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Health condition · Clinically reviewed

Bed sores, prevention, staging and the right dressing at the right time.

Pressure ulcers develop quickly and heal slowly. Prevention, early staging and a coordinated wound team make the biggest difference.

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Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE CG179, NG74 and NPUAP/EPUAP/PPPIA standards you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK guidance on prevention, SSKIN bundles, dressings and reconstructive surgery.

Key facts

Bed sores at a glance.

The essentials, in plain English. What they are, where they form, and how modern UK wound care handles them.

  • What they are

    Localised damage to skin and underlying tissue from prolonged pressure, shear or friction, usually over a bony prominence.

  • Where they form

    Sacrum, heels, ischial tuberosities, greater trochanter, occiput, elbows and malleoli. Also under medical devices.

  • Who is at risk

    Anyone with immobility, reduced sensation, malnutrition, incontinence, older age or advanced illness.

  • How they are graded

    Stages 1 to 4, plus unstageable, deep tissue injury, medical device-related and mucosal categories.

  • Prevention

    SSKIN bundle, repositioning, pressure-redistributing mattresses, heel offloading and nutrition.

  • Serious harm

    A hospital-acquired stage 3 or 4 ulcer is a reportable Serious Incident in the NHS.

Why this guide matters

Most pressure ulcers are preventable.

The three points below shape the whole page. Prevention is cheaper and kinder than treatment, and staging drives everything else.

  • The SSKIN bundle works

    Skin, Surface, Keep moving, Incontinence and Nutrition together prevent far more damage than any single measure.

  • Stage drives the plan

    A stage 2 ulcer is not a stage 4. Correct staging chooses the mattress, the dressing and whether surgery is needed.

  • Nutrition is treatment

    Healing needs calories, protein, vitamin C, zinc and fluids. Dressings alone cannot compensate for undernutrition.

How the assessment is made

From risk score to a written plan.

The steps a ward nurse, tissue viability specialist or community team will normally follow, in order.

  1. 01

    Screening

    Risk assessment on admission

    Waterlow, Braden, Norton or PURPOSE-T scored within six hours of admission and then weekly or on any change in condition.

  2. 02

    Screening

    Daily skin inspection

    Pressure points checked every day, with a low threshold in darker skin tones where erythema can be harder to see.

  3. 03

    Screening

    SSKIN bundle applied

    Skin, Surface, Keep moving, Incontinence and Nutrition addressed together, not one at a time.

  4. 04

    Assessing

    Full staging and TIMES

    Any ulcer is staged 1 to 4 and assessed for Tissue, Infection, Moisture, Edge and Surrounding skin.

  5. 05

    Assessing

    Nutrition and bloods

    MUST screening, plus albumin, prealbumin and infection markers when clinical suspicion is present.

  6. 06

    Investigating

    Imaging for deep infection

    X-ray, MRI and probe-to-bone testing when osteomyelitis is suspected under a stage 3 or 4 ulcer.

  7. 07

    Investigating

    Biopsy if chronic

    A long-standing non-healing ulcer needs biopsy to exclude squamous cell carcinoma (Marjolin ulcer).

Typical timeline: first risk screen within hours, full plan within a day.

Staging

What each stage of a pressure ulcer looks like.

The international NPUAP/EPUAP/PPPIA system runs from intact red skin to exposed bone, plus special categories for deep tissue injury and medical devices.

  • Stage 1 - non-blanchable erythema

    Intact skin with persistent redness that does not fade under fingertip pressure. The earliest warning sign.

  • Stage 2 - partial-thickness loss

    A shallow open ulcer or intact or ruptured blister with exposed dermis. Painful and easy to miss under dressings.

  • Stage 3 - full-thickness loss

    Subcutaneous fat is visible but bone, tendon and muscle are not exposed. Slough may be present.

  • Stage 4 - deep tissue exposed

    Full-thickness loss with exposed bone, tendon or muscle. High risk of osteomyelitis and reconstructive need.

  • Unstageable

    Depth obscured by slough or eschar. Cannot be staged until the wound bed is visible.

  • Deep tissue injury

    Persistent non-blanchable deep red, maroon or purple discolouration. Often heralds a much deeper wound.

  • Medical device-related

    From NG tubes, oxygen tubing, urinary catheters, splints and casts. Mirrors the shape of the device.

  • Red flag - systemic infection

    Fever, rigors, spreading cellulitis, malodour or sudden deterioration. Needs urgent sepsis review.

Treatment

How bed sores are treated in the UK.

Offload the pressure, prepare the wound bed, choose the right dressing, treat infection and feed the healing. Surgery for the deepest wounds.

  • Repositioning and offloading

    30-degree tilt, two to four hourly turns and heel-offloading boots or cushions. The single most effective intervention.

  • Pressure-redistributing surface

    Static foam, alternating air, low air loss or air fluidised mattress, matched to risk and current wound stage.

  • Skin protection and moisture

    Barrier films and creams, prompt incontinence care and moisture-wicking fabrics to reduce maceration and friction.

  • Debridement

    Autolytic (hydrocolloid, hydrogel), enzymatic, mechanical, sharp or biosurgical larvae. Necrotic tissue must go before healing can start.

  • Modern dressings

    Hydrocolloid, foam, alginate, hydrogel and antimicrobial silver, iodine or honey chosen by wound bed and exudate.

  • Negative pressure wound therapy

    VAC dressings for deep, granulating stage 3 and 4 wounds to promote contraction and perfusion.

  • Nutrition support

    30 to 35 kcal/kg and 1.25 to 1.5 g protein/kg daily, plus vitamin C, zinc and arginine where clinically indicated.

  • Reconstructive surgery

    Fasciocutaneous or myocutaneous flap coverage of stage 3 or 4 ulcers in appropriate candidates, led by plastic surgery.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and international consensus standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your tissue viability nurse, GP or hospital team knows your skin and history and can tell you which parts apply to you. If in doubt, get seen.

  • NICE. Pressure ulcers: prevention and management (CG179).

  • NICE. Advanced wound dressings and antimicrobial dressings (NG74 related guidance).

  • NPUAP/EPUAP/PPPIA. International Clinical Practice Guideline on the prevention and treatment of pressure ulcers/injuries.

  • NHS England. Pressure ulcer categorisation and Serious Incident framework.

Red flags

When a pressure ulcer needs urgent attention.

Many ulcers can be managed at home or on the ward. These are the situations where escalation is not optional.

  • Sepsis or spreading cellulitis

    Fever, tachycardia, hypotension or expanding erythema around an ulcer needs same-day medical review and IV antibiotics.

  • Suspected osteomyelitis

    Deep, non-healing stage 4 wounds, probe-to-bone or exposed bone need urgent imaging and a bone and joint infection team.

  • Necrotising fasciitis

    Pain out of proportion, dusky skin, crepitus or rapidly spreading redness. A surgical emergency.

  • Sudden deep tissue injury

    A new area of maroon or purple discolouration in a pressure zone signals extensive underlying damage.

  • Chronic non-healing ulcer

    An ulcer open for months, especially with raised edges, needs biopsy to exclude Marjolin (squamous cell) transformation.

  • Hospital-acquired grade 3 or 4

    Reportable as a Serious Incident in NHS trusts and always warrants a tissue viability and safeguarding review.

  • Care-related pressure damage

    In vulnerable adults, unexplained pressure damage can be a safeguarding concern and should be escalated.

  • Uncontrolled pain

    Pressure ulcers are painful, especially on dressing change. Regular analgesia and premedication are essential.

  • Device-related damage

    New skin damage under NG tubes, oxygen tubing or catheters needs immediate device review and repositioning.

Living with it

A serious condition, managed by a team.

Four things carry most of the weight day to day. Move, match the surface, feed the healing and use the whole team.

A quiet reminder

Small consistent changes protect fragile skin.

Two-hourly turns and a dry, well-nourished patient do more than any single dressing on the market.

  1. 01 Move

    Keep changing position

    Even small, regular position changes reduce sustained pressure. Two to four hourly is the working rule.

  2. 02 Surface

    Match the mattress to the risk

    A foam mattress is not enough for high-risk skin. Alternating air or low air loss surfaces protect fragile tissue.

  3. 03 Nutrition

    Eat and drink for healing

    Protein, calories, vitamin C, zinc and fluids matter as much as any dressing. Ask for a dietitian if intake is poor.

  4. 04 Team

    Use the whole MDT

    Tissue viability nurses, physiotherapists, dietitians and community teams all have a role. Do not try to manage a serious ulcer alone.

Frequently asked

Everything we get asked about bed sores.

Quick answers on risk, staging, prevention, dressings and when to escalate.

  • What are bed sores?

    Bed sores (pressure ulcers, pressure injuries or decubitus ulcers) are localised areas of skin and underlying tissue damage caused by prolonged pressure, shear or friction. They usually form over bony prominences such as the sacrum, heels, hips and elbows.

  • Who is most at risk?

    People with reduced mobility (spinal cord injury, stroke, Parkinson's), reduced sensation, poor nutrition, incontinence, older age, peripheral vascular disease, diabetes, anaemia, steroid use or terminal illness. A previous pressure ulcer is a strong risk factor for another.

  • How are they staged?

    The international system runs from stage 1 (non-blanchable erythema of intact skin) through stage 2 (partial-thickness loss), stage 3 (full-thickness loss into fat) and stage 4 (bone, tendon or muscle exposed). Wounds obscured by slough or eschar are unstageable, and deep purple discolouration is called a deep tissue injury.

  • Can bed sores be prevented?

    Most are preventable. The SSKIN bundle brings together Skin inspection, Surface (mattress), Keep moving, Incontinence care and Nutrition. Repositioning every two to four hours, heel offloading and a suitable pressure-redistributing mattress make the biggest difference.

  • How are they treated?

    Treatment combines pressure offloading, wound bed preparation (debridement of dead tissue), modern dressings matched to exudate, treatment of infection, and nutritional support. Deep stage 3 or 4 wounds may need negative pressure wound therapy or reconstructive flap surgery.

  • When do bed sores need hospital care?

    Signs of sepsis, spreading cellulitis, suspected osteomyelitis, exposed bone, necrotising fasciitis or a rapidly deteriorating wound need urgent hospital assessment. In NHS trusts, hospital-acquired stage 3 and 4 ulcers are reportable as Serious Incidents.

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