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).
• Moisture that stays on the skin.

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.¹ 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:^{2, 3, 4}

• 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, such as a hip fracture).
• 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 stiffens and is not able to distribute pressure evenly. In addition, skin becomes thinner and less elastic, and injures more easily.¹
• 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

Symptoms

Pressure sores usually develop on the skin over a bony area where there is less cushion between the skin and bones. About 95% of 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.⁵ 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 :⁶

• Stage 1 sores are not open wounds. The skin is closed and may be painful. The skin may appear reddened or darker than normal, like a bruise, and there are no breaks or tears in the skin. Skin temperature is often warmer, but can be cooler than the skin around it. And the stage 1 sore can feel either firmer or softer than the surrounding skin.
• 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.⁶

• In some cases, a deep pressure sore is suspected, but cannot be confirmed. The area of skin may look purple or dark red, or have a blood-filled blister. If you or your doctor suspect 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.

Conditions that have symptoms similar to pressure sores include:⁵

• Tissue death from other causes (gangrene).
• Skin sores due to other conditions, such as venous insufficiency, peripheral arterial disease (PAD), diabetes, or injury.
• Skin cancer, which may cause sores similar in appearance to pressure sores.

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.
• Skin biopsy, if the cause of a skin problem is unknown or your health professional suspects skin cancer.

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).⁷ 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 difficult to treat and can lead to complications.

Most stage 1 and stage 2 pressure sores will heal within 60 days with proper treatment.⁴ 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. They can use materials including foam, air, water, beads, and fiber. Your doctor and other health professionals, such as nurses and physical therapists, will help find the right support surface for you.
  • Avoid using doughnut-type devices to cushion any area, or boots filled with air to support the heels. These devices may actually cause or aggravate pressure sores.⁵
• Change positions often, or help a person at risk of pressure sores change often. Most people change positions many times an hour, even if they are sitting down. All these movements and adjustments help relieve pressure. A person who cannot 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. Most experts recommend changing positions at least every 2 hours.
• Avoid positions that put pressure directly on an existing pressure sore.
• Avoid positions that will allow you to slide, slip, or slump. Recliner chairs are likely to allow slipping.
• Watch for pressure from parts of wheelchairs, braces, or other equipment, or from body parts pressing and rubbing together. For example, the knees or ankles of a person who spends long periods in bed can rub together and cause sores. Work with your health provider to be sure there is either no pressure or that there is good padding between the skin and other surfaces.
• Avoid sliding. This causes friction (rubbing) on the skin that can lead to sores.

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.⁸ 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 include⁹:
  • 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 while 100% oxygen is pumped in at high pressure. This 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 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 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.¹⁰

• 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.^{1, 9} 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:¹¹

• 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 reduce the incidence of new pressure sores for people older than age 18 at risk of developing pressure sores.¹² If you want to try the special sheepskin or foam, talk to your doctor about where to get them. These are special products for medical use, not the usual foam or sheepskin.
  • At least every 2 hours, reposition yourself or the person you are caring for to help reduce the risk of developing new pressure sores or irritating current sores.
  • Avoid using doughnut-type devices or boots filled with air to support the heels. These devices may actually cause or aggravate pressure sores.⁵
• 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.⁸
• 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.¹
• Avoid smoking and tobacco smoke, which dries out the skin and reduces blood supply to the skin.

Other Places To Get Help

Online Resources

Related Information

• Cellulitis
• Necrotizing Fasciitis (Flesh-Eating Bacteria)
• Peripheral Arterial Disease of the Legs
• Skin Cancer, Melanoma
• Skin Cancer, Nonmelanoma
• Skin Changes
• Venous Skin Ulcer

References

Citations

1. O'Connor K (2005). Pressure ulcers. In JA DeLisa et al., eds., Physical Medicine and Rehabilitation: Principles and Practice, 4th ed., vol. 2, pp. 1605-1618. Philadelphia: Lippincott Williams and Wilkins.

2. American Medical Directors Association (1996; reviewed 2004). Pressure Ulcers. Columbia, MD: American Medical Directors Association. Also available online: http://www.guideline.gov/summary/summary.aspx?doc_id=1811.

3. Bates-Jensen BM (2001). Quality indicators for prevention and management of pressure ulcers in vulnerable elders. Annals of Internal Medicine, 135(8, Part 2): 744-751.

4. Palmer RM (2004). Management of common clinical disorders in geriatric patients. In DC Dale, DD Federman, eds., ACP Medicine, section 8, chap. 9. New York: WebMD.

5. Losh DP (2000). Decubitus ulcer. In RE Rakel, ed., Saunders Manual of Medical Practice, 2nd ed., pp. 1287-1289. Philadelphia: W.B. Saunders.

6. National Pressure Ulcer Advisory Panel (2007). Pressure ulcer stages. Available online: http://www.npuap.org/documents/NPUAP2007_PU_Def_and_Descriptions.pdf.

7. Bergstrom N, et al. (1994; reviewed 2000). Treatment of Pressure Ulcers. Clinical Practice Guideline No. 15 (AHCPR Publication No. 95-0652). Rockville, MD: Agency for Health Care Policy and Research.

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

9. National Guideline Clearinghouse (2006). Management and treatment of pressure ulcers. Available online: http://www.guideline.gov/Compare/pdf.aspx?file=PRESSURE_ULCER_TREATMENT1.inc&out=1.

10. Agency for Health Care Policy and Research (1994). Treating Pressure Sores. Consumer guide number 15 (AHCPR Publication No. 95-0645). Available online: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid+hstat2.chapter.9615.

11. Bergstrom N, et al. (1992; reviewed 2000). Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guideline No. 3 (AHCPR Publication No. 92-0047). Rockville, MD: Agency for Health Care Policy and Research.

12. Cullum N, et al. (2006). Pressure ulcers, search date February 2005. Online version of Clinical Evidence (15): 1-15.

Other Works Consulted

• Lyder CH (2003). Pressure ulcer prevention and management. JAMA, 289(2): 223-226.

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