Decubitis ulcers

Decubitis ulcers are more commonly called decubitus ulcers, pressure ulcers, pressure sores, or pressure injuries. They are areas of damaged skin and deeper tissue caused by sustained pressure or pressure combined with shear. Shear occurs when the skin stays in place while tissue underneath slides, such as when someone slips down in bed.

Pressure ulcers often develop over bony areas, including the heels, ankles, hips, tailbone, elbows, shoulders, and back of the head. They can also form under medical equipment, such as oxygen tubing, masks, splints, or casts.

Pressure reduces blood flow to compressed tissue. Without enough oxygen and nutrients, tissue becomes injured and may die. Damage can begin below the skin before a surface wound is visible.

Some pressure ulcers affect only the upper skin layers. Others extend into fat, muscle, tendon, or bone. Early recognition and pressure relief may prevent deeper injury.

An early pressure injury may look like a patch of skin that remains red after pressure is removed. On brown or black skin, redness may be difficult to see. The area may instead appear purple, blue, darker, lighter, or unusually shiny.

Other early changes include pain, tenderness, itching, warmth, coolness, swelling, or different firmness from nearby skin. People with reduced sensation may not feel these changes.

As an injury becomes deeper, symptoms can include:

• A blister or shallow open sore
• Loss of the full thickness of the skin
• A crater-like wound with visible fat
• Yellow or dark dead tissue
• Visible muscle, tendon, cartilage, or bone
• Fluid, pus, blood, or an unpleasant smell

Clinicians classify pressure injuries by depth and appearance. Stage 1 has intact skin with persistent discoloration that does not turn pale when pressed. Stage 2 involves partial skin loss or an exposed, moist skin layer. Stage 3 extends through the full skin thickness into fatty tissue. Stage 4 exposes or involves muscle, tendon, cartilage, or bone.

An injury is unstageable when dead tissue covers its base, hiding its true depth. A deep tissue pressure injury may appear dark red, maroon, or purple even when the skin remains intact.

Pressure ulcers result from pressure or pressure combined with shear. Friction makes skin less able to tolerate these forces. Moisture from sweat, urine, stool, or wound drainage can also weaken skin, although moisture damage is not the same as a pressure ulcer.

Anyone can develop a pressure ulcer if enough pressure is applied for long enough. Risk is higher when a person cannot change position or feel discomfort that would normally prompt movement.

Risk factors include:

• Limited movement because of illness, injury, paralysis, sedation, or surgery
• Long periods in a bed, chair, or wheelchair
• Reduced sensation from spinal cord injury, nerve damage, or another condition
• Poor blood flow or low oxygen delivery
• Frail or easily damaged skin
• Poor nutrition, dehydration, or unplanned weight loss
• Urine or stool remaining against the skin
• Medical devices pressing against the body
• A previous pressure ulcer
• Difficulty communicating pain or discomfort

Pressure ulcers are not necessarily evidence of poor care. They may develop despite careful prevention, particularly during severe illness or when blood flow and movement are greatly limited.

A pressure ulcer is usually diagnosed by examining the skin and wound. The clinician assesses its location, depth, colour, size, drainage, surrounding skin, and exposed tissue. They may gently check whether discoloration turns pale when pressed.

The wound is staged after visible tissue has been assessed. A healing stage 4 ulcer is not reclassified as stage 3 or stage 2 because its original depth remains clinically important.

Tests are not always needed. Blood tests may be used if infection, anaemia, inflammation, dehydration, or poor nutrition is suspected. Tissue or fluid may be sampled when the result could guide infection treatment. Bacteria on the surface do not necessarily mean the wound is infected.

An X-ray or MRI may be considered if infection may have reached bone. A bone biopsy is sometimes needed to confirm osteomyelitis, meaning infection within a bone.

Clinicians may also assess mobility, circulation, sensation, nutrition, continence, pain, and equipment used for sitting or lying down.

Treatment focuses on reducing pressure and supporting healing. Care depends on the ulcer’s depth, location, drainage, infection risk, and the person’s overall health.

A repositioning plan limits time spent on the affected area. Timing and technique should account for mobility, skin tolerance, comfort, medical condition, and the support surface. No single repositioning schedule suits everyone.

Pressure-redistributing mattresses, cushions, heel supports, or other surfaces spread weight more evenly. They do not replace movement and skin checks. Ring-shaped cushions can concentrate pressure around their edges and are generally not recommended.

Open ulcers are usually cleaned and covered with a suitable dressing. Dressings protect the wound, manage fluid, and maintain a healing environment. Choice depends on wound depth, drainage, surrounding skin, comfort, and how often changes are needed.

Dead tissue may require debridement using dressings, instruments, or other methods. Stable, dry tissue covering a heel is sometimes left in place if there are no signs of infection or instability, but this requires professional assessment.

Pain treatment may be needed for daily activities and dressing changes. A nutrition assessment can identify low food intake, weight loss, or other barriers to healing. Supplements are not needed by everyone and do not replace assessment.

Antibiotics like amoxicillin or doxycycline are used for clinical infection, such as spreading skin infection, bone infection, or infection affecting the whole body. They are not routinely prescribed simply because bacteria are present in a chronic wound.

Deep or slow-healing ulcers may require specialist wound care. Surgery may be considered after pressure, nutrition, infection, and other health concerns have been addressed.

Pressure ulcers can become deeper or larger if pressure continues. Poor circulation, infection, inadequate nutrition, repeated shear, or another illness may delay healing.

Possible complications include cellulitis, abscesses, and infection of nearby bone. Rarely, bacteria enter the bloodstream and cause sepsis, a dangerous whole-body response to infection.

Chronic wounds may cause persistent drainage, odour, pain, sleep problems, reduced movement, and difficulty using a wheelchair or taking part in usual activities.

Deep wounds can leave scars and changes in body shape. Scarred tissue tolerates pressure less well, increasing the risk of recurrence.

Many pressure ulcers can be prevented, but not every case is avoidable. Risk may remain high during critical illness, severe circulation problems, or when movement is medically restricted.

Prevention focuses on reducing pressure and identifying skin changes early. A care plan may include:

• Regular position changes when movement is limited
• Daily checks of pressure-prone areas and skin under medical devices
• A suitable mattress, seat cushion, or heel support
• Keeping skin clean and managing excess moisture promptly
• Avoiding dragging during transfers or repositioning
• Keeping clothing and bedding smooth and dry
• Addressing poor appetite, weight loss, or difficulty eating and drinking

Do not rub or massage persistent discoloration. This adds friction and may worsen injured tissue.

Wheelchair users may need seating and posture assessment. Equipment should fit correctly and be reassessed after changes in weight, mobility, posture, or health.

Healing may take weeks or months. Shallow injuries often close sooner than deep wounds, but healing also depends on circulation, pressure relief, nutrition, infection, and other health conditions. Some deep ulcers do not fully heal.

Healthy new tissue is often pink or red and slightly bumpy. A healing wound usually becomes smaller and shallower. A sudden increase in size, drainage, odour, pain, or dark tissue needs assessment and should not be assumed to be part of healing.

Daily care may involve planned position changes, dressings, equipment checks, and help with transfers. If sensation is reduced, visual skin checks are especially important because pain may not provide a warning.

After an ulcer closes, new tissue remains more vulnerable than uninjured skin. Continue pressure protection and routine checks. Recurrence is possible, especially when mobility, sensation, or circulation problems remain.

Arrange prompt medical assessment for persistent discoloration, a blister over a pressure point, broken skin, or a wound that is becoming deeper. Also seek assessment if a medical device leaves a lasting mark.

Seek urgent medical help if an ulcer develops increasing warmth, swelling, redness, pain, pus, bad-smelling drainage, black tissue, or rapidly worsening skin changes. Fever or feeling newly unwell with a wound also requires urgent assessment.

Seek emergency care for confusion, fainting, severe weakness, difficulty breathing, very fast breathing, mottled skin, or rapidly spreading redness with serious illness. These may indicate sepsis or another emergency.

Continue routine follow-up even when the wound appears to improve. Follow-up allows clinicians to measure healing, review dressings, check pressure-relief equipment, and adjust the care plan.

Are decubitus ulcers the same as bedsores?

Yes. Decubitus ulcers, bedsores, pressure sores, pressure ulcers, and pressure injuries describe the same general condition. “Pressure injury” reflects that significant damage can exist before the skin opens.

Can a pressure ulcer heal completely?

Many heal, particularly when found early and pressure is effectively relieved. Deep wounds may take months, and some do not fully close. The area remains vulnerable after healing.

How often should someone be repositioned?

There is no safe interval for everyone. Repositioning should reflect mobility, skin condition, comfort, illness, equipment, and tissue tolerance. A pressure-relieving mattress does not remove the need for movement and skin checks.

Should I put antiseptic or cream on a pressure ulcer?

Not every product is suitable. Some antiseptics damage healing tissue, while creams may trap moisture or interfere with dressings. The wound should be assessed so cleaning and dressing choices match its condition.

Are pressure ulcers contagious?

No. A pressure ulcer cannot spread between people. However, wounds may contain bacteria, so use careful hand hygiene and dispose of used dressings correctly.

Why did an ulcer appear even though preventive care was used?

Prevention reduces but cannot eliminate risk. Severe illness, poor blood flow, fragile tissue, reduced sensation, medical devices, and limits on safe movement can lead to an ulcer despite appropriate care.