PassFinals
Dermatology

Pressure Ulcers

Localised damage to skin and underlying tissue, usually over a bony prominence, caused by sustained pressure or pressure combined with shear; early recognition and pressure relief are the core interventions.

In a nutshell

Pressure ulcers are localised tissue injury, usually over bony prominences, caused by sustained pressure with or without shear. Think of immobility, reduced sensation, previous ulceration, malnutrition, incontinence and critical illness; inspect skin early, including for darker-skin discolouration. Categorise the ulcer, offload it, reposition, use an appropriate support surface, manage moisture and nutrition, and treat only clinical infection.

Classic presentation

An immobile or unwell person with pain or discolouration over the sacrum or heel, ranging from non-blanching intact skin to a deep ulcer.

Key points

  • Non-blanching erythema or discolouration is an early pressure injury; start prevention immediately.
  • At-risk adults should change position at least every 6 hours; adults at high risk at least every 4 hours, with an individualised documented plan.
  • Use high-specification foam mattresses for adults admitted to secondary care, at high risk in community care or with an established ulcer; offload heels.
  • Category 1 is intact non-blanching skin; category 2 partial-thickness loss; category 3 full-thickness loss into subcutaneous tissue; category 4 exposes or reaches muscle, tendon, cartilage or bone.
  • Do not routinely swab, use antibiotics to heal the wound, or treat a positive culture without clinical infection.
  • Sepsis, spreading cellulitis, suspected osteomyelitis, necrotising infection, gangrene and exposed deep structures need urgent escalation.

First-line investigation

Clinical risk and skin assessment, followed by measurement and validated categorisation of any ulcer; assess nutrition and infection according to findings.

Management

Triage for infection and deep injury

  • Escalate sepsis, rapidly spreading cellulitis, severe disproportionate pain, necrosis, exposed deep structures, suspected osteomyelitis, gangrene or limb-threatening ischaemia.1,5,6

Offload and reposition

  • Start a documented individualised repositioning plan, offload heels and affected areas, encourage safe mobility and use an appropriate high-specification support surface.1,3

Assess and treat the wound

  • Measure and categorise the ulcer, manage moisture and nutrition, choose a suitable dressing, and debride devitalised tissue when assessment identifies a need.1,2

Treat clinical infection only

  • Use systemic antibiotics for sepsis, spreading cellulitis or underlying osteomyelitis with local microbiology guidance; do not treat colonisation or a positive culture alone.1,4,5,6

Refer complex or non-healing wounds

  • Involve tissue-viability, wound, surgical, vascular or other specialist services for deep, atypical, infected, non-healing or function-threatening ulcers, aligned with goals of care.1,2

Reassess the whole plan

  • Review size, category, depth, pain, exudate, pressure relief, nutrition, moisture, perfusion, infection and concordance, and safety-net for deterioration.1,2

Exam traps

  • A positive wound swab does not by itself prove infection or justify antibiotics.
  • Category 1 is non-blanching, not blanching, erythema of intact skin; colour change may be subtle or darker in brown or black skin.
  • Unstageable means the base is obscured, not that the ulcer is superficial.
  • Do not massage or rub at-risk fragile skin.
  • The support surface and offloading plan do not replace repositioning and reassessment.
  • A heel ulcer requires pressure offloading and consideration of perfusion; do not assume every heel lesion is uncomplicated.

Illustrations

Stage 4 pressure ulcer with exposed boneA clinical photograph of a deep stage 4 pressure ulcer over a bony prominence, with full-thickness tissue loss and exposed bone.Noles1984, Wikimedia Commons · Public domain

Key sources

  1. NICE CG179: Pressure ulcers: prevention and management (NICE prevention and management recommendations for adults and children, including risk assessment, skin inspection, repositioning, support surfaces, nutrition, categorisation, dressings, debridement and infection; guideline published 23 April 2014, last reviewed 30 November 2018, link updates including sepsis cross-reference November 2025; accessed 4 August 2026.)Updated 1 Nov 2025
  2. NHS: Pressure ulcers (pressure sores) (Current NHS information on symptoms, skin colour changes, urgent infection advice, treatment, risk factors and prevention; page last reviewed 6 July 2023 and accessed 4 August 2026.)Updated 6 Jul 2023
  3. NICE QS89: Pressure ulcers (NICE quality standard on pressure-redistributing devices, risk factors and high-risk status; accessed 4 August 2026.)
  4. NICE NG15: Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use (NICE antimicrobial-stewardship recommendations for prescribing, reviewing, documenting and narrowing antimicrobial treatment; published 18 August 2015 and accessed 4 August 2026.)Updated 18 Aug 2015
  5. NICE NG253: Suspected sepsis in people aged 16 or over: recognition, assessment and early management (Current NICE adult sepsis recognition and early-management pathway, published 19 November 2025 and accessed 4 August 2026.)Updated 19 Nov 2025
  6. British National Formulary (BNF) (BNF online prescribing information for analgesia, wound-care products and antibiotics; current product-specific details, contraindications, interactions and monitoring must be checked at the point of care; accessed 4 August 2026.)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.