Is Treating Patients With Stage 4 Pressure Ulcers With Vitamins A and C, Zinc, and Arginine Justified?

Kunaal Bafna, MS; Tian Chen, PhD; Richard Simman, MD, FACS, FACCWS


Wounds. 2021;33(3):77-80. 

In This Article


It is estimated that up to 50% of hospitalized patients are malnourished. Malnutrition related to reduced intake of nutrients, underlying comorbidities, inflammation, and metabolic alterations related to disease states has been found to be a significant factor influencing pressure injury risk and wound healing.[3] Pressure injuries can present as intact skin or as a painful open wound commonly located on the back, sacral, coccyx, buttock, and heel areas. Although pressure injury prevention requires multidimensional complex care, it has long been understood hospitalized patients benefit from interventions that focus on improving oral nutrition to enhance wound healing and reduce pressure injury risk. In 2019, Citty et al[3] suggested that although patients at risk for pressure injuries should obtain adequate vitamins and minerals, evidence for recommendations on vitamin supplementation is limited. Despite the fact that vitamin C supplementation in wound healing is believed to impact collagen formation, immunomodulation, and antioxidant function, the current study found that the OR for vitamin C deficiency vs albumin deficiency was only 0.62.[4] This suggests that the odds of having albumin deficiency (a marker of nutritional deficiency) is only 0.62 times greater than the odds for patients without vitamin C deficiency. In other words, the odds of patients with vitamin C deficiency also having albumin deficiency is 38% lower than the odds for patients without vitamin C deficiency. As such, the question becomes whether nutritionally depleted patients with healing wounds should receive vitamin C supplementation without first checking vitamin C levels. Vitamin C toxicity from oversupplementation may manifest as diarrhea, nausea, vomiting, heartburn, abdominal cramps, headache, and insomnia.

Similarly, vitamin A is believed to be helpful in wound healing, especially in patients who have a documented deficiency or who have inadequate intake of foods rich in vitamin A.[5] This study, however, found that vitamin A deficiency is less likely to be associated with albumin deficiency, as the odds of patients with vitamin A deficiency also having albumin deficiency is 73% lower than the odds for patients without vitamin A deficiency. Therefore, it seems likely that many hospitalized patients with pressure wounds may be overtreated with vitamin A. Oversupplementation with vitamin A may yield toxic symptoms, including vision changes, bone pain, skin changes, liver damage, and increased intracerebral pressure.

On the contrary, the current study found the odds of patients with zinc deficiency also having albumin deficiency are 25.67 times greater than those for patients without zinc deficiency. The odds of having albumin deficiency for patients with zinc deficiency is 240.67% higher than those without zinc deficiency. Although immediate zinc supplementation seems appropriate for patients with healing pressure wounds due to the strong correlation between nutritional status and zinc deficiency, it may still be appropriate to obtain zinc levels first as zinc toxicity is associated with impaired neutrophil and lymphocyte function. It is also associated with gastrointestinal tract irritation, nausea, vomiting, and diarrhea.[6] Similarly, this study showed that patients with arginine deficiency were more likely to have albumin deficiency than patients without arginine deficiency. However, it should also be noted that arginine supplementation has been associated with nausea, vomiting, and blood abnormalities that should be considered before treating patients with complex pressure wounds.