Bedsores (Pressure Ulcers): Causes, Symptoms, Diagnosis, Treatment & Prevention

What is Bedsores?

Bedsores, also called pressure ulcers, pressure injuries, or decubitus ulcers, are localized damage to the skin and underlying tissue that occurs when sustained pressure—or a combination of pressure, shear, and friction—impedes blood flow to an area. When tissues do not receive adequate oxygen and nutrients, cells begin to die, leading to an open wound that can range from a reddened patch of skin to a deep crater exposing muscle or bone.

They most commonly develop over bony prominences such as the heels, sacrum (lower back), hips, elbows, and the back of the head. While anyone who spends long periods in the same position can develop a bedsore, they are especially prevalent in people who are immobile due to spinal cord injury, stroke, advanced age, or chronic illness.

Source: Mayo Clinic; National Pressure Injury Advisory Panel (NPIAP).

Common Causes

Bedsores are rarely the result of a single factor. The following conditions or situations increase the risk of developing a pressure ulcer:

• Immobility: Prolonged lying or sitting (e.g., bedridden patients, wheelchair users).
• Reduced sensation: Neuropathy from diabetes, spinal cord injury, or multiple sclerosis limits the ability to feel discomfort.
• Advanced age: Skin becomes thinner, less elastic, and has reduced blood flow.
• Chronic illness: Cancer, heart failure, respiratory disease, and renal failure can impair circulation and healing.
• Malnutrition or dehydration: Inadequate protein, calories, vitamins (A, C, zinc) weaken skin integrity.
• Incontinence: Moisture from urine or feces macerates skin, making it more vulnerable to pressure.
• Obesity: Excess weight increases pressure on bony areas and can limit repositioning.
• Medications: Steroids, anticoagulants, and drugs that cause sedation or vasoconstriction affect tissue perfusion.
• Smoking: Nicotine constricts blood vessels, reducing oxygen delivery to skin.
• Shear and friction: Sliding down in bed or a poorly fitted wheelchair can stretch and damage skin.

Associated Symptoms

Because bedsores develop gradually, early signs can be subtle. Common accompanying features include:

• Persistent redness or discoloration: Skin may turn pink, red, purple, or a darker hue.
• Temperature change: The affected area may feel warmer (inflammation) or cooler (poor perfusion).
• Pain or tenderness: Especially in stage I–III ulcers; pain may be absent in individuals with reduced sensation.
• Swelling or edema: Soft tissue around the ulcer can become inflamed.
• Skin breakdown: Open wound, blister, or ulcer that may produce drainage.
• Foul odor: Indicates bacterial colonization or infection.
• Fever or chills: Systemic signs that suggest infection spreading.
• Undermining: The wound edges may appear intact while tissue beneath erodes.

When to See a Doctor

Prompt medical attention can prevent a bedsore from progressing to a deep, infected ulcer. Contact a healthcare professional if you notice:

• Red or purple skin that does not blanch (turn white) when pressed.
• Open wounds larger than a dime, especially if they produce pus or a foul smell.
• Increasing pain, swelling, or warmth around a sore.
• Fever (≥100.4°F / 38°C), chills, or unexplained fatigue.
• Signs of infection such as red streaks spreading from the ulcer.
• Any ulcer that is not improving after a few days of proper at‑home care.
• Persistent skin breakdown in a person with diabetes, spinal cord injury, or the elderly.

Early evaluation is especially important for individuals with compromised immunity or who are unable to report symptoms themselves.

Diagnosis

Healthcare providers use a combination of visual assessment, staging systems, and, when necessary, advanced testing to evaluate a pressure ulcer.

Clinical Staging (NPIAP)

1. Stage I: Intact skin with non‑blanchable redness; may feel warm or painful.
2. Stage II: Partial‑thickness loss of dermis presenting as a shallow open ulcer with a pink/red wound bed.
3. Stage III: Full‑thickness tissue loss; fat may be visible, but bone, tendon, or muscle are not exposed.
4. Stage IV: Full‑thickness tissue loss with exposed bone, tendon, or muscle; often accompanied by extensive necrosis.
5. Unstageable: Full‑thickness loss covered by slough or eschar, obscuring the depth.
6. Deep Tissue Injury (DTI): Persistent non‑blanchable deep red, purple, or maroon discoloration; may evolve into a ulcer.

Additional Assessment Tools

• Wound measurement: Length, width, depth, and drainage amount are recorded.
• Photographic documentation: For tracking healing over time.
• Laboratory tests: CBC, CRP, blood glucose, albumin, and wound cultures if infection is suspected.
• Imaging: X‑ray, MRI, or CT may be ordered if underlying osteomyelitis (bone infection) is a concern.
• Risk assessment scales: Braden Scale or Norton Scale help identify patients at high risk.

Treatment Options

Treatment aims to relieve pressure, promote healing, and manage infection. The plan is individualized based on ulcer stage, location, and the patient’s overall health.

1. Pressure Relief

• Repositioning: Turn or shift weight every 2 hours for bedridden patients; every 15 minutes for wheelchair users.
• Support surfaces: Specialized mattresses (alternating pressure, low‑air loss) and cushions.
• Off‑loading devices: Heel protectors, donut cushions, and elbow pads.

2. Wound Care

• Cleaning: Gentle irrigation with saline or prescribed wound cleanser.
• Debridement: Removal of necrotic tissue (sharp, enzymatic, mechanical, autolytic, or surgical) to stimulate healing.
• Dressing selection:
  • Hydrocolloid or foam for stage I–II.
  • Alginate, hydrogel, or antimicrobial dressings (silver‑impregnated) for exudative or infected wounds.
  • Negative pressure wound therapy (NPWT) for complex, deep ulcers.
• Moisture balance: Keep the wound moist but not overly saturated to promote granulation.

3. Infection Management

• Topical antimicrobials (e.g., mupirocin, silver dressings) for mild colonization.
• Systemic antibiotics guided by culture results for cellulitis, osteomyelitis, or systemic infection.
• Regular surveillance for signs of spreading infection.

4. Nutritional Support

• Protein 1.2–1.5 g/kg/day.
• Calories 25–30 kcal/kg/day.
• Micronutrients: Vitamin C (500 mg/day), zinc (30 mg/day), and vitamin A (if deficient).
• Hydration: Minimum 2 L of fluid daily unless contraindicated.

5. Pain Management

• Topical anesthetics (lidocaine), oral analgesics (acetaminophen, NSAIDs), or stronger agents for severe pain.
• Address underlying neuropathic pain with gabapentin or pregabalin if needed.

6. Surgical Intervention

• Flap reconstruction or skin grafts for chronic, non‑healing stage III/IV ulcers.
• Debridement of infected bone (sequestrectomy) in osteomyelitis.

7. Home Care Strategies

• Educate caregivers on repositioning schedules and proper technique.
• Maintain a clean, dry environment; use barrier creams for incontinence.
• Monitor wound measurements and photograph regularly.
• Coordinate with a home health nurse or wound‑care specialist when appropriate.

Prevention Tips

Preventing pressure ulcers is often more effective than treating them after they appear. Implement these evidence‑based strategies:

• Risk assessment on admission: Use the Braden Scale to identify high‑risk patients.
• Regular repositioning: Every 2 hours for bed‑bound, every 15 minutes for wheelchair users.
• Pressure‑relieving surfaces: Invest in alternating‑pressure mattresses and cushions.
• Skin inspection: Daily visual checks of bony prominences; use mirrors or ask a caregiver to assist.
• Maintain skin hygiene: Gentle cleansing, thorough drying, and barrier ointments for moisture‑associated skin damage.
• Nutrition & hydration: Adequate protein, calories, and fluids; consider supplements if dietary intake is insufficient.
• Manage incontinence: Prompt cleaning, use of absorbent pads, and skin protectants.
• Smoking cessation: Improves peripheral circulation.
• Educate patients & families: Teach signs of early pressure injury and proper positioning techniques.
• Physical activity: When possible, encourage range‑of‑motion exercises to improve circulation.

Emergency Warning Signs

If any of the following occur, seek emergency medical care immediately (call 911 or go to the nearest emergency department):

• Rapidly spreading redness or swelling beyond the original ulcer.
• Severe, uncontrollable pain despite analgesics.
• Fever ≥ 101°F (38.3°C) with chills, indicating possible systemic infection.
• Black or foul‑smelling discharge suggestive of necrotizing infection.
• Sudden loss of sensation or new neurological deficits near the ulcer.
• Signs of septic shock: low blood pressure, rapid heartbeat, confusion, or bluish lips.

Bottom line: Bedsores are preventable yet serious complications of immobility. Early identification, meticulous skin care, pressure redistribution, and proper nutrition are the cornerstones of both treatment and prevention. When in doubt, always involve a qualified healthcare professional.

References:

• Mayo Clinic. “Pressure ulcers.” https://www.mayoclinic.org
• National Pressure Injury Advisory Panel. “Revised Pressure Injury Staging System.” 2022.
• Cleveland Clinic. “Pressure Ulcers: Treatment and Prevention.” https://my.clevelandclinic.org
• World Health Organization. “Guidelines for the Prevention and Management of Pressure Injuries.” 2020.
• National Institutes of Health. “Nutrition for Wound Healing.” https://www.nhlbi.nih.gov