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Indentation of Skin (Pressure Ulcer)

What is Indentation of Skin (Pressure Ulcer)?

A pressure ulcer, also called a decubitus ulcer or bedsore, is a localized injury to the skin and underlying tissue that results from prolonged pressure, friction, or shear forces. The pressure compresses blood vessels, reducing oxygen and nutrient delivery to the affected area. When the tissue does not receive adequate blood flow for an extended period, it can become pale, break down, and form an indentation or “dented” area on the skin surface.

Pressure ulcers are staged (Stage 1‑4) based on depth and severity, but early signs often appear as a pink or red indentation that does not blanch (turn white) when pressed. Recognizing this early change is crucial because it offers the best chance for simple, non‑invasive treatment before the wound deepens.

Common Causes

Any condition that creates sustained pressure on a bony prominence or limits a person’s ability to shift weight can lead to an indentation of the skin. The most frequent contributors include:

• Immobility: Prolonged bed rest, wheelchair use, or paralysis.
• Neurological disorders: Stroke, spinal cord injury, multiple sclerosis, or Parkinson’s disease that reduce sensation.
• Chronic illnesses: Advanced diabetes, heart failure, or chronic obstructive pulmonary disease (COPD) that limit mobility.
• Malnutrition & dehydration: Low protein intake, vitamin deficiencies, or inadequate fluid consumption weaken skin integrity.
• Obesity: Increases pressure on skin folds and makes repositioning more difficult.
• Incontinence: Moisture from urine or stool irritates skin and reduces its ability to resist pressure.
• Reduced blood flow: Peripheral arterial disease, peripheral neuropathy, or venous insufficiency compromises circulation.
• Improper positioning devices: Cushions, mattresses, or splints that concentrate pressure rather than distribute it.
• Surgical positioning: Long operative times with the patient in one fixed position.
• Age‑related changes: Thinner skin and decreased subcutaneous fat in older adults increase vulnerability.

Associated Symptoms

While the primary sign is a shallow indentation, other symptoms frequently accompany the early stage of a pressure ulcer:

• Skin discoloration – red, pink, or purplish hue that does not turn white when pressed.
• Warmth or coolness compared with surrounding skin.
• Itching, tingling, or a “tight” feeling under the area.
• Minor pain or tenderness when pressure is applied.
• Swelling or edema around the affected site.
• Skin that feels softer or more fragile than adjacent areas.
• In later stages: open wound, drainage, foul odor, or visible tissue loss.

When to See a Doctor

Early intervention can prevent a simple indentation from progressing to a full‑thickness ulcer. Seek medical care promptly if you notice any of the following:

• The indentation is larger than a pencil eraser or does not improve after repositioning.
• Skin becomes painful, increasingly red, or begins to blister.
• There is any drainage (clear, yellow, or bloody) from the area.
• Fever, chills, or a general feeling of being unwell develop.
• Underlying conditions (e.g., diabetes) that impair healing are present.
• Repeated episodes occur despite preventive measures.

For people with spinal cord injury, severe immobility, or advanced age, a routine skin‑check by a health professional every 24‑48 hours is recommended—even if no symptoms are obvious.

Diagnosis

Health‑care providers use a combination of visual inspection, patient history, and sometimes imaging to assess a pressure ulcer.

1. Physical examination: The clinician evaluates size, depth, color, and stage of the lesion, and checks for surrounding tissue damage.
2. Palpation: Gentle pressure helps determine if the area blanches (an indication of early, superficial damage).
3. Risk‑assessment tools: Scales such as the Braden or Norton scores quantify a patient’s overall risk for pressure injuries.
4. Laboratory tests: When infection is suspected, a wound swab for culture, complete blood count (CBC), and inflammatory markers (CRP, ESR) may be ordered.
5. Imaging (if needed): X‑ray, ultrasound, or MRI can reveal underlying osteomyelitis (bone infection) in deeper ulcers.

Documentation of the ulcer’s location (e.g., sacrum, heels, trochanters), dimensions, and stage provides a baseline for monitoring response to treatment.

Treatment Options

Treatment strategies focus on relieving pressure, promoting healing, and preventing infection. The plan is tailored to the ulcer’s stage and the patient’s overall health.

Immediate Pressure Relief

• Reposition the patient every 2 hours (or less if possible) using a turning schedule.
• Use pressure‑redistributing mattresses, low‑air‑loss beds, or specialty cushions.
• Apply a silicone or foam dressing that cushions the area while maintaining a moist environment.

Wound Care

• Cleaning: Gentle irrigation with normal saline; avoid harsh antiseptics that damage new tissue.
• Debridement: Removal of dead tissue (mechanical, enzymatic, or surgical) to stimulate granulation.
• Dressings: Hydrocolloid, alginate, or foam dressings for Stage 1‑2 ulcers; antimicrobial dressings (silver, iodine) if infection risk is high.
• Topical agents: Silver sulfadiazine or mupirocin for colonized wounds.

Systemic Therapy

• Oral antibiotics if cellulitis or deeper infection is confirmed.
• Analgesics for pain control – acetaminophen, NSAIDs (if renal function allows), or short‑term opioids for severe pain.
• Nutritional support – high‑protein diet (1.2‑1.5 g/kg/day), vitamin C, zinc, and adequate calories to promote tissue repair.

Surgical Intervention

Advanced ulcers (Stage 3‑4) may require:

• Flap or skin‑graft surgery to close the defect.
• Debridement under anesthesia.
• Management of underlying osteomyelitis with long‑term antibiotics.

Home‑Care Recommendations

• Follow the repositioning schedule and keep the skin clean and dry.
• Inspect the area daily for changes in color, size, or drainage.
• Maintain optimal hydration (≈2‑3 L water/day unless contraindicated).
• Use barrier creams (e.g., zinc oxide) if incontinence is an issue.
• Report any worsening signs to a health‑care professional immediately.

Prevention Tips

Most pressure ulcers are preventable with proactive measures.

• Regular repositioning: Every 2 hours for bedridden patients; every 15‑30 minutes for wheelchair users.
• Pressure‑relieving surfaces: Invest in specialty mattresses, foam overlays, or adjustable beds.
• Skin hygiene: Gently cleanse skin, dry thoroughly, and apply moisturizers to keep skin pliable.
• Nutrition & hydration: Adequate protein (≥20 g per meal), vitamins A, C, and zinc; limit alcohol and smoking.
• Manage incontinence: Timely cleaning, use of absorbent pads, and barrier creams to protect skin.
• Risk‑assessment tools: Incorporate Braden/Norton scoring into routine care for early identification.
• Education: Train caregivers, family members, and patients on signs of early pressure injury.
• Exercise & mobility: Encourage safe range‑of‑motion exercises and, when possible, ambulation.

Emergency Warning Signs

References

• Mayo Clinic. Pressure ulcers (bed sores). https://www.mayoclinic.org/diseases-conditions/pressure-ulcers
• Centers for Disease Control and Prevention. Preventing pressure ulcers in hospitals. https://www.cdc.gov/infectioncontrol/guidelines/pressure-ulcers/
• National Institutes of Health, National Pressure Injury Advisory Panel. Pressure Injury Staging. https://www.npisap.org/
• World Health Organization. Safe patient handling and mobilisation. https://www.who.int/
• Cleveland Clinic. How to treat and prevent pressure ulcers. https://my.clevelandclinic.org/health/diseases/21504-pressure-ulcers
• Gefen A. “Shear and pressure: the two major contributors to pressure injury formation.” *Journal of Wound Care* 2022;31(5):306‑313.

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