Pressure sores

Specialties > Dermatology

Background knowledge 🧠

Definition

Pressure sores, also known as pressure ulcers or bedsores, are areas of localized damage to the skin and underlying tissue, primarily caused by prolonged pressure, friction, or shear.
They commonly occur over bony prominences such as the sacrum, heels, and hips.

Epidemiology

Pressure sores affect approximately 4-10% of hospital inpatients.
Higher prevalence in elderly, immobile, and critically ill patients.
Common in patients with spinal cord injuries.
Significant cause of morbidity and healthcare costs.

Aetiology and Pathophysiology

Prolonged pressure over bony prominences impedes blood flow, leading to ischemia and tissue necrosis.
Friction and shear forces exacerbate tissue damage by disrupting the integrity of the skin and underlying structures.
Contributing factors include immobility, malnutrition, moisture (incontinence), and reduced sensation.

Types

Classified into four stages:
Stage 1: Non-blanchable erythema of intact skin.
Stage 2: Partial-thickness skin loss with exposed dermis.
Stage 3: Full-thickness skin loss; adipose tissue visible.
Stage 4: Full-thickness skin and tissue loss; muscle, tendon, or bone exposed.
Unstageable: Obscured full-thickness skin and tissue loss.
Deep tissue injury: Persistent non-blanchable deep red or maroon discoloration.

Clinical Features 🌡️

Symptoms

Pain or discomfort over affected areas, particularly in earlier stages.
Loss of sensation in severe cases, especially in patients with neuropathy.
Patients may report itching or burning in affected areas.
Signs of infection may include increased pain, erythema, and malodorous discharge.

Signs

Erythema that does not blanch under pressure (Stage 1).
Ulceration of varying depth depending on the stage.
Presence of necrotic tissue, slough, or eschar in more advanced stages.
Surrounding skin may show signs of inflammation or cellulitis.
Possible underlying osteomyelitis or septic arthritis in deep ulcers.
Unpleasant odor or discharge may suggest infection.

Investigations 🧪

Tests

Primarily a clinical diagnosis based on history and examination.
Wound swabs or biopsies if infection is suspected.
Blood tests including FBC, CRP, and ESR may be used to assess systemic infection or inflammation.
X-rays, MRI, or bone scans may be indicated to rule out osteomyelitis.
Nutritional assessments are often recommended for at-risk patients.

Management 🥼

Management

Pressure relief: Frequent repositioning and use of pressure-relieving devices (mattresses, cushions).
Wound care: Regular cleaning and dressing changes; consider hydrocolloid, foam, or alginate dressings.
Debridement: Removal of necrotic tissue via surgical, enzymatic, or autolytic methods.
Infection control: Topical or systemic antibiotics for infected sores.
Nutritional support: Ensure adequate protein and caloric intake; consider supplementation.
Multidisciplinary approach: Involvement of wound care specialists, dietitians, and physical therapists.

Complications

Infection: Cellulitis, osteomyelitis, and sepsis.
Chronic pain and discomfort.
Malignancy: Marjolin’s ulcer (squamous cell carcinoma in chronic wounds).
Impaired mobility and quality of life.

Prognosis

Prognosis varies depending on stage, patient comorbidities, and effectiveness of management.
Stage 1 sores may heal within days with proper care.
Advanced stage ulcers may take months to heal and may require surgical intervention.
High risk of recurrence if underlying risk factors are not addressed.

Key Points

Prevention is critical and involves regular repositioning, skin inspection, and use of pressure-relieving devices.
Early detection and treatment are essential to prevent progression and complications.
Multidisciplinary care improves outcomes and reduces morbidity associated with pressure sores.
Education of healthcare staff and carers is key to effective prevention and management.

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