Pressure ulcer stages: What to know about bedsores

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Pressure ulcers (also known as pressure sores) are injuries caused by prolonged pressure on your skin. In the beginning, they only affect the top layer of your skin, but without treatment they can turn into open wounds.

Pressure ulcers are more common in people who need to spend most of their time in a bed or chair because of a medical condition. People who are bedridden often get them, which is why they’re commonly known as bedsores.

It’s good to know the stages and symptoms of pressure ulcers, particularly if you or a loved one uses a wheelchair or is on bed rest. Pressure ulcers are much easier to treat when they’re caught at an earlier stage.

Below, we’ll explain the symptoms and stages of pressure ulcers, the causes and what to do if you or someone else has one.

First, what is a pressure ulcer or bedsore?

Pressure ulcers (decubitus ulcers) are injuries to the skin and underlying tissue that are caused by laying or sitting in the same position for too long. Pressure ulcers can develop quickly, and it’s possible to get one even if you’re on bed rest only for a brief period of time.

In the beginning, a pressure ulcer is little more than irritated skin. But as pressure ulcers get worse, they may become open wounds. If they become more severe, they can damage your skin, tissues, muscles and bones.

What causes pressure ulcers? Well, it’s usually pressure

Pressure ulcers get their name from their main cause, which is prolonged pressure on a certain part of the body. But they can also happen when your body’s tissues are pulled the wrong way or are rubbed a lot during movement. Here’s more about the causes of pressure ulcers:

  • Pressure: Lying or sitting down reduces blood supply to the areas of your body that are under pressure. This isn’t normally a problem since every time you move, it shifts the pressure and the blood supply. But if you stay in the same position for a long time, the tissues that are under pressure aren’t able to get enough oxygen and nutrients. When this happens, the skin and tissues can get damaged, and you can develop pressure ulcers.
  • Friction: Your skin is usually pretty strong and doesn’t break down. But if your skin is sensitive or moist, it’s possible for it to be damaged when it rubs against soft items like bedding or hard objects like the arm of a wheelchair. The rubbing can cause heat, removing the top layer of skin.
  • Shear: This is when surfaces move in opposite directions. In your body, shear can happen if one of your bones and the skin over it don’t move together – for example, if your tailbone slips down the surface of an adjustable bed, but the skin over your tailbone doesn’t move because it’s stuck to the mattress.

Bedsores are most likely to develop on any body part under prolonged pressure

Different positions put pressure and stress on your body in different ways, so the locations of pressure sores can vary depending on how your body is positioned over long periods of time. Pressure ulcers are most common near bony prominences, the areas where bones are close to the surface and aren’t well padded with muscle or fat.

  • If you’re bedridden: The location of bedsores will likely depend on your sleeping position and which bones are touching the bed. For example, a back sleeper may get them on their shoulder blades while a side sleeper may get them on their shoulder. Other possible locations for bedsores include your head, hips, lower back, tailbone, heels and ankles, and behind your knees.
  • If you’re in a wheelchair: The most common locations for pressure ulcers include your bottom, tailbone, shoulder blades and backbone, and the back of your arms and legs.

The stages of pressure ulcers: How to tell by what bedsores look and feel like

There are four stages of pressure ulcers. You may be able to tell which you have based on your symptoms.

Stage 1 pressure ulcer symptoms: The skin is unbroken but appears red

A stage 1 pressure ulcer only affects the upper layer of the skin – there are no breaks in the surface. Stage 1 pressure ulcers can often be treated at home and usually go away after 2-3 days.

What a stage 1 pressure ulcer looks like

At the beginning stage, a pressure ulcer looks like a patch of skin that’s a different color. The skin usually looks red if you have lighter skin, and if you have darker skin, the pressure ulcer may look lighter or darker than the surrounding skin. One way to know if it’s a pressure ulcer is to press on your skin. If the skin doesn’t get lighter when you press on it, it may mean that less blood is getting to the area.

What a stage 1 pressure ulcer feels like

The pressure ulcer may feel warmer or cooler than the surrounding tissue. It may also feel firmer or softer than the skin around it. Burning and itching are other common symptoms.

Stage 2 pressure ulcer symptoms: The skin starts to wear down

If you have a stage 2 pressure ulcer, it means the top layer of your skin is beginning to wear down and the ulcer extends to the deeper layers of your skin. You should make an appointment with a primary care doctor if you think you have a stage 2 pressure ulcer, especially if it’s a stage 2 pressure ulcer with broken skin. Recovery time is usually between three days and three weeks with treatment.

What a stage 2 pressure ulcer looks like

A stage 2 pressure sore can look like a scrape, fluid-filled blister or a shallow crater in your skin. It may also ooze clear fluid. The skin around the pressure ulcer will likely be swollen and discolored.

What a stage 2 pressure ulcer feels like

Pressure ulcers are painful and tender at this stage.

Stage 3 pressure ulcer symptoms: A deeper open wound where fat may be visible

With a stage 3 pressure ulcer, the damage goes all the way through the skin and into deeper tissue and fat. At this point, however, it hasn’t yet reached your muscles, tendons or bones. If you think you or a loved one has a stage 3 pressure ulcer, you should see a doctor at a wound care clinic or a podiatrist (for foot ulcers) as soon as you can. With treatment, a stage 3 pressure ulcer may go away in 1-4 months.

What a stage 3 pressure ulcer looks like

A stage 3 pressure ulcer generally looks like a hole that’s so deep you’re able to see the fatty tissue layer at the bottom. There may also be black (dead) tissue in or around the sore. If a bedsore is infected, it may have red edges, drain pus and have a bad smell.

What a stage 3 pressure ulcer feels like

Pressure ulcers at this stage are painful. If it’s infected, your wound will likely be hot to the touch, and you may have a fever.

Stage 4 pressure ulcer symptoms: Large open wounds with discolored tissue

With this stage of pressure ulcers, the damage goes all the way into muscle, tendon or bone, and they are very likely to get infected. Stage 4 pressure ulcers are the most serious and you should go to urgent care or the emergency room to get treatment right away. Even with treatment, these wounds can take a long time to heal – months or even years.

What a stage 4 pressure ulcer looks like

Stage 4 pressure ulcers are open wounds that are large and deep. Inside the hole, you may be able to see tendons, muscles or bone, and there may be black tissue in and around the wound. If it’s infected, the wound may be red, ooze pus and have a bad odor.

What a stage 4 pressure ulcer feels like

Stage 4 pressure ulcers can be extremely painful. If it’s infected, the wound will likely feel hot and you may have a fever.

But doctors can’t always stage pressure ulcers right away

Sometimes a doctor won’t be able to immediately tell the stage of a pressure ulcer by looking at it. Instead, they may say you have one of the following:

  • An unstageable bedsore – The stage isn’t clear because the doctor can’t see the base of the wound since it’s covered by a layer of dead tissue (which can be yellow, grey, green, black or brown in color). Once the wound is cleaned out, your doctor should be able to tell its stage.
  • A suspected deep tissue injury – These may look like a stage 1 or 2 pressure ulcer, but your doctor believes there’s damage to the tissues under the skin that may go down into your fat, tendons, muscle or bone. You may have a suspected deep tissue injury if you have a patch of skin that looks purple or dark red, or if there’s a blister filled with blood.

Risk factors that can lead to pressure sores

Pressure sores are more likely in people who have certain risk factors – and you’re more likely to have these risk factors as you get older:

  • Limited body movement: Certain parts of your body may be under constant pressure if you use a wheelchair to get around or spend most of your time in bed.
  • Incontinence: Incontinence (urine or stool) can leave you with moist, sensitive skin that’s more easily damaged during movement.
  • Unbalanced diet: What you eat and drink play a role in your body’s ability to maintain healthy skin and prevent tissue breakdown. A diet that’s high in sugar and “bad” fats, and low in nutrients can make it harder for your body to heal.
  • Poor blood flow: A condition like diabetes or vascular disease limits blood flow, which means you’re more likely to develop pressure ulcers that can get worse quickly. For example, if you have diabetes, foot pressure ulcers commonly become diabetic wounds that won’t heal.
  • Limited sensory perception: If your sensory perception is affected by a spinal cord injury or a neurological disorder, you may not feel the pain or discomfort that signals you should change position.

What happens if pressure sores go untreated?

It’s best to catch and treat pressure ulcers as soon as possible. When a pressure sore moves from an early stage to an advanced one, it increases the chances of complications, such as:

  • An infection that spreads to your bones, blood or heart
  • Urinary tract infections
  • Breathing problems
  • Extended bed rest
  • Amputation

Some of these complications can be life threatening. If you have a pressure ulcer with broken skin or it doesn’t get better within a couple of days (or gets worse), make an appointment.

Pressure ulcer or bedsore treatments start with self-care and behavior changes

If you catch a pressure ulcer early, it may go away in a few days with home care. But if the skin is open, it’s time to see a doctor. As pressure ulcers get worse, they take much longer to heal and can turn into chronic wounds. Keep reading for some of the steps you can take to help treat a pressure sore.

The first thing to do: Relieve pressure on the area

If you think you have a pressure sore, the first thing you’ll want to do is relieve the pressure on the area. If you catch it soon enough, that may be all you need to do to help it go away. If the pressure ulcer is in a later stage, lessening pressure on the area will help keep it from getting worse and help it heal.

Change the position of your body regularly

Moving your body is the best way to relieve pressure and prevent pressure ulcers. This may be tough to do on your own, so get help if you need it.

  • When in bed: Reposition your body at least once every two hours.
  • When sitting: Change your position every 15 minutes.

Change how you sleep and sit

Pressure ulcers are more likely if you have bony prominences that are under pressure. If you’re able to sit or lay so that there’s less pressure on these bony parts, it can reduce your chance of pressure ulcers.

  • Use padding: Pillows and cushions can help keep pressure off your bones – for example, you might place a pillow between your knees while sleeping. There are also special mattress covers and wheelchair cushions for pressure relief. But don’t use donut cushions since they tend to increase pressure on specific areas.
  • Change the angle: Adjustable beds and specialty wheelchairs make it easier to reposition your body and reduce pressure on your bony parts. Some wheelchairs allow you to tilt and shift pressure off your back and pelvis. When in bed, increasing the elevation of your head reduces pressure on your back, head and shoulders – but keep the angle to 30 degrees or less since greater angles increase the chance of shearing.

Keep your skin clean and dry to help it heal faster

Taking proper care of your skin can stop a pressure sore from getting worse and keep you from developing new ones.

  • Unbroken skin: If you have an early-stage pressure ulcer, wash it with mild soap and water, and dry gently. Do this frequently, especially if the skin comes into contact with moisture, urine or stool. If incontinence is a concern, use a cream with zinc oxide or lanolin to form a moisture barrier to protect the skin.
  • Open wounds: If the skin’s broken, ask your doctor how you should clean your wound. They may recommend that you wash it with water or a saltwater solution, and then cover it with a bandage.

Eat a balanced diet for better wound healing

Your diet plays an important role in the stages of wound healing. It’s important to eat a balanced diet that includes lean proteins, carbohydrates, healthy fats and lots of fruits and vegetables. In particular, you’ll want to focus on getting enough iron, zinc, and vitamins A and C. Also make sure you’re drinking lots of water – your body works best when it’s fully hydrated.

Quit smoking for improved wound healing (and overall health)

Smoking increases inflammation and reduces circulation, making it more likely that you’ll get pressure ulcers and that they’ll take longer to heal. If you’d like help quitting, talk to your primary care doctor.

How more advanced pressure ulcers are treated

If a pressure ulcer has broken your skin, you’ll likely need medical treatments in order to get better.

You’ll need antibiotics if you have an infection

If the wound is infected, your doctor will likely prescribe an oral antibiotic to kill or slow the growth of the bacteria causing the infection. This will help prevent the infection from getting worse and spreading. Plus, it’s easier for a pressure ulcer to heal when it’s not infected.

The right wound dressing can speed up healing

A wound dressing is a cover you wear over your wound to protect it and keep it clean. There are many different options, and your doctor will choose the best one to help the pressure ulcer heal.

Removing unhealthy tissue (debridement) can support new skin growth

Wounds need to be free of damaged, dead or infected tissue to heal properly. And if you have an unstageable ulcer, getting rid of the old tissue is the first step in diagnosing the stage of the pressure ulcer.

To remove damaged tissue, your doctor may gently flush the wound with water or cut out damaged tissue – this is a procedure called wound debridement. In some cases, your doctor may use healthy skin from another part of your body to place over the pressure ulcer. This can help your body grow healthy skin over the wound.

Hyperbaric oxygen therapy can help pressure ulcers that won’t heal

Late-stage pressure ulcers can take a long time to completely heal. Hyperbaric oxygen (HBO) therapy can help heal chronic pressure ulcers, even ones that you’ve had for months or even years.

During each HBO therapy session, you’ll breathe 100% oxygen in an enclosed chamber. The atmospheric pressure in the chamber is higher than normal. This increases the amount of oxygen in your blood, allowing red blood cells to pass more easily through the plasma into the wounds to heal them from the inside out.

Pressure ulcer surgery is usually a last option

Surgery is occasionally used for large or deep pressure ulcers that don’t heal. There are different types of surgery. One of the more common is flap surgery, a procedure that uses a piece of your muscle, skin or other tissue to cover the wound and cushion the nearby bone.

Get the care you need for pressure ulcers and bedsores

You’ll want to get medical attention if you have a pressure ulcer with open skin. Usually, it makes sense to start with your primary care doctor. But for serious or nonhealing ulcers, getting advanced care at the Wound Healing Center is likely the better option – no referral is needed.

Head to urgent care if you have signs of infection, such as fever, drainage from a sore, a sore that smells bad, changes in skin color, warmth or swelling around the sore.