Pressure Ulcer

Overview

A pressure ulcer, also called a pressure injury or bedsore, is damage to the skin and underlying tissue caused by prolonged pressure. It most often develops over bony areas of the body, such as the tailbone, hips, heels, ankles, elbows, shoulders, or back of the head. Pressure ulcers can occur when a person stays in one position for a long time, especially if movement is limited due to illness, surgery, injury, paralysis, or advanced age.

Pressure ulcers range from mild skin redness to deep wounds that may involve muscle, tendon, or bone. They can be painful, slow to heal, and may affect quality of life. In some cases, they may become infected or require reconstructive treatment by a plastic surgery team. Early recognition and medical care are important to reduce complications and support healing.

Symptoms

The signs of a pressure ulcer can vary depending on how deep the tissue damage is. Early changes may be subtle, especially in people with reduced sensation or darker skin tones, where color changes may be harder to notice.

• Persistent redness, darkening, or discoloration of the skin over a pressure area
• Skin that feels warmer, cooler, firmer, softer, or more tender than the surrounding area
• Pain, burning, itching, or discomfort in the affected area
• Blistering, peeling, or a shallow open sore
• A deeper wound or crater in the skin
• Drainage, unpleasant odor, swelling, or increasing tenderness
• Black, brown, yellow, or gray tissue within the wound

Some pressure ulcers may extend beneath the surface before the skin appears severely damaged. People with nerve damage, spinal cord injury, or reduced awareness may not feel pain, so regular skin checks by caregivers or healthcare professionals can be important.

Causes and Risk Factors

Pressure ulcers develop when pressure reduces blood flow to the skin and tissues. Without enough blood supply, the tissue does not receive adequate oxygen and nutrients, which can lead to injury. Friction and shear can also contribute. Friction occurs when skin rubs against a surface, while shear happens when the skin stays in place but deeper tissues move, such as when a person slides down in bed.

Risk factors include:

• Limited mobility or being confined to bed or a wheelchair
• Reduced sensation, such as after spinal cord injury or nerve damage
• Advanced age or fragile skin
• Poor nutrition or dehydration
• Incontinence, which can expose the skin to moisture and irritation
• Chronic conditions that affect blood circulation or healing
• Recent major surgery or long hospital stays
• Use of medical devices that press on the skin, such as casts, braces, tubes, or masks

Pressure ulcers are not a sign of poor hygiene alone. They are usually the result of multiple factors, including pressure, medical condition, nutrition, mobility, and skin health.

Diagnosis

Diagnosis is usually made through a physical examination of the skin and wound. A healthcare professional assesses the location, size, depth, appearance, drainage, odor, surrounding skin condition, and signs of infection. The wound may be classified by severity to help guide treatment planning.

The medical team may also review the patient’s overall health, mobility, nutrition, circulation, medications, and underlying conditions that could affect healing. In some cases, additional tests may be needed to check for infection, involvement of deeper tissues, or bone infection. Imaging or laboratory tests may be considered depending on the wound’s appearance and the patient’s general condition.

For complex or non-healing pressure ulcers, a multidisciplinary evaluation may be recommended. This can involve plastic surgeons, wound care specialists, rehabilitation physicians, nurses, dietitians, and other specialists. The goal is to understand both the wound and the factors that caused it.

Treatment Options

Treatment depends on the severity of the pressure ulcer, the patient’s overall health, and the underlying causes. A key part of care is reducing pressure on the affected area. This may involve specialized mattresses, cushions, positioning support, mobility planning, and caregiver education. These measures should be guided by healthcare professionals, especially for patients with limited movement or complex medical needs.

Wound care may include cleaning, protective dressings, management of drainage, and removal of unhealthy tissue when appropriate. If infection is suspected, medical evaluation is necessary. Good nutrition, adequate fluid intake, and management of underlying conditions are also important for healing.

Plastic surgery may be involved when a pressure ulcer is deep, recurrent, or not healing with standard wound care. Surgical treatment may include removal of damaged tissue and reconstruction using nearby healthy tissue, such as a flap, to cover the wound and provide padding over bony areas. Surgery is considered only after careful assessment, because long-term success also depends on pressure relief, nutrition, rehabilitation, and prevention of recurrence.

Not every pressure ulcer requires surgery. Some wounds heal with comprehensive non-surgical care, while others need advanced wound management or reconstructive procedures. The treatment plan is individualized and may change over time as the wound responds.

When to See a Doctor

Medical advice should be sought if there is persistent redness or discoloration over a pressure area, an open sore, blistering, drainage, increasing pain, swelling, or a wound that does not improve. People with limited mobility, reduced sensation, or a history of pressure ulcers should have regular skin assessments and professional guidance.

Urgent medical care is needed if there are signs of infection, such as fever, spreading redness, warmth, pus-like drainage, worsening odor, increasing pain, confusion, or a sudden decline in general condition. Deep wounds, black tissue, exposed bone or tendon, or rapidly worsening skin changes also require prompt evaluation.

Early treatment can help prevent complications and may reduce the need for more extensive procedures. For international patients, bringing previous medical records, wound photographs, test results, and information about current mobility and care routines can help the medical team plan appropriate evaluation and treatment.