How Different Stages of Pressure Ulcers Look

Pressure ulcers are staged—or named—based on symptoms and the extent of damage. This system provides a way of describing the type of pressure ulcer.

Prevention and early diagnosis are crucial to avoid severe problems. Without care, this type of wound can become infected. This can put you at risk of extreme outcomes like sepsis (a full-body response to an infection in your bloodstream).

This article describes pressure ulcer causes, staging, treatment, and ways to prevent this problem.

When Does a Pressure Ulcer Form?

A pressure ulcer forms on an area of the skin with prolonged pressure due to immobility. It can also form in areas that remain wet due to constant contact with body fluids like urine or sweat.

The continued pressure reduces blood flow and other fluids to the tissue in the affected area. This causes damage that leads to cell death, skin breakdown, and the eventual formation of an open wound.

The appearance of a pressure ulcer can happen quickly in a period as short as two hours, or it can occur over days. The wound is vulnerable to pain, disability, and infection.

Without correcting the circumstances causing the pressure, the skin damage is progressive. The deterioration eventually spreads to deeper tissue layers, affecting muscles, tendons, and bones.

Having one or more of the following internal and external risk factors for pressure ulcers can make you more susceptible to these wounds:

Internal risk factors for pressure ulcers include:

• Spinal cord injury
• Prolonged immobility on a spinal board, table, or bed
• Decreased sensation that causes an inability to recognize pain from pressure and the need to reposition
• Diabetes
• Smoking
• Vascular disease
• Poor nutrition
• Immunosuppression
• Contractures (decreased elasticity of muscle, tendons, ligaments, or skin that prevents normal movement of the affected body part)
• Inability to control your bladder or bowels

External risk factors for pressure ulcers include:

• Lying on hard surfaces for extended periods
• Use of patient restraints
• Wearing poor-fitting prostheses or other medical devices that come in contact with tissue
• Prolonged wheelchair use
• Nursing home resident
• Poor skin hygiene
  

Among people with these risk factors, those with spinal cord injuries and those who live in nursing homes have the highest incidence of pressure ulcers.

Staging of Pressure Ulcer Symptoms

The staging of pressure ulcer symptoms describes symptoms, the extent of tissue loss, and the anatomical features of each pressure ulcer stage. While there are different classification systems, the National Pressure Ulcer Advisory Panel (NPUAP) included the most recent research and clinical expertise regarding these conditions in its 2016 revision of its staging system to include the following criteria:

Stage 1 (the earliest stage of a pressure ulcer)

• Intact skin with persistent erythema (redness) of a localized area, usually over an area of bony prominence
• Non-blanchable erythema that remains red instead of blanching (blanching describes the lightening of the skin with pressure, and then darkening again when the pressure is released)
• Observable differences in the affected area may include one of the following characteristics:
• Changes in temperature to cool or warm
• Induration (hardening of tissues)
• Edema (tissue swelling)
• Burning
• Pain
• Itchiness
• Blue or purple color in people who have dark skin

Stage 2

• Partial-thickness skin loss involving the epidermis (outermost layer of skin) and dermis (a thick layer of skin below the epidermis)
• Possible breakage at the top layer of skin, making the sore resemble a shallow cut, blister, or abrasion
• Discoloration of the skin around the sore
• Pain at the site of the sore
• Pink, red, and moist wound bed
• Warm to the touch
• Potential clear fluid in the broken skin
• Lack of the following characteristics:
• Eschar (scab or dead dry, thick leathery tissue that appears black or brown)
• Granulation tissue (growth of healing skin that is pink or red and uneven)
• Slough (soft, moist, light yellow/cream-colored tissue that sticks to the wound bed in clumps or strings)

Stage 3

• Full-thickness loss of skin that extends to the hypodermis or subcutaneous tissue (the innermost layer of skin made of fat and connective tissue that includes blood vessels and nerves)
• Sore with a crater-like appearance
• Increased damage below the surface of the epidermis, making the wound deeper
• No exposure of bone, tendon, or muscle
• Potential infection with the following signs:
• Foul odor
• Pus
• Redness
• Discolored drainage
• Potential presence of one or more of the following characteristics:
• Granulation tissue
• Rolled edges of the wound
• Slough
• Eschar

Stage 4

• Full-thickness tissue loss with exposed bone, tendon, ligament, fascia, cartilage, or muscle
• Severely damaged skin and tissue
• Large wound
• Potential infection of the wound
• Potential presence of one or more of the following characteristics:
• Rolled edges of the wound
• Slough
• Eschar
• Undermining (a shallow region under the overlying loose skin that covers a wider area in multiple directions)
• Tunneling (a deep passageway under the surface of the wound that causes damage in one direction)

Unstageable pressure injury

• Stages 3 or 4 full-thickness injury
• Entire wound base is obscured by slough and/or eschar

Deep tissue pressure injury

• Intact or non-intact skin with localized area of persistent non-blanching deep red, maroon, or purple discoloration OR
• Epidermal separation that reveals a dark wound bed or blood-filled blister
• Skin color changes preceded pain and temperature changes
• Variation of discoloration in darkly pigmented skin
• Possible evolution to reveal the extent of tissue injury
• Possible resolution without tissue loss
  
  

Treating and Tending to a Pressure Ulcer

Treatment of a pressure ulcer depends on the extent of the injury when it is diagnosed. Your healthcare provider and wound team will determine the seriousness of your pressure ulcer and the most appropriate treatment.

Treatment varies based on the site, stage, and potential pressure ulcer complications. Open or broken pressure ulcers often require longer and more complex treatment than closed pressure ulcers.

Treatments commonly used for pressure ulcers include the following:

Conservative treatment (usually adequate for stages 1 and 2 pressure ulcers) includes:

• Remove the source of pressure from the affected area.
• Keep the wound clean with mild soap and water or a saline rinse as directed. (Avoid hydrogen peroxide or iodine cleaners, which can damage your skin.)
• Cover the pressure ulcer with medicated gauze or other special dressings.
• Maintain proper moisture balance by keeping the affected area moist with a water-resistant agent like Vaseline (petroleum jelly) so it can heal.
  
• Ensure good nutrition and hydration.
• Divert urinary and fecal materials away from the pressure ulcer, depending on its location.
• Powder sheets lightly to avoid rubbing on them.

Surgical treatment (may be necessary for stages 3 and 4 pressure ulcers when conservative treatment is not adequate) includes:

• Debridement (removing the damaged, infected, or dead skin tissue) followed by flap reconstruction (using your own tissue to fill the hole left by the wound
• Skin grafts (transplanting healthy skin to the wound area)
• Negative pressure wound therapy (a sealed wound dressing attached to a vacuum pump that sucks fluid away from the wound)
  

Pressure Ulcer Healing

Pressure ulcer healing can vary greatly based on the location and extent of damage when treatment begins. Other factors, such as your general health and medical conditions, can also affect healing.

Healing times can range from days to years. General average pressure ulcer healing times by stage include the following:

• Stage 1: About three days
• Stage 2: About three days to three weeks
• Stage 3: More than one to four months
• Stage 4: Three months to two years
  

Signs of pressure ulcer healing include the following changes:

• Decrease in pressure ulcer size
• Formation of pinkish tissue along the edges moving toward the center of the pressure ulcer
• Smooth or bumpy surfaces of new tissue
• Some bleeding (a positive sign that shows there is good blood circulation, which promotes healing at the affected site)

During the healing process, a pressure ulcer can become infected. Contact your healthcare provider if any of the following occurs:

• Increase in pressure ulcer size
• Increase in drainage from the pressure ulcer
• Increase in redness or the formation of black areas around the pressure ulcer
• Foul smell released from the pressure ulcer
• Drainage from the pressure ulcer changes to green
• Fever

Caring for Someone to Prevent Pressure Ulcers

Taking the following precautions can help prevent pressure ulcers when caring for someone who is at risk for this condition:

• Reposition a bedridden person every two hours.
• Use turning aids to protect their skin during turning.
• Position pillows to add comfort and reduce pressure on bony areas.
• Use support surfaces on their bed and in their wheelchair to evenly distribute pressure.
• When seated in a wheelchair, encourage them to do a weight shift every 15 minutes. If they can't shift their own weight, use a power mechanism for independent pressure relief every 30 minutes for 30 seconds.
• Perform a visual check of their skin at least once in the morning and once in the evening, paying special attention to common sites of pressure ulcers.
• Keep their skin clean and dry after sweating and after a bowel or bladder accident.
• Avoid drying out their skin with harsh soaps or lotions that contain alcohol.
• Do not use hot water, which can dry out or burn skin, when assisting in their bathing.
• Do not rub or massage their skin with too much pressure.
  
• Check their equipment regularly to identify areas of wear that no longer provide support.
• Provide a well-balanced diet and plenty of fluids.

Home Setup and Pressure Ulcer Risk

If you or a loved one living at home is at risk for pressure ulcers, a healthcare provider and rehabilitation team can help you determine the type of home setup needed to reduce your individual pressure ulcer risk.

Support surfaces reduce the risk of pressure, especially in areas vulnerable to pressure ulcer development. Avoid recycling a previously used support surface until your healthcare provider approves it as being safe for your needs. Beware that your needs can change throughout your care.

Financial coverage (reimbursement) for specialty devices may be available for certain products. Check with your insurance carrier to determine whether these items are covered.

Some common items for a home setup include the following:

• Static support surfaces for the bed
• Mattresses or mattress overlays that may be air-filled or made of foam, a gel material, or a combination
• Dynamic support surfaces
• Powered alternating air pressure mattresses
• Non-powered air displacement mattresses
• Specialty beds
• Low-air loss beds (hospital-quality beds that reduce pressure and control moisture)
• Air-fluidized beds (home beds that reduce pressure and manage moisture)
• Wheelchair seat cushions
  

Summary

A pressure ulcer or pressure injury is an area of skin that breaks down as a result of constant pressure. This problem occurs most often among people who remain in bed or a wheelchair for long stretches.

Treatment varies by person based on the stage of a pressure ulcer when it is found. Other factors such as health problems can also affect treatment options. Stages 1 and 2 pressure ulcers can often improve with conservative treatment. Stages 3 and 4 pressure ulcers can involve severe deep tissue damage that requires surgery.

Preventing the onset of pressure ulcers is the best way to avoid the severe problems that can result. Frequent movement or change of position, proper bedding, cushions, and sound skin hygiene can reduce your risk of having this problem.