Bed sores (pressure ulcers): treatment, stages, causes and prevention

Bed sores are the everyday name for pressure ulcers, also called pressure sores. The NHS describes them as areas of damage to the skin and the tissue underneath. NICE Clinical Knowledge Summaries defines a pressure ulcer as localised damage to the skin and/or underlying tissue as a result of pressure, or pressure combined with shear, usually over a bony prominence but sometimes related to a medical device or other objects.

They range from patches of discoloured skin to extensive wounds filled with dead tissue that involve muscle and bone. NICE says anyone is potentially at risk, although they are far more likely in people who cannot easily change position.

The NHS says how a pressure ulcer is treated depends on how severe it is, and that changing position and moving regularly is important to relieve pressure and help stop new ulcers forming. Other treatments include specially designed mattresses and cushions, dressings to protect the ulcer and help it heal, creams and ointments, antibiotics if the ulcer is infected, and cleaning the ulcer.

If the pressure ulcer is severe, or other treatments have not worked, the NHS says surgery may be needed to clean and close the ulcer.

NICE Clinical Knowledge Summaries sets out what a clinician considers when managing an ulcer: the prevention steps above plus a nutritional risk assessment, considering pressure-redistributing devices, debriding the wound if indicated (removing dead tissue), prescribing systemic antibiotics if indicated, and recommending appropriate wound dressings. It adds that wounds should only be swabbed if infection is suspected.

The ulcer is also staged or graded using a validated tool, which NICE says guides ongoing prevention and management, and its surface area and depth are recorded so that healing can be tracked.

There is no single answer. NHS inform says how quickly pressure ulcers heal is different for everyone and depends on your treatment plan, how severe the ulcer is, your nutrition, whether there is an infection and whether you have other health conditions. If you are worried that an ulcer is not healing, speak to a healthcare professional.

The most important factor is taking the pressure off the area. The NHS says the ulcers usually develop gradually, but can sometimes appear over a few hours, and that if left untreated they can get worse and eventually reach deeper layers of skin, muscle and bone.

NHS inform explains that healthcare professionals in Scotland use a grading system, and elsewhere a category or stage system is used. The higher the grade, the more severe the ulcer. NHS inform also notes that pressure ulcers can be harder to see on brown or black skin, so they may not be identified until they are more severe.

The NHS says pressure ulcers usually form on bony parts of the body, such as the heels, elbows, hips and tailbone. Symptoms include discoloured patches of skin that do not change colour when pressed, usually red on white skin or purple or blue on black or brown skin, a patch of skin that feels warm, spongy or hard, and pain or itchiness. They can become a blister or open wound.

NHS inform advises anyone at risk to check their skin for areas that are discoloured or feel unusually spongy or tough, using a mirror for parts that are hard to see, such as the back or buttocks, and to contact a GP or healthcare team if they notice any signs of damage.

Pressure ulcers are caused by something putting pressure on, or rubbing, your skin, for example a bed or a wheelchair. It can happen to anyone, but the NHS says it is usually when you have problems moving, as the weight of your body is always on the same areas of skin.

NICE adds that risk factors include reduced mobility, nutritional deficiency, older age, and conditions that cause inadequate blood flow to the skin and soft tissues, such as diabetes and peripheral vascular disease. A validated risk scale, such as the Braden or PURPOSE T tool, is used to support clinical judgement.

• Problems moving.

• Having had a pressure ulcer before.

• Having been seriously ill in intensive care, or recent surgery.

• Being underweight.

• Swollen, sweaty or broken skin, or fragile skin.

• Poor circulation.

• Problems feeling sensation or pain.

The NHS and NHS inform give consistent advice for people being cared for at home. If you are at risk, you can ask a GP for a risk assessment so your care team can make a plan to prevent pressure ulcers.

• Change position regularly.

• Use specially designed mattresses and cushions.

• Keep skin as clean and dry as possible.

• Check your skin every day for signs of a pressure ulcer.

• Try to stay active, if possible.

• Eat a healthy, balanced diet.

• Do not smoke.

• NICE adds a tailored care plan, a skin assessment, extra pressure relief at at-risk sites, and consideration of a barrier preparation if moisture or incontinence is a concern.

The NHS says to see a GP if you think you or someone you care for have a pressure ulcer. Ask for an urgent GP appointment or get help from NHS 111 if you have symptoms of a pressure ulcer and any of the following.

• Hot, swollen or red skin, which can look blue or purple on brown or black skin.

• Pus coming out of the ulcer.

• A high temperature.

• Severe pain, or pain that is getting worse.

NHS inform says pressure ulcers can become infected, with infections including cellulitis, sepsis and bone and joint infections. Other complications include pain, distress, longer hospital stays and reduced quality of life. NICE Clinical Knowledge Summaries lists pain, infection and increased mortality as complications.

If a wound is long-standing or the diagnosis is uncertain, NICE says investigations may be needed to exclude other problems such as venous ulcers, bone infection (osteomyelitis), peripheral arterial disease or malignancy.

On the NHS, pressure ulcers are usually managed by a GP practice nurse, district or community nurses, tissue viability specialists and, in hospital, the ward team, with pressure-relieving equipment arranged through the community or hospital. NICE guideline CG179 covers risk assessment, prevention and treatment in children, young people and adults across NHS settings.

Some families arrange private nursing or wound care at home. The principles are the same: regular repositioning, the right mattress and cushions, good nutrition and early review of any change in the skin. Make sure your GP knows about any ulcer and any equipment or dressings being used.