What Is It?

Bedsores, also called pressure ulcers or decubitus ulcers, are areas of broken skin that can develop in people who:

• Have been confined to bed for extended periods of time
• Are unable to move for short periods of time, particularly if they are thin or have blood vessel (vascular) disease or neurological diseases
• Use a wheelchair or bedside chair (a hospital chair that allows a patient to sit upright next to the bed)

Bedsores generally form at points of pressure, where the weight of the patient’s body presses the skin against the firm surface of the bed. In people confined to bed, bedsores are most common over the hip, spine, lower back, shoulder blades, elbows and heels. In people who use a wheelchair, bedsores are most common on the lower back, buttocks and legs. This pressure temporarily cuts off the skin’s blood supply, which injures skin cells and can cause them to die. Unless the pressure is relieved and blood is allowed to flow to the skin again, the skin soon begins to show signs of injury. At first, there may be only a patch of redness. If this red patch is not protected from additional pressure, the redness can rapidly form blisters or open sores (ulcers). In severe cases, damage may extend through the entire thickness of the skin and create a deep crater that exposes muscle or bone.

Muscle is even more prone to severe injury from pressure than skin. This means that mild injury to the skin may cover a deeper, more pronounced injury to muscle.

The pressure does not have to be very intense to cause bedsores. Pressure of less than 25 percent the pressure of a normal mattress can lead to bedsores. Normally, our skin is protected from being injured by this pressure because we move frequently, even when asleep.

Although persistent pressure on the skin is the most important cause of bedsores, other factors often contribute to the problem. These include:

• Shearing forces and friction — Shearing and friction causes skin to stretch and blood vessels to kink, which can impair blood circulation in the skin. In a person confined to bed, shearing and friction can occur when the person is dragged or slid across the bed sheets. These forces also can occur when the head of the bed is raised more than 30 degrees. This increases shearing forces over the lower back and tail bone.



• Moisture — Wetness from perspiration, urine or feces can make the skin too soft and more likely to be injured by pressure. For this reason, people who are incontinent are at high risk of developing bedsores.



• Decreased movement — People who can move without assistance have a lower risk of bedsores because they can shift their weight periodically. However, bedsores are common in people who can’t move because they are paralyzed, are recuperating from surgery for a prolonged time, are being treated in intensive care for a long time, or are incapacitated by severe arthritis, stroke or a neurological problem such as multiple sclerosis.



• Decreased sensation — Bedsores are common in people who have spinal cord injuries or other neurological problems that decrease the ability to feel pain or discomfort. Without these feelings, the person cannot feel the effects of prolonged pressure on the skin and therefore don’t ask for assistance in shifting pressure away from the affected area.



• Circulatory problems — People with atherosclerosis, circulatory problems from long-term diabetes or localized swelling (edema) may be more likely to develop bedsores. This is because the blood flow in their skin is impaired even before the skin is exposed to pressure. People with anemia are also at risk because their blood cannot carry enough oxygen to skin cells, even though circulation may be normal.



• Poor nutrition — If a person is poorly nourished, he or she is more likely to develop bedsores. Studies show that bedsores are more likely to develop in people who have an inadequate daily intake of protein, vitamin C, vitamin E, calcium or zinc.



• Age — Elderly people, especially those over 85, are more likely to develop bedsores because skin usually becomes thinner with age. Also, as we age, superficial fat tends to shift away from the body surface, where it acts as a cushion, to deeper areas of the body.

Bedsores are a common health problem for people in hospitals and nursing homes and in people being cared for at home. In the United States, approximately 9 percent of all hospitalized patients develop bedsores, as do 3 percent to 14 percent of people in home care and 3 percent to 12 percent of all nursing home residents. Patients transferred from a hospital to a nursing home are particularly vulnerable, with 10 percent to 35 percent having sores at the time they are admitted to the nursing home

Bedsores can lead to severe medical complications, include bone and blood infections, infectious arthritis, penetrating holes below the wound that burrow into bone or deeper tissues, and scar carcinoma, a form of cancer that develops in scar tissue.

Bedsores sometimes are classified into four stages, depending on the severity of skin damage:

• Stage I (earliest signs of skin damage) — White people or people with pale skin will develop a persistent patch of red skin that does not turn white (blanch) when you press it with your finger. In people with darker skin, the patch may be red, purple or blue. The skin also may be tender or itchy, and it may feel warm or cold and firm.



• Stage II — The injured skin blisters or develops an open sore or abrasion that does not extend through the full thickness of the skin. There may be a surrounding area of red or purple discoloration, mild swelling and some oozing.



• Stage III — The ulcer has become a crater and invades soft tissues just below the skin surface.



• Stage IV — The crater has deepened and reaches into a muscle, bone, tendon or joint.

Because the broken skin of a bedsore is a prime target for bacteria, bedsores are extremely vulnerable to infections. This is especially true if the sore is contaminated frequently by the urine or feces of a patient with incontinence. Signs of infection in a bedsore can include:

• Pus draining from the sore
• A foul smelling odor
• Tenderness, heat and increased redness in the surrounding skin
• Fever

In most cases, a doctor or nurse can diagnose a bedsore simply by examining the patient’s skin. Testing is usually unnecessary unless there are symptoms of infection.

If a person with bedsores develops symptoms of infection, then a doctor may order diagnostic tests to determine whether the infection has invaded the soft tissues, bones, bloodstream or another site. These tests may include blood tests, a laboratory examination of tissue or secretions from the bedsore, and radiological tests to look for evidence of a bone infection called osteomyelitis. If you care for a family member who is confined to a bed or wheelchair, your doctor or home care nurse will instruct you how to identify the earliest signs of bedsores. You’ll leanr which areas of skin are particularly vulnerable and what to look for. Once you know how to recognize the earliest signs of skin damage, you can take steps to prevent areas of redness from progressing to full blown ulcers.

Many factors influence how long a bedsore lasts, including the severity of the sore, the type of treatment and the person’s age, overall health, nutrition and ability to move. For example, there is a good chance that a Stage II bedsore will heal within one to six weeks in a relatively healthy older person who eats well and is able to move. Deeper Stage II and Stage IV ulcers may take six weeks to three months to heal. Often, they can last longer. Thirty percent of stage II ulcers, 50 percent of stage III ulcers, and 70 percent of stage IV ulcers take longer than six months to heal.

Bedsores can be an ongoing problem in chronically ill people who have multiple risk factors, such as incontinence, an inability to move and circulatory problems. For this group, the fight against bedsores is often a long-term battle.

Health care experts believe that at least 50 percent of bedsores can be prevented by using simple measures to relieve pressure and decrease the skin’s vulnerability to injury. To help prevent bedsores in a person who is confined to a bed or chair, a professional should do a comprehensive evaluation and create a plan of care. The plan may include these strategies:

• Relieve pressure on vulnerable areas of skin — Change the person’s position every two hours when in bed and every hour when sitting in a chair. Use pillows as needed to raise the person’s arms, legs, buttocks and hips. Relieve pressure on the back with an egg-crate foam mattress, a water mattress or a sheepskin. Two types of beds — air-fluidized beds and low-air-loss beds — are more expensive, but have been shown to reduce pressure ulcers by up to two thirds.



• Reduce shear and friction — Avoid dragging the person across the bed sheets. Either lift the person or have the person use an overhead trapeze to briefly raise his or her body. Keep the bed free from crumbs and other small particles that can rub and irritate the skin. Do not raise the head of the bed more than 30 degrees, unless your doctor instructs you otherwise. Use sheepskin boots and elbow pads to reduce friction on heels and elbows. Wash the person gently. Avoid rubbing or scrubbing the skin.



• Inspect the person’s skin at least once each day — Early detection can prevent Stage I redness from becoming worse.



• Minimize irritation from chemicals — Avoid using irritating antiseptics, hydrogen peroxide, povidone iodine solution or other harsh chemicals to clean or disinfect the skin.



• Encourage the person to eat well — The diet should include enough calories, protein, calcium, and zinc and vitamins C and E. If the person cannot eat enough food, ask your doctor about nutritional supplements.



• Encourage daily exercise — Exercise increases blood flow and speeds healing. In many cases, even bedridden people can do stretches and isometric exercises.



• Keep the skin clean and dry — Clean the skin with saline (a non-irritating salt solution) rather than harsh soaps. Use absorbent pads to draw moisture away from vulnerable areas. If the person is incontinent, ask your doctor about ways to control or limit the leakage of urine or feces.

If you care for someone with bedsores, your doctor or home care nurse may ask you to help with treatment by following preventive steps. These strategies should stop further damage to vulnerable skin and increase the chances of healing.

Additional treatments, usually done by health-care professionals, depend on the stage of the bedsore. First, areas of unbroken skin near the bedsore are covered with a protective barrier film or a moisture barrier lubricant to protect them from injury. Next, special dressings are applied to the injured area either to promote healing or to help remove small areas of dead tissue. If necessary, larger areas of dead tissue may be trimmed away surgically or dissolved with a special medication. Deep craters may need skin grafting and other forms of reconstructive surgery.

If the person’s skin does not begin to heal within a few days after treatment starts, the doctor may prescribe antibiotics, which may be applied as an ointment, taken as a pill or given intravenously (into a vein). Antibiotics also are used to treat bedsores that show obvious signs of infection.

If you find a suspicious area of redness or blistering on a person you are caring for, call a doctor promptly or discuss the problem with your home care nurse.

In many cases, the prognosis for bedsores is good. Simple bedside treatments can heal most Stage II bedsores within a few weeks. If conservative methods fail to heal a Stage III or Stage IV bedsore, reconstructive surgery often can repair the damaged area.

Diseases and Conditions Center

All ArmMed Media material is provided for information only and is neither advice nor a substitute for proper medical care. Consult a qualified healthcare professional who understands your particular history for individual concerns.