Pressure ulcers
Exam Tips
- In OSCEs, always combine risk assessment + skin inspection + staging; examiners reward a prevention-first plan.
- Non-blanchable erythema is an early warning sign; in darker skin look for persistent colour change, warmth, induration, and tenderness rather than redness alone.
- State clearly that diagnosis is clinical and routine swabbing is inappropriate unless infection is suspected.
- If asked about management, prioritize: off-load pressure, optimize support surface, manage moisture/nutrition, treat pain, then treat infection only when clinically indicated.
- Remember device-related pressure ulcers: lesion shape may match mask/tube/collar footprint.
- Use a staging diagram in revision notes for visual recall of Category I-IV, unstageable, and deep tissue injury (image reference: standard NPUAP/EPUAP staging figure in wound-care teaching resources).
Definition
A pressure ulcer is a localized injury to skin and/or underlying soft tissue caused by sustained pressure, or pressure combined with shear, most often over bony prominences (for example sacrum, heels, ischial tuberosities). Severity ranges from persistent non-blanching erythema to deep full-thickness tissue loss with necrosis, and lesions may also be caused by medical devices where the wound shape mirrors the device.
Pathophysiology
Prolonged mechanical loading deforms soft tissue, compresses capillaries, and impairs lymphatic drainage, producing ischemia, reperfusion injury, inflammation, and eventually cell death. Shear (such as sliding down a bed) amplifies deep tissue stress by stretching and tearing microvasculature; friction causes superficial barrier injury that facilitates deeper damage. Moisture from incontinence/sweat macerates stratum corneum, increases friction coefficient, and reduces skin resilience. Tissue tolerance is lowered by poor perfusion (for example peripheral arterial disease, heart failure, hypotension, sepsis, diabetes), malnutrition, aging skin, and immobility, so even lower pressure over longer periods can ulcerate.
Risk Factors
- Significantly limited mobility (for example frailty, spinal cord injury, post-operative immobility)
- Inability to reposition independently
- Reduced sensation (neuropathy, neurological impairment)
- Cognitive impairment or reduced awareness of discomfort
- Previous or current pressure ulcer
- Nutritional deficiency, weight loss, low protein intake, dehydration
- Moisture exposure/incontinence and poor skin condition
- Poor posture, contractures, deformity
- Comorbid poor perfusion states (peripheral vascular disease, diabetes, heart failure, hypotension, sepsis)
- Older age
- Use of non-pressure-relieving mattresses/chairs
- Medical devices (CPAP masks, NG tubes, cervical collars, splints)
Clinical Features
Symptoms
- Localized pain or tenderness over pressure areas (may be absent with neuropathy)
- Burning/discomfort at sacrum, heels, hips, elbows, occiput, or beneath devices
- Reduced mobility and distress due to wound pain
- Possible malodour or discharge if infected
- Systemic symptoms (fever, confusion) if spreading infection/sepsis develops
Signs
- Non-blanchable erythema or persistent discolouration (including subtle colour change in darker skin tones)
- Local warmth/coolness, oedema, induration, or boggy tissue
- Partial-thickness skin loss (Category/Stage II)
- Full-thickness skin loss with visible fat, slough, or necrosis (Category/Stage III/IV)
- Undermining/tunnelling, exposed tendon or bone in advanced ulcers
- Wound shape conforming to a device in device-related pressure injury
Investigations
Management
Lifestyle Modifications
- Immediate pressure redistribution: frequent repositioning plan, heel off-loading, avoid shear when moving.
- Use high-specification foam/alternating-pressure support surfaces for bed/chair based on risk and ulcer category.
- Optimize skin care and microclimate: cleanse gently, protect from moisture (continence care, barrier products), reduce friction.
- Nutritional optimization: dietetic assessment, adequate calories/protein/fluids; address reversible causes of poor intake.
- Regular wound measurement/staging documentation (photo/trace where locally approved) and multidisciplinary review.
- Review and refit/remove causative medical devices where possible.
- Assess safeguarding concerns where neglect/poor care may have contributed.
Pharmacological Treatment
Analgesics (stepwise pain control)
- Paracetamol 1 g orally every 4-6 hours when required (maximum 4 g/24 h; lower maximum in low body weight/frailty as per BNF)
- Ibuprofen 400 mg orally up to three times daily with food (use lowest effective dose, shortest duration; max usually 2.4 g/day prescribed)
- Codeine phosphate 30-60 mg orally every 4 hours when required (maximum 240 mg/24 h)
Use WHO-style stepwise analgesia and reassess pain regularly. Avoid/limit NSAIDs in CKD, heart failure, active GI ulcer, anticoagulation risk, or dehydration. Opioids may cause constipation, sedation, and delirium in older adults; prescribe laxative if needed.
Antibiotics (only for clinical infection, not routine colonization)
- Flucloxacillin 500 mg orally four times daily for 5-7 days for surrounding cellulitis
- Clarithromycin 500 mg orally twice daily for 5-7 days if penicillin allergy
- Co-amoxiclav 500/125 mg orally three times daily when broader mixed-flora cover is clinically required
Do not use routine systemic or topical antibiotics for uninfected pressure ulcers. Escalate urgently for sepsis, rapidly spreading infection, necrotizing infection, or suspected osteomyelitis. Check allergy status, renal/hepatic function, drug interactions (for example macrolides), and local antimicrobial guidance.
Topical barrier preparations for moisture-associated skin damage prevention
- Dimeticone 5% barrier cream thin layer at each continence episode
- Zinc oxide barrier ointment applied to vulnerable periwound skin
These protect periwound skin and reduce maceration; they are adjuncts and do not replace pressure relief.
Surgical / Interventional
- Sharp/surgical debridement of devitalized tissue where appropriate (avoid aggressive debridement in dry stable heel eschar without infection/ischemia signs).
- Negative pressure wound therapy in selected deeper exudative ulcers after specialist assessment.
- Definitive flap reconstruction for selected Stage III/IV ulcers when comorbidity, nutrition, and pressure off-loading can be optimized.
- Drainage/debridement and prolonged targeted therapy for osteomyelitis or deep abscess in conjunction with microbiology/surgical teams.
Complications
- Persistent pain, sleep disturbance, and psychological distress
- Local infection (cellulitis), deep soft-tissue infection, and osteomyelitis
- Bacteraemia and sepsis
- Delayed recovery, prolonged hospital/community care needs, and reduced quality of life
- Higher morbidity and mortality, especially in frail patients with severe ulcers
- Recurrence after healing if risk factors are not corrected
Prognosis
Prognosis depends mainly on ulcer stage, burden of comorbidity, and whether pressure/shear risks can be controlled. Superficial ulcers can heal well with early off-loading and good wound care, whereas advanced ulcers in frail or poorly perfused patients heal slowly and may not close without major intervention; peripheral arterial disease and greater ulcer severity predict poorer healing.
Sources & References
🏥BMJ Best Practice(1)
✅NICE Guidelines(1)
- Pressure ulcers[overview]