Pressure ulcer - Causes, Treatment & When to See a Doctor

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What is Pressure ulcer?

A pressure ulcer, also called a bed‑sores or decubitus ulcer, is an area of damaged skin and underlying tissue that develops when pressure, shear, or friction exceeds the blood flow to that region. The lack of oxygen and nutrients leads to tissue death (necrosis). Pressure ulcers most often appear over bony prominences such as the heels, sacrum, hips, elbows, and the back of the head.

They are graded by severity, from non‑blanchable erythema (Stage I) to full‑thickness tissue loss with exposure of muscle or bone (Stage IV). Unstageable and deep‑tissue injuries are also recognized when the depth cannot be determined because of slough or eschar.

According to the National Pressure Injury Advisory Panel (NPIAP), millions of adults in the United States develop pressure ulcers each year, and they are associated with increased morbidity, longer hospital stays, and higher health‑care costs.

Common Causes

Pressure ulcers are multifactorial. The most common precipitating conditions include:

• Immobility: Prolonged bed rest, wheelchair use, or limited ability to change position.
• Reduced sensation: Neurological disorders (e.g., spinal cord injury, stroke, diabetic neuropathy) that prevent the person from feeling discomfort.
• Moisture: Incontinence, sweating, or wound drainage that macerates skin.
• Nutrition deficits: Protein‑energy malnutrition, low vitamin C, zinc, or iron levels impair healing.
• Advanced age: Skin becomes thinner and less resilient with age.
• Vascular disease: Peripheral arterial disease or venous insufficiency reduces blood flow.
• Obesity: Increased pressure over bony prominences and difficulty repositioning.
• Medical devices: Oxygen masks, endotracheal tubes, casts, or braces that press against skin.
• Chronic illnesses: Cancer, heart failure, or chronic kidney disease that affect tissue perfusion.
• Medication side effects: Sedatives, anticholinergics, or corticosteroids that decrease mobility or impair wound healing.

Associated Symptoms

While the hallmark of a pressure ulcer is a visual skin change, patients often experience additional symptoms:

• Localized pain, burning, or itching (may be absent if sensation is impaired).
• Redness that does not blanch when pressed (Stage I).
• Swelling or edema surrounding the wound.
• Drainage that can be clear, serous, purulent, or odorous, indicating infection.
• Fever, chills, or increased heart rate if infection spreads.
• Reduced joint mobility when ulcers involve areas near joints.
• Psychological distress, anxiety, or depression related to chronic wounds.

When to See a Doctor

Prompt medical evaluation is essential to prevent progression. Seek care if you notice any of the following:

• Red or purple skin that does not turn white when pressed (non‑blanchable).
• Open sores, blisters, or areas of broken skin that are deeper than the skin’s surface.
• Increasing pain, swelling, or foul‑smelling discharge from a wound.
• Fever, chills, or unexplained fatigue.
• Changes in the color of the wound (e.g., black or gray tissue) suggesting necrosis.
• Rapid spreading of redness beyond the original area.
• Any ulcer that does not improve within 48‑72 hours despite basic wound care.

Diagnosis

Diagnosis is primarily clinical, but several tools help stage and plan treatment:

1. Physical Examination: A clinician inspects the wound, assesses depth, size, edge, and surrounding tissue.
2. Staging System: The NPIAP staging criteria (Stage I–IV, unstageable, deep‑tissue injury) guide management.
3. Imaging: X‑ray, ultrasound, or MRI may be ordered when osteomyelitis (bone infection) or deeper tissue involvement is suspected.
4. Laboratory Tests: CBC, CRP, ESR, and blood cultures if systemic infection is suspected; wound swab cultures for bacterial identification.
5. Nutrition Assessment: Serum albumin, pre‑albumin, and micronutrient levels to guide dietary optimization.
6. Pressure Mapping: In some facilities, pressure‑mapping devices evaluate high‑risk areas for targeted preventive measures.

Treatment Options

Treatment is individualized based on stage, size, infection status, and patient factors. It combines wound care, addressing underlying causes, and supportive therapies.

General Principles

• Pressure Relief: Frequent repositioning (every 2 hours for bedbound patients, every 15 minutes for wheelchair users) and use of pressure‑redistributing surfaces (special mattresses, cushions).
• Moisture Management: Keep skin clean and dry; use barrier creams and absorbent pads.
• Nutrition Optimization: High‑protein diet (1.2‑1.5 g/kg body weight), extra calories, vitamin C (500 mg/day), zinc (30 mg/day), and adequate fluid intake.
• Infection Control: Systemic antibiotics for cellulitis or osteomyelitis; topical antimicrobial dressings for localized colonization.

Stage‑Specific Interventions

Stage I

• Remove pressure; use a low‑air‑loss mattress or foam overlay.
• Apply a protective barrier cream (e.g., zinc oxide) to reduce friction.
• Monitor daily for progression.

Stage II

• Maintain a moist wound environment with hydrocolloid, foam, or silicone dressings.
• Debridement (soft‑tissue removal) if necrotic tissue is present.

Stage III

• Advanced dressings: alginate, honey‑based, or collagen dressings to promote granulation.
• Sharp or enzymatic debridement to remove slough.
• Consider negative‑pressure wound therapy (NPWT) for larger defects.

Stage IV

• Comprehensive debridement (sharp, mechanical, or surgical).
• NPWT or wound vac to manage exudate and stimulate tissue growth.
• Skin grafts, muscle flaps, or free tissue transfer for extensive tissue loss.
• Long‑term antibiotics if osteomyelitis is confirmed.

Unstageable / Deep‑Tissue Injury

• Gentle debridement to reveal underlying tissue.
• Frequent reassessment; treat as the appropriate stage once depth is clarified.

Home Care Recommendations

• Change position as advised; use a schedule sheet or alarm.
• Inspect skin at least once daily; look for color changes, warmth, or drainage.
• Keep dressings clean; follow provider instructions for changes.
• Maintain adequate protein (e.g., lean meats, beans, dairy) and hydration.
• Report any worsening signs to your health‑care team promptly.

Prevention Tips

Most pressure ulcers are preventable with systematic care.

• Risk Assessment: Use validated tools such as the Braden Scale on admission and regularly thereafter.
• Repositioning Schedule: Turn or shift weight at least every 2 hours; use a repositioning pillow for off‑loading.
• Support Surfaces: Invest in pressure‑relieving mattresses, overlays, and cushions (e.g., alternating‑pressure, low‑air‑loss, gel‑filled).
• Skin Care: Cleanse with mild, pH‑balanced soap; pat dry; apply moisturizers to dry skin; use barrier creams over vulnerable areas.
• Moisture Control: Manage incontinence with absorbent pads, catheter care, and skin protectants.
• Nutrition & Hydration: Aim for 30 kcal/kg and 1.5 g protein/kg daily; supplement with vitamins and minerals as recommended.
• Education: Train patients, families, and caregivers on proper turning techniques and skin inspection.
• Device Management: Pad or reposition medical devices regularly; avoid tight straps.
• Exercise & Mobility: Encourage active or passive range‑of‑motion exercises as tolerated.

Emergency Warning Signs

References

• Mayo Clinic. Pressure ulcers (bed sores). https://www.mayoclinic.org
• National Pressure Injury Advisory Panel (NPIAP). Pressure Injury Staging. 2023.
• Centers for Disease Control and Prevention (CDC). Prevention of Pressure Ulcers in Health Care Settings. 2022.
• National Institutes of Health (NIH). Nutrition and Wound Healing. 2021.
• Cleveland Clinic. Bed‑Sore Treatment and Prevention. https://my.clevelandclinic.org
• World Health Organization (WHO). Guidelines on Pressure Injury Prevention. 2020.

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