Pressure Ulcers (Pressure Injuries) and Their Treatment

What a pressure ulcer is and how it forms

Skin and the tissue beneath it depend on a fine network of capillaries. When body weight rests on the same point over a bony prominence for long enough, those capillaries are compressed and blood flow to the tissue falls away. If the pressure continues, the muscle and fat under the skin are damaged first, while the surface may still look intact for a while. This is why pressure ulcers are so often deeper than they appear: a small opening on the surface can sit above a much larger area of tissue loss.

Two further forces work alongside pressure. The first is shear: when a patient is dragged up the bed, or when the head of the bed is raised steeply and the body slides down, the skin stays put while the tissues beneath it move in the opposite direction, kinking the small vessels inside. The second is moisture. Skin kept damp by sweat, incontinence or wound exudate becomes thin and far more vulnerable to friction. Pressure injuries appear where these three — pressure, shear and moisture — act together.

• Prolonged dependence on a bed or wheelchair
• Inability to change position independently
• Loss of sensation: spinal cord injury, advanced neuropathy, reduced consciousness
• Skin kept constantly damp by urinary or faecal incontinence
• Poor nutrition, weight loss, low serum albumin
• Older age, thin fragile skin, vascular disease

Who is most at risk

Pressure injuries can appear wherever immobility exists. Bed-bound patients, people in intensive care for long periods, those with spinal cord injury who have lost both sensation and movement, older people immobilised after a hip fracture, and frail patients whose general condition has deteriorated all sit in the highest-risk group. Long operations on the table, casts and splints, and even a poorly fitted wheelchair seat can produce the same result.

The single most important factor is being unable to shift position independently. A healthy person moves many times an hour even while asleep, and those unnoticed adjustments constantly redistribute pressure. When sensation or movement is lost, that protection disappears. Add poor nutrition, anaemia, diabetes, impaired circulation or oedema, and the tissue gives way considerably sooner. The message for families is straightforward: prevention starts the moment the risk is recognised, not when the first wound appears.

Where they appear and how they are staged

Pressure injuries do not develop at random — they form where bone lies closest to the skin. In someone lying on their back, the sacrum and coccyx and the heels are affected most often, with the shoulder blades, elbows and back of the head also at risk during long periods in bed. In a side-lying position it is the greater trochanter of the hip, the outer ankle and the inner knee. For people who sit for long periods, particularly wheelchair users, the ischial tuberosities are the commonest site. Wounds also develop under medical devices — oxygen tubing, catheters, the edges of casts and splints — and these sites are frequently missed during skin checks.

Wounds are staged by depth. In stage 1 the skin is unbroken but shows persistent redness that does not blanch under finger pressure; on darker skin it may show instead as a change in colour, firmness or temperature rather than redness. Stage 2 is superficial tissue loss, appearing as an abrasion or a blister. In stage 3 the wound extends into the fat beneath the skin and forms a crater. In stage 4 muscle, tendon or bone is exposed. When the wound base is covered by dead tissue, the true depth can only be judged after debridement. And when intact skin shows a deep purple or maroon discolouration, that can signal deep tissue injury which may open up over the following days.

• Sacrum and coccyx — the commonest site in people nursed on their back
• Heels — very little tissue lies between skin and bone
• Ischial tuberosities — the sitting bones, in wheelchair users
• Greater trochanter — the side of the hip, in side-lying
• Elbows, shoulder blades, outer ankles and the back of the head
• Under catheters, oxygen tubing, casts and splint edges

Repositioning, support surfaces and skin care

The most effective treatment for a pressure ulcer is removing the pressure, and no dressing substitutes for it. For someone in bed, repositioning roughly every two hours is the usual recommendation; for a wheelchair user who can lift or lean, weight should be shifted far more often — every 15 to 30 minutes. These intervals are a general framework and vary with the person's skin, circulation and the surface they are on. When turning someone onto their side, supporting them with pillows at roughly 30 degrees rather than fully onto the hip keeps weight off the trochanter. For heels, the simplest and most reliable measure is a pillow running lengthways under the calves so that the heels float clear of the mattress altogether.

Pressure-redistributing mattresses and cushions spread load over a wider area and lower the risk, but they do not replace repositioning. Move the patient by lifting or by using a slide sheet rather than dragging, and avoid raising the head of the bed higher than necessary — both reduce shear. Check the skin every day, and make it part of washing and changing. Clean and dry damp areas gently, and use a barrier cream where incontinence is a factor. Do not massage a reddened area over a bony prominence: the tissue there is already injured and rubbing can worsen the damage. Ring or doughnut cushions are also unsuitable, because they concentrate pressure into a narrow circle and further compromise the circulation beneath it.

• Reposition in bed roughly every two hours
• Shift weight every 15-30 minutes when sitting
• Use pillows for a 30-degree tilt rather than a full side turn
• Float the heels off the bed with a pillow under the calves
• Lift or use a slide sheet — never drag the patient up the bed
• Do not massage red areas; do not use ring or doughnut cushions

Nutrition and healing

A wound is dressed from the outside but heals from the inside. Building new tissue is metabolic work, and without enough calories — and above all enough protein — a wound struggles to close. Many patients with pressure ulcers are already undernourished, whether through poor appetite, swallowing difficulty, dependence on others for meals, or other illness. Assessing nutritional state therefore matters as much as the technical details of wound care. Weight loss, muscle wasting and a low albumin level are all findings that need to be taken seriously.

Daily protein and calorie needs depend on body weight, the size of the wound and any coexisting conditions; there is no standard prescription. Where intake by mouth is not sufficient, protein-enriched supplements or, in some situations, tube feeding may be considered. Fluid intake is easily overlooked: dehydration makes skin more fragile and slows healing. Vitamin and zinc supplementation is judged on whether a deficiency exists rather than given to everyone. Where diabetes is present, bringing blood glucose under control is directly relevant to whether the wound heals.

Wound care, debridement and reconstruction

The first requirement is that pressure over the wound is genuinely relieved; without that, no method delivers lasting results. On top of this, care is matched to the stage and the state of the wound base. Superficial wounds may need no more than a dressing that protects the skin and balances moisture. Where dead tissue, thick eschar or infected exudate is present, debridement is needed to give the wound a living base — and it is usually repeated at intervals rather than done once. For deep, heavily exuding wounds, methods such as negative pressure wound therapy can help the wound bed recover. Signs of infection — redness spreading into surrounding skin, warmth, foul smell, increasing discharge, fever, or a general decline in the patient — should never be left to the next appointment, and where bone is exposed, osteomyelitis is investigated.

Reconstructive surgery is considered for deep wounds that are not expected to close on their own. After the wound has been thoroughly debrided, and the underlying bony prominence reshaped where appropriate, the defect is closed with a flap raised from the patient's own tissue. For that repair to last, several conditions have to hold together: pressure on the area must genuinely be relieved, infection controlled, nutrition corrected, smoking stopped, and the positioning rules afterwards must be something the patient and carers can realistically follow. If those conditions cannot be met, a sustainable long-term wound care plan may serve the patient better than an operation — that is a considered choice, not a retreat. At İzmir Cerrahi Merkezi patients with pressure ulcers are assessed across all of these areas at once, and the plan is made together with the family. Because stage, depth and general condition differ from person to person, any treatment decision can only be made after examination.