophylactic dressing and fatty acids oil in the prevention of pressure injuries." J Wound Care 26(SUPPL): 424.
Chiew, S. F., H. J. Liu, H. T. Toh and R. Dari (2010). "Does sanyrene solution reduce incidence of pressure ulcer among the elderly with hip fracture? A randomised controlled trial." Proceedings of Singapore Healthcare 19(2 (Suppl)): S154.
Díaz-Valenzuela, A., F. P. García-Fernández, P. Carmona Fernández, M. J. Valle Cañete and P. L. Pancorbo-Hidalgo (2019). "Effectiveness and safety of olive oil preparation for topical use in pressure ulcer prevention: Multicentre, controlled, randomised, and double-blinded clinical trial." Int Wound J 16(6): 1314-1322.
Fallahi, M., A. Soroush, N. Sadeghi, F. Mansouri, T. Mobaderi and S. Mahdavikian (2022). "Comparative Evaluation of the Effect of Aloe Vera Gel, Olive Oil, and Compound Aloe Vera Gel-Olive Oil on Prevention of Pressure Ulcer: A Randomized Controlled Trial." Adv Biomed Res 11: 6.
Haesler, E., J. Pittman, J. Cuddigan, S. Law, Y. Y. Chang, K. Balzer, D. Berlowitz, K. Carville, J. Kottner, M. Litchford, Z. Moore, P. Mitchell and D. Sigaudo-Roussel (2022). "An exploration of the perspectives of individuals and their caregivers on pressure ulcer/injury prevention and management to inform the development of a clinical guideline." J Tissue Viability 31(1): 1-10.
Houwing, R., W. van der Zwet, S. van Asbeck, R. Halfens and J. W. Arends (2008). "An unexpected detrimental effect on the incidence of heel pressure ulcers after local 5% DMSO cream application: A randomized, double-blind study in patients at risk for pressure ulcers." Wounds 20(4): 84-88.
Lechner, A., S. Coleman, K. Balzer, J. J. Kirkham, D. Muir, J. Nixon and J. Kottner (2022). "Core outcomes for pressure ulcer prevention trials: results of an international consensus study." Br J Dermatol 187(5): 743-752.
Lin, H.-C., L.-Y. Yang, Y.-C. Su and B.-O. Lee (2025). "The effectiveness of plant-based topical agents for the prevention of pressure injuries: Systematic review of randomised controlled trials." International Journal of Nursing Studies 167: 105069.
Lupiañez-Pérez, I., J. C. Morilla-Herrera, S. Kaknani-Uttumchandani, Y. Lupiañez-Perez, M. Cuevas-Fernandez-Gallego, F. Martin-Santos, J. Caro-Bautista and J. M. Morales-Asencio (2017). "A cost minimization analysis of olive oil vs. hyperoxygenated fatty acid treatment for the prevention of pressure ulcers in primary healthcare: A randomized controlled trial." Wound Repair and Regeneration 25(5): 846-851.
Madadi, Z. A., R. Zeighami, J. Azimian and A. Javadi (2015). "The effect of topical olive oil on prevention of bedsore in intensive care units patients." Int J Res Med Sci 3(9): 2342-2347.
Moore, E. M., C. Wagner and S. Komarnytsky (2020). "The enigma of bioactivity and toxicity of botanical oils for skin care." Frontiers in Pharmacology(11): 785.
Patton, D., Z. E. H. Moore, F. Boland, W. P. Chaboyer, S. L. Latimer, R. M. Walker and P. Avsar (2024). "Dressings and topical agents for preventing pressure ulcers." Cochrane Database of Systematic Reviews 12: Art. No. CD009362.
Shannon, R. J., M. Coombs and D. Chakravarthy (2009). "Reducing hospital-acquired pressure ulcers with a silicone-based dermal nourishing emollient-associated skincare regimen." Advances in Skin & Wound Care 22(10): 461-467.
Sönmez, M. and Ü. Yapucu Güneş (2020). "Preventive effect of extra virgin olive oil on pressure injury development: A randomized controlled trial in Turkey." Complement Ther Clin Pract 40: N.PAG-N.PAG.
Torra i Bou, J. E., T. Segovia Gómez, J. Verdú Soriano, A. Nolasco Bonmatí, J. Rueda López and M. Arboix i Perejamo (2005). "The effectiveness of a hyperoxygenated fatty acid compound in preventing pressure ulcers." J Wound Care 14(3): 117-121.
