Pressure Sores

Topic Overview

What are pressure sores?

A pressure sore (bed sore) is an injury to the skin and/or the tissues under the skin. Constant pressure on an area of skin reduces blood supply to the area. Over time, it can cause the skin to break down and form an open sore (ulcer). Pressure sores are more likely to form if you or a person you are caring for is in the hospital or is confined to a chair or bed.

Pressure sores most often form on the skin over bony areas where there is little cushion between the bone and the skin. Most pressure sores form on the lower part of the body, including over the tailbone and on the back along the spine, on the buttocks, on the hips, and on the heels. Other common spots are the back of the head; the backs of the ears; the shoulders, elbows, and ankles; and between the knees where the legs rub together.

Pressure sores can range from red areas on the surface of the skin to severe tissue damage that goes deep into muscle and bone. These sores are hard to treat and slow to heal. Other problems, such as bone, blood, and skin infections, can develop when pressure sores do not heal properly.

What causes pressure sores?

Things that cause pressure sores include:

Constant pressure on the skin and tissues. This is by far the most common cause of pressure sores.
Sliding down in a bed or chair, forcing the skin to fold over itself ("shear force").
Being pulled across bed sheets or other surfaces (friction burns).
Irritation of the skin from things such as sweat, urine, or feces.

As we get older, our skin gets more thin and dry and less elastic, so it is easier to damage. Poor nutrition—common among older people and people who cannot move easily—makes these natural changes in the skin worse. Skin in this condition may easily develop a pressure sore.

How are they treated?

Treatment focuses on preventing a sore from getting worse and on making the skin healthy again. Treatment includes:

Relieving pressure on the area by changing positions often and spreading body weight evenly with special mattresses or other support.
Keeping the sore clean and covered, and not letting it dry out.
Eating a healthy diet with enough protein to help the skin heal.
Keeping healthy tissue around a pressure sore clean and dry.
In most cases, removing dead tissue and applying medicated ointments or creams to reduce the risk of infection. Only use medicines prescribed by the doctor to treat pressure sores, and follow all instructions carefully.

If infection develops, the person will need antibiotics. Severe pressure sores may need surgery.

How can you prevent pressure sores?

These steps can help keep skin healthy:

Prevent constant pressure on any part of the body.
- Change positions and turn often to help reduce constant pressure on the skin. Learn the proper way to move yourself or a person you are caring for so that you avoid folding and twisting skin layers.
- Spread body weight. Use pressure-relieving devices or cushions, especially if a person is confined to a bed or chair for any length of time, to help prevent pressure sores. Pad metal parts of a wheelchair to help reduce pressure and friction.
Eat a healthy diet with enough protein.
Keep the skin clean and free of body fluids or feces.
Use skin lotions to keep the skin from drying out and cracking, which makes the skin more likely to get pressure sores. Barrier lotions or creams have ingredients that can act as a shield to help protect the skin from moisture or irritation.

What increases the risk of getting pressure sores?

People at greatest risk for getting pressure sores are those who:

Are confined to a bed or chair, especially if it’s because of a spinal injury.
Cannot move without help (as with paralysis, coma, or recovering from surgery or injury).
Have had a hip fracture. The risk for pressure sores continues even after coming home from the hospital or nursing home.
Cannot control their bladder or bowels. Excess moisture can irritate or soften skin and lead to pressure sores.
Are not eating a healthy diet with enough protein. Poor nutrition can lead to unhealthy skin and slow healing.
Are not as alert as normal due to other health problems, from taking certain medicines, or after surgery. People who are not alert and thinking clearly may not understand why preventing pressure sores is important, or they may not be able to take the prevention steps that are needed.
Are older. As people age, the soft tissue becomes more fragile. In addition, skin becomes thinner and less elastic, and injures more easily.
Are smokers. Smoking dries out the skin and reduces blood flow to the skin.
Have a fever. A higher body temperature puts extra stress on areas of the skin that may already be at risk for pressure sores.
Have another health problem that makes healing difficult, such as diabetes.

Frequently Asked Questions

Learning about pressure sores:	What are pressure sores? What causes pressure sores? Who gets pressure sores? Can pressure sores be prevented? Are there different types of pressure sores? What are the symptoms of pressure sores? Where do pressure sores develop ? What are complications of pressure sores?
Being diagnosed:	How are pressure sores diagnosed? What is a skin and wound culture? What is a skin biopsy?
Getting treatment:	How are pressure sores treated? Are medicines used to treat pressure sores? What can I do at home to treat pressure sores? How can I prevent pressure sores?
Ongoing concerns:	What if a pressure sore gets worse?

Symptoms

Pressure sores usually develop on the skin over a bony area where there is less cushion between the skin and bones. Most pressure sores develop on the lower part of the body, on the skin over the sacrum and tailbone (the lowest part of the back), the hips, buttocks, or heels. Pressure sores also occur on the back of the head, the backs of ears, around the shoulders and elbows, between the knees, and over the ankles.

Pressure sores are described in four stages:¹

Stage 1 sores are not open wounds. The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose color briefly when you press your finger on it then remove your finger). In a dark-skinned person, the area may appear to be a different color than the surrounding skin, but it may not look red. Skin temperature is often warmer. And the stage 1 sore can feel either firmer or softer than the area around it.
At stage 2, the skin usually breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion) or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid. At this stage, some skin may be damaged beyond repair or may die.
During stage 3, the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone.
At stage 4, the pressure sore is very deep, reaching into muscle and bone and causing extensive damage. Damage to deeper tissues, tendons, and joints may occur.

In stages 3 and 4 there may be little or no pain due to significant tissue damage. Serious complications, such as infection of the bone (osteomyelitis) or blood (sepsis), can occur if pressure sores progress.

Sometimes a pressure sore does not fit into one of these stages.

In some cases, a deep pressure sore is suspected but can't be confirmed. When there isn't an open wound but the tissues beneath the surface have been damaged, the sore is called a deep tissue injury (DTI). The area of skin may look purple or dark red, or have a blood-filled blister. If you or your doctor suspects a pressure sore, the area is treated as though a pressure sore has formed.
There are also pressure sores that are "unstageable," meaning that the stage is not clear. In these cases, the base of the sore is covered by a thick layer of other tissue and pus that may be yellow, gray, green, brown, or black. The doctor cannot see the base of the sore to determine the stage.

Exams and Tests

Pressure sores are usually diagnosed with a physical examination.

Tests to confirm a diagnosis may include a:

Skin and wound culture, to detect and identify organisms (bacteria or fungi) that may be infecting the skin or a wound.
Blood tests such as complete blood count (CBC) or c-reactive protein (CRP), to check for infection.
Blood tests such as total serum protein, to see if you are getting enough protein in your diet.
Skin biopsy, if the cause of a skin problem is unknown or your doctor suspects skin cancer.
X-ray or other imaging study, such as MRI, to see if the bone is infected.

Treatment Overview

Treatment focuses on preventing pressure sores from getting worse and on restoring healthy skin.

Steps to treat pressure sores include:

Managing the tissue load. Tissue load includes pressure, shear (such as when you slide down in a chair and your skin pulls and folds), and friction (rubbing). All of these forces can damage your skin and deeper tissues.
Keeping the sore area clean and covered, and not letting it dry out.
Keeping healthy tissue around the sore clean and protecting it from moisture.
Eating a healthy diet.
Avoiding smoking. Smoking dries out the skin and reduces blood supply to the skin, so it can help pressure sores form and also slow the healing process.

Early treatment can help prevent damage from pressure sores. After a sore progresses to a more serious stage, it becomes hard to treat and can lead to complications.

Most stage 1 and stage 2 pressure sores will heal within several weeks with proper treatment. Stage 3 and 4 pressure sores can take months or even years to heal. Even though progress is slow, continued care and treatment can prevent complications such as further tissue damage, infection, and pain.

Pressure sores occur most frequently in people who are confined to beds or chairs. In many cases, a person with a pressure sore also has one or more medical conditions that may affect treatment and healing. These conditions include diabetes, kidney disease, and heart disease.

Manage tissue load

Relieving and spreading out pressure is the most important part of preventing and treating pressure sores. When pressure is in one spot for long periods of time, the blood flow to that area is decreased. This damages or kills the cells, and creates a sore. Pressure can be relieved and spread in several ways. Often a combination of these is best. To relieve and spread pressure:

Use special support surfaces. There are mattresses, bed covers, and chair cushions designed to help reduce and spread pressure. Other products, such as doughnut-type devices, may actually cause pressure sores. So talk with your doctor about the support surfaces and pressure-relieving products that would be best for you.
Change positions at least every 2 hours if you are confined to a bed, or as often as every 15 minutes if you are in a wheelchair. A person who can't easily move themselves or who does not have normal feeling in their body or mental awareness to tell them when to change positions is at risk of pressure sores. These people need a regular schedule for position changes and usually need help being turned or repositioned.
Avoid sliding, slipping, or slumping, or positions that put pressure directly on an existing pressure sore. Recliner chairs are likely to allow slipping.
Check the person’s skin from head to toe daily, or as often as your doctor recommends. Watch for pressure from many sources, such as:
- Body parts or skin folds, especially in people who are overweight or obese. For example, the knees or ankles of a person who spends long periods in bed can rub together and cause sores. Work with your doctor to be sure there is either no pressure or that there is good padding between the skin and other surfaces.
- Chair arms, parts of wheelchairs, braces, or other places where people may rest their elbows or other body parts.
- Oxygen masks or oxygen tubing. Tubing or straps that rest on the nose or ears may cause pressure injuries.

Protect and treat the sore area

The basics of wound care are cleaning, covering, and keeping slightly moist to provide the best chance for wound healing.

A stage 1 pressure sore still has the skin intact. Keep it clean, do not allow moisture such as body fluids to stay on the skin, and protect the skin with a mild cream or lotion. Special creams or lotions called moisture barriers are also available. These are very good if there are problems with bowel or bladder control and a person is often wet from body fluids.
To help prevent infection and promote healing, dead tissue is debrided (removed) often, usually by your doctor or another health professional. If there is dead tissue in the pressure sore, it gives bacteria a good place to grow and can cause infection. Dead tissue in the wound can also slow the growth of healthy tissue.
- Sometimes it is best to leave the dead tissue or scab in place and let it act as a sort of bandage. Your doctor may do this if the tissue is very stable, or if the sore is not likely to heal.
The pressure sore must be cleaned every time the bandage (dressing) is changed. Saline (a saltwater solution available at the drug store) is often used for cleaning, but there are many cleansing products. Your doctor will recommend a cleansing solution for you. Do not use antiseptic solutions such as Betadine, Hibiclens, or hydrogen peroxide.² These can damage new and normal tissue.
Your doctor will recommend a bandage (dressing) for the pressure sore. There are many types of bandages. The general idea is to keep the wound a little moist and not let it dry out between bandage changes, and to keep the moist part of the bandage right down in the sore, placed loosely against the healing tissue. Over time, your doctor may use several different types of bandage, as the pressure sore heals. The moist bandage is covered with a dry bandage to help keep the sore clean and to keep the healthy skin around the pressure sore dry.
Several other treatments are sometimes used in treating pressure sores. These are found most commonly in clinics that specialize in treating serious wounds. Researchers continue to study these and other treatments for pressure sores and other wounds. Some insurance will not cover the newer treatments without special approval. Treatments include:
- Electrical stimulation. Gentle electrical current is used in and near the wound to help make tiny blood vessels and new tissue grow.
- Negative-pressure wound therapy (sometimes called "vacuum-assisted closure"). A sterile sponge is placed in the sore and covered with a sticky bandage that does not allow any air in. The small vacuum is then turned on and kept on at all times until the next treatment. The vacuum pulls drainage from the wound to help keep germs from collecting and growing there, and gently pulls the blood supply close to the surface of the sore to bring nutrients to the sore and to make new tissue grow.
- Hyperbaric oxygen therapy. The person is put in a chamber where he or she breathes oxygen at high pressure. This treatment may be used to increase the oxygen level in the blood so more oxygen reaches skin and tissues, which can prevent tissue death, promote healing, and help fight infection. This treatment is not approved for treating the pressure sores themselves, but it is approved for conditions that can occur with pressure sores, such as bone infection (osteomyelitis) or a surgical closure of the sore that is not healing.
- Growth factor. Proteins that help new cells grow are applied to the pressure sore.
Skin grafts or surgical flaps are sometimes needed. Skin grafts help new skin grow at the site of the sore if the wound extends into muscle and deeper tissues. The wound may be surgically closed to promote healing after a skin graft.

Protect healthy skin

In addition to avoiding pressure, take steps to protect healthy skin.

Bathe as often as needed to be clean and comfortable.
Use gentle soap to bathe, and use warm (not hot) water.
Use moisturizing creams or lotions to keep skin soft and keep it from getting dry.
Check your skin every day for signs of pressure sores. Look closely for changes in color or for sores. Pay special attention to the common areas where pressure sores develop, such as over the tailbone and heels.
If you have problems with bowel or bladder control:
- Clean your skin right away if it becomes soiled or wet.
- Use a protective barrier cream, lotion, or ointment to protect your skin from wetness.
- Use pads or briefs that absorb moisture and pull it away from your skin.

Eat a healthy diet

Good nutrition is important to both preventing and treating pressure sores. Focus on getting enough liquids, calories, protein, and vitamins, and on controlling your weight. Both increases and decreases in body weight can help cause pressure sores.³ Talk to your doctor or a registered dietitian about a healthy diet for you.

Treat infection as needed

Open sores, such as pressure sores, are easy places for infections to start. Your doctor will be watching for signs of infection, and you can help watch for these signs. Tell your doctor if you notice:

Redness or warmth in the skin around the sore, or red streaks leading away from the sore area.
Tenderness around the sore.
Pus in the drainage from the sore.
A bad smell from the sore or from the bandage.
Fever.

To treat an infection, you may use medicine such as antibiotics, along with special care of the wound. You and the people around you will also be taught to take steps to keep germs from spreading to other parts of your body or to other people. These steps include keeping the sore covered at all times except during treatment, good hand-washing before and after caring for the pressure sore, and properly wrapping and throwing away used bandages.

Treat pain as needed

Pain may or may not be a problem with pressure sores. If you do have pain, talk to your doctor. Some people with pressure sores do not need any pain medicine, some need pain medicine just when the sore is being treated, and some need pain control medicine on a regular schedule.

Home Treatment

Most pressure sores develop when you or a person you are caring for is hospitalized or confined to a chair or bed. You can take steps to prevent pressure sores. After a pressure sore has developed, you can help prevent the sore from getting worse. To prevent or help heal pressure sores:

Minimize constant pressure, sliding across sheets or other surfaces, and slumping down in a chair or bed. You reduce the risk of pressure sores if all areas of the skin and tissue receive an adequate blood flow.
- Use pressure-relieving devices or cushions if you or the person you care for is confined to a bed or chair.
- Use sheepskin layers or foam alternatives on chairs and beds, which helps prevent new pressure sores in people older than age 18 at risk of developing pressure sores.⁴ If you want to try the special sheepskin or foam, talk to your doctor about where to buy it. These are special products for medical use, not the usual foam or sheepskin.
- Frequently reposition yourself or the person you are caring for to help reduce the risk of developing new pressure sores or irritating current sores. Talk with your doctor about how often to change positions.
- Talk with your doctor about pressure-relieving products that might help you. Some products, such as doughnut-type devices, may actually cause or aggravate pressure sores.
Keep yourself or the person you are caring for active, if possible.
Inspect skin daily, especially around bony areas such as along the spine, at the lowest part of the back, around the hips, elbows, and knees, and at the back of the head and heels. When a pressure sore is forming, skin temperature is often warmer—but can be cooler—than the skin around it, and the skin can feel either firmer or softer than the surrounding skin.
Learn to recognize what pressure sores look like.
Keep skin clean and free of sweat, wound drainage, urine, and feces. Use a mild cleansing soap to keep skin healthy, but be careful not to scrub the skin too hard.
Moisturize skin with lotion, and limit exposure to dry, cold weather, because dry skin is more easily damaged.
Do not use antiseptic solutions such as Betadine, Hibiclens, or hydrogen peroxide. These can damage new and normal tissue.²
Provide good nutrition through a healthy diet with enough protein to keep skin healthy and able to heal more quickly.
Maintain a healthy weight, without swings of gain or loss. Weight changes can lead to increased pressure on certain body areas, or to problems with support equipment that no longer fits.³
Watch for problems with clothing and accessories. Be sure your shoes aren't too loose or too tight. Avoid tight clothing, clothing with heavy seams, and nylon underwear.
Avoid smoking and tobacco smoke, which dries out the skin and reduces blood supply to the skin.

Other Places To Get Help

Organizations

Agency for Healthcare Research and Quality
540 Gaither Road
Suite 2000
Rockville, MD 20850
Phone:	(301) 427-1104
Web Address:	www.ahrq.gov

The Agency for Healthcare Research and Quality (AHRQ) is one agency within the U.S. Department of Health and Human Services. AHRQ supports research initiatives that seek to improve the quality of health care in America. AHRQ's mission is to improve the quality, safety, efficiency, effectiveness, and cost-effectiveness of health care for all Americans. The website provides evidence-based information to help people make decisions about health care services.

American Academy of Family Physicians: FamilyDoctor.org
P.O. Box 11210
Shawnee Mission, KS 66207-1210
Phone:	1-800-274-2237
Fax:	(913) 906-6075
Web Address:	www.familydoctor.org

The website FamilyDoctor.org is sponsored by the American Academy of Family Physicians. It offers information on adult and child health conditions and healthy living. There are topics on medicines, doctor visits, physical and mental health issues, parenting, and more.

American Geriatrics Society: The AGS Foundation for Health in Aging
40 Fulton Street
18th Floor
New York, NY 10038
Phone:	1-800-563-4916
Phone:	(212) 308-1414
Email:	StaffHIA@americangeriatrics.org
Web Address:	www.healthinaging.org

The AGS Foundation for Health in Aging was started by the American Geriatrics Society (AGS). The foundation works on behalf of older adults in the areas of wellness and preventive care, self-responsibility and independence, and connections to family and community. This website has stories about healthy aging, information on caring for elders at home, and tips on winter safety, preparing for emergencies, and meeting the challenges of healthy aging. The site also has links to many other Internet resources on aging.

Related Information

References

Citations

National Pressure Ulcer Advisory Panel (2007). Pressure ulcer stages. Available online: http://www.npuap.org/pr2.htm.

Thomas DR (2003). Management of chronic wounds. In CK Cassel et al., eds. Geriatric Medicine, 4th ed., pp. 967–977. New York: Springer-Verlag.

Ho CH, Bogie K (2010). Pressure ulcers. In WR Frontera et al., eds., DeLisa's Physical Medicine and Rehabilitation: Principles and Practice, 5th ed., vol. 2, pp. 1393–1409. Philadelphia: Lippincott Williams and Wilkins.

Reddy M (2011). Pressure ulcers, search date June 2010. BMJ Clinical Evidence. Available online: http://www.clinicalevidence.com.

Other Works Consulted

American Medical Directors Association (2008). Pressure Ulcers in the Long-Term Care Setting. Clinical Practice Guideline. Columbia, MD: American Medical Directors Association.

European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (2009). Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel.

Hall KE, et al. (2012). Management of common clinical disorders in geriatric patients. In EG Nabel, ed., ACP Medicine, section 8, chap. 2. Hamilton, ON: BC Decker.

Ho CH, Bogie K (2010). Pressure ulcers. In WR Frontera et al., eds., DeLisa's Physical Medicine and Rehabilitation: Principles and Practice, 5th ed., vol. 2, pp. 1393–1409. Philadelphia: Lippincott Williams and Wilkins.

Hyperbaric oxygen therapy for refractory wounds (2010). Medical Letter on Drugs and Therapeutics, 52(1333): 19–20.

Powers JG, et al. (2012). Decubitus (pressure) ulcers. In LA Goldsmith et al., eds., Fitzpatrick's Dermatology in General Medicine, 8th ed., vol. 1, pp. 1121–1129. New York: McGraw-Hill.

Reddy M, et al. (2006). Preventing pressure ulcers: A systematic review. JAMA, 296(8): 974–984.

Reddy M, et al. (2008). Treatment of pressure ulcers: A systematic review. JAMA, 300(22): 2647–2662.

Credits

By	Healthwise Staff
Primary Medical Reviewer	E. Gregory Thompson, MD - Internal Medicine
Specialist Medical Reviewer	Margaret Doucette, DO - Physical Medicine and Rehabilitation, Wound Care, Hyperbaric Medicine
Last Revised	February 15, 2011