Pressure Ulcers

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Synonyms: pressure sores, bed sores, decubitus ulcers

Pressure ulcers may present as persistently red, blistered, broken or necrotic skin and may extend to underlying structures, eg muscle and bone. A pressure ulcer may be caused by pressure, shear, friction or a combination of these. The cost of treating a pressure ulcer varies from £1,214 (category 1) to £14,108 (category IV). Costs increase with ulcer severity because the time to heal is longer and the incidence of complications is higher in more severe cases[1]

Risk factors

There are a number of conditions that increase the risk of developing an ulcer.  The most importat risk factor is immobility. Others include:

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Risk assessment

  • Risk assessment tools should only be used as an aide-mémoire and should not replace clinical judgment.[2]
  • Commonly used assessment scales include the Norton, Braden, and Waterlow scales.[3]
  • The Braden Risk Assessment Scale is a scale made up of six subscales: sensory perception, moisture, activity, mobility, nutrition, friction/shear. Each item is scored between 1 and 4. The lower the score, the greater the risk.[4]

Pressure ulcers can develop in any area of the body. In adults, damage usually occurs over bony prominences, such as the sacrum. Patients with pressure ulcers should receive an initial and ongoing assessment which should include:

  • Health status: illness, nutrition, pain, continence, neurological (sensory impairment, level of consciousness, cognitive status), blood supply, mobility, posture, signs of local or systemic infection, medication (pressure ulcers and the person's general physical condition are very closely related and the two should be assessed together).
  • Previous pressure damage.
  • Psychological and social factors.
  • Ulcer assessment: should be supported by photography (calibrated with a ruler) and tracings. Ulcer assessment should include:
    • Cause of ulcer.
    • Site/location.
    • Dimensions of ulcer.
    • Stage or grade (see 'Classification system', below).
    • Exudate amount and type.
    • Local signs of infection.
    • Pain.
    • Wound appearance.
    • Surrounding skin.
    • Undermining/tracking (sinus or fistula).
    • Odour.

Reassessment of the ulcer should be performed at least weekly but may be required more frequently. The overall goals are to acheive a healthy wound bed and promote healing.

Classification system

European Pressure Ulcer Advisory Panel grading system:[6]
  • Grade 1: non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin - in whom it may appear blue or purple.
  • Grade 2: partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister. Surrounding skin may be red or purple.
  • Grade 3: full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
  • Grade 4: extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures with or without full-thickness skin loss. Extremely difficult to heal and predispose to fatal infection.

Patients with extensive superficial pressure ulcers, Grade 3 or 4 pressure ulcers or those that are deteriorating should be referred to a specialist service.

Healing is not usually a fast process.  However, as long as the patient has adequate pressure redistribution, good nutrition and appropriate wound management, the ulcer will heal in most cases.

  • Repositioning of the patient.
  • Treatment of concurrent conditions which may delay healing.
  • Pressure-relieving support surfaces such as beds, mattresses, overlays or cushions.
  • Local wound management using modern or advanced wound dressings and other technologies.
  • Patients with identified Grade I pressure ulcers are at a significant risk of developing more severe ulcers and should receive interventions to prevent deterioration.
  • Pain relief:
    • Pain is often significant and disabling for those with pressure ulcers.
    • Paracetamol may be sufficient, but patients often require stronger analgesia.
    • Non-steroidal anti-inflammatory drugs may increase peripheral oedema and are inappropriate for patients with pressure ulcers.
    • Pain relief may need to be increased for dressing changes.
    • Patients may require referral to a pain clinic.
  • Infection control:
    • All pressure ulcers are colonised with bacteria. Most local infection can be managed using antimicrobial wound products, and systemic antibiotics should not be used routinely for local infection.
    • Reduce risk of infection and enhance wound healing by hand washing, wound cleansing and debridement. Protect from exogenous sources of contamination, eg faeces.
    • At the time of dressing, cleaning wounds with sterile water, saline or a topical antiseptic can reduce the bacterial burden and the risk of infection. 
    • If purulent material or foul odour is present, more frequent cleansing and possibly debridement are required.
    • The simplest method for debriding necrotic tissue involves careful use of a sterile scalpel with adequate analgesia or anaesthesia. Alternative approaches include the use of topical hydrating products, such as hydrogels, cadexomer iodine beads or larval therapy.
    • Systemic antibiotics are required for patients with bacteraemia, sepsis, advancing cellulitis or osteomyelitis.
  • Nutritional support should be given to patients who have an identified nutritional deficiency.
  • Malnutrition and/or dietary deficiency can adversely affect wound healing.
  • Any patient who is recognised to be poorly nourished and at risk of pressure ulceration should be referred to a dietician.[7] 

Mobility and positioning

Patients at risk of pressure ulcer development should be positioned to minimise pressure, friction and shear, and the potential for further tissue damage. Patients who can move independently should be encouraged and enabled to do so.[8]

  • All patients with pressure ulcers should actively mobilise, change their position or be repositioned frequently.
  • Passive movements should be considered for patients with pressure ulcers who have compromised mobility.
  • Avoid positioning individuals directly on pressure ulcers or bony prominences.

Pressure relief

Pressure-relieving equipment - eg, alternating pressure systems, redistributes the load or relieves the pressure at regular intervals. Pressure-reducing equipment redistributes pressure by spreading the weight over a larger surface area, eg mattresses, cushions and dynamic air loss systems.

Patients with pressure ulcers should have access to appropriate pressure-relieving support surfaces 24 hours a day and this applies to all support surfaces.[9]

Current consensus recommends that:[9]

  • All individuals assessed as having a Grade 1-2 pressure ulcer should be placed on a high-specification foam mattress or cushion with pressure-reducing properties, combined with close observation of skin changes and a documented positioning and repositioning regime.
  • If there is any perceived or actual deterioration of affected areas or further pressure ulcer development, an alternating pressure mattress (replacement or overlay) or sophisticated continuous low-pressure system (eg, low air loss, air fluidised, air floatation, viscous fluid) should be used.
  • Depending on the location of an ulcer, individuals assessed as having a Grade 3-4 pressure ulcer (including intact eschar where depth cannot be assessed) should be placed on an alternating-pressure mattress or sophisticated continuous low-pressure system.
  • If alternating-pressure equipment is required, the first choice should usually be an overlay system.

Dressings and topical agents

  • There is no conclusive research evidence to guide clinicians' decision-making about which dressings are most effective in pressure ulcer management.
  • The ideal dressing should be easy to apply and remove, have low allergenic potential, be sterile and impermeable to micro-organisms, provide a moist environment but remove excess exudate, reduce pain and not add to wound debris.
  • Excess loose slough and exudate should be removed prior to a dressing change.
  • Modern dressings (eg, hydrocolloids, hydrogels, foams, films, alginates, soft silicones) should be used in preference to basic dressing types, eg gauze, paraffin gauze and simple dressing pads.
  • Barrier creams should not be used with superficial pressure ulcers.
  • Products for wound management, listed in the table below, are currently widely available for the management of pressure ulcers.
Products for the Management of Wounds
Alginates: these are often used for ulcers with moderate to heavy exudate.
Cadexomer iodine: this works well for sloughy or infected wounds.
Films: these work best on epithelialising wounds with low exudate.
Foams: different foams have different levels of absorbancy. They are best used on granulating wounds.
Hydrocolloids: these may be used for most types of wounds with low to moderate exudate. Not suitable for infected wounds.
Hydrogel: this provides moisture to dry sloughy or necrotic wounds and assists autolytic debridement. Can be used on wounds with low exudate. Not suitable for infected wounds.
Silver: silver is an antibacterial and is generally found as a composite dressing with other products - eg, alginates, foams, hydrocolloids. Use on infected wounds.
Soft polymers: these are non-adherent and best used on granulating wounds.

Debridement[8] 

Debridement may be autolytic (see below), enzymatic (using enzymes to produce slough of necrotic tissue), mechanical (allowing a dressing to become moist and then wet before manually removing the dressing), or surgical.

  • The presence of devitalised tissue delays the healing process.
  • Superficial pressure ulcers may benefit from autolytic debridement techniques, which use the body's own enzymes and moisture to rehydrate, soften and liquefy hard eschar and slough.
  • Autolytic debridement can be achieved with the use of occlusive or semi-occlusive dressings which maintain wound fluid in contact with the necrotic tissue.
  • For individuals who are terminally ill or with other comorbidities, overall quality of life should be considered before deciding whether and how to debride.

For deep pressure ulcers not responding to standard care, surgery can offer a rapid closure for some patients.  This is usually undertaken by plastic surgeons and often involves creating rotational flaps.

  • Pressure ulcers are often slow to heal, because of continued adverse factors such as pressure or poor nutrition.
  • May spread to deep tissues and also cause localised infection, including osteomyelitis, and systemic infection.
  • The presence of pressure ulcers is associated with a twofold to fourfold increased risk of death, but this is because pressure ulcers are a marker for underlying disease severity and other comorbidities.
  • The majority of pressure ulcers can be prevented.
  • Skin injury due to friction and shear forces should be minimised through correct positioning, transferring and repositioning techniques.
  • Pressure redistributing equipment should be used. 
  • Eliminate any source of excess moisture due to incontinence, perspiration or wound drainage.
  • Reduce underlying risk factors such as poor nutrition.
  • Education and training - eg, mobility, positioning, skin care, use of equipment, for patients and their carers.
  • Consider the use of emollients if the skin is dry or barrier products if the skin is excessively moist.

Further reading & references

  1. The cost of pressure ulcers in the United Kingdom. J Wound Care. 2012 Jun;21(6):261-2, 264, 266.
  2. Pressure relieving devices, NICE Clinical Guidance (2003)
  3. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, et al; Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs. 2006 Apr;54(1):94-110.
  4. Braden Risk Assessment Tool, NHS Quality Improvement Scotland
  5. Pressure Ulcers - Good Practice Guide, British Geriatrics Society (2012)
  6. Pressure Ulcer Grading System, European Pressure Ulcer Advisory Panel, 2003
  7. Pressure Ulcer Prevention, National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel, 2009
  8. Best Practice Statement: prevention and management of pressure ulcers, NHS Quality Improvement Scotland (March 2009)
  9. Pressure ulcers: The management of pressure ulcers in primary and secondary care, NICE Clinical Guideline (2005)

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Louise Newson
Current Version:
Peer Reviewer:
Dr Hannah Gronow
Last Checked:
02/10/2012
Document ID:
2662 (v23)
© EMIS