Bedsores, also called pressure sores or pressure ulcers, are areas of damaged skin and tissue that develop when sustained pressure cuts off circulation to vulnerable parts of your body, especially the skin on your buttocks, hips and heels. Without adequate blood flow, the affected tissue dies. Bedsores can develop quickly, progress rapidly and are often difficult to heal.
If you use a wheelchair, you’re most likely to develop a pressure sore on:
- Your tailbone or buttocks
- Your shoulder blades and spine
- The backs of your arms and legs where they rest against the chair
When you’re bed-bound, pressure sores can occur in any of these areas:
- The back or sides of your head
- The rims of your ears
- Your shoulders or shoulder blades
- Your hipbones, lower back or tailbone
- The backs or sides of your knees, heels, ankles and toes
Bedsores symptoms fall into one of four stages based on their severity.
- Stage I. A pressure sore begins as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. In blacks, Hispanics and other people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage I wounds are superficial and go away shortly after the pressure is relieved.
- Stage II. At this stage, some skin loss has already occurred — either in the outermost layer of skin (the epidermis), the skin’s deeper layer (the dermis), or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration.
- Stage III. By the time a pressure ulcer reaches this stage, the damage has extended to the tissue below the skin, creating a deep, crater-like wound.
- Stage IV. This is the most serious and advanced stage. A large-scale loss of skin occurs, along with damage to underlying muscle, bone, and even supporting structures such as tendons and joints.
If you’ve been immobilized, bedsores can be caused by:
- Sustained pressure. When your skin and the underlying tissues are trapped between bone and a surface such as a wheelchair or bed, blood flow is restricted. This deprives tissue of oxygen and other nutrients, and irreversible damage and tissue death can occur. This tends to happen in areas that aren’t well padded with muscle or fat and that lie just over a bone, such as your spine, tailbone (coccyx), shoulder blades, hips, heels and elbows.
In some cases, the pressure that cuts off circulation comes from unlikely sources: the rivets and thick seams in jeans, crumbs in your bed, wrinkled clothing or sheets, a chair whose tilt is slightly off — even perspiration, which can soften skin, making it more vulnerable to injury.
- Friction. Frequent shifts in position are the key to preventing pressure sores. Yet the friction that occurs when you simply turn from side to side can damage your skin, making it more susceptible to pressure sores.
- Shear. This occurs when your skin moves in one direction, and the underlying bone moves in another. Sliding down in a bed or chair or raising the head of your bed more than 30 degrees is especially likely to cause shearing, which stretches and tears cell walls and tiny blood vessels. Especially affected are areas such as your tailbone where skin is already thin and fragile.
Bedsores are usually unmistakable, even in the initial stages
Treating bedsores is challenging. Open wounds are slow to heal, and because skin and other tissues have already been damaged or destroyed, healing is never perfect. Most stage I and stage II sores will heal within weeks with conservative measures. But stage III and stage IV wounds, which are less likely to resolve on their own, may require surgery.
The first step in treating a sore at any stage is relieving the pressure that caused it. You can reduce pressure by:
- Changing positions often. Carefully follow your schedule for turning and repositioning — approximately every 15 minutes if you’re in a wheelchair and at least once every two hours when you’re in bed.
- Using support surfaces. These are special cushions, pads, mattresses and beds that relieve pressure on an existing sore and help protect vulnerable areas from further breakdown.
The most effective support depends on many factors, including your level of mobility, your body build and the severity of your wound. No one support surface is appropriate for all people or all situations. In general, protective padding such as sheepskin isn’t thick enough to reduce pressure, but it’s helpful for separating parts of your body and preventing friction damage.
You can use a variety of foam, air-filled or water-filled devices to cushion a wheelchair, but avoid using pillows and rubber rings, which actually cause compression.
Other nonsurgical treatments of pressure sores include:
Cleaning. It’s essential to keep wounds clean to prevent infection. A stage I wound can be gently washed with water and mild soap, but open sores should be cleaned with a saltwater (saline) solution each time the dressing is changed. Avoid antiseptics such as hydrogen peroxide and iodine, which can damage sensitive tissue and delay healing.
Controlling incontinence as far as possible is crucial to helping sores heal. If you’re experiencing bladder or bowel problems, you may be helped by lifestyle changes, behavioral programs, incontinence pads or medications.
Removal of damaged tissue . To heal properly, wounds need to be free of damaged, dead or infected tissue. This can be accomplished in several ways — the best approach depends on your overall condition, the type of wound and your treatment goals.
One approach is surgical debridement, a procedure that involves using a scalpel or other instrument to remove dead tissue. Surgical debridement is quick and effective, but it can be painful. For that reason, your doctor may use one or more nonsurgical approaches. These include removing devitalized tissue with a high-pressure irrigation device (mechanical debridement), allowing your body’s own enzymes to break down dead tissue (autolytic debridement), or applying topical debriding enzymes (enzymatic debridement).
Dressings. A variety of dressings are used to help protect wounds and speed healing — the type usually depends on the stage and severity of the wound. The basic approach, however, is to keep the wound moist and the skin surrounding it dry. Stage I sores may not need any covering, but stage II lesions are usually treated with hydrocolloids, or transparent semipermeable dressings that retain moisture and encourage skin cell growth. Other types of dressings may be more beneficial for weeping wounds or those with surface debris. Contaminated sores may also be treated with a topical antibiotic cream.
Hydrotherapy. Whirlpool baths can aid healing by keeping skin clean and naturally removing dead or contaminated tissue.
Oral antibiotics. If your pressure sores appear infected, your doctor may prescribe oral antibiotics.
Healthy diet. Eating a nutritionally rich diet with adequate calories and protein and a full range of vitamins and minerals — especially vitamin C and zinc — may improve wound healing. Being well nourished also protects the integrity of your skin and guards against breakdown. If you’re at risk of or recovering from a pressure sore, your doctor may prescribe vitamin C and zinc supplements.
Muscle spasm relief. This is essential for both preventing and treating pressure sores. To help alleviate spasticity, your doctor may recommend skeletal muscle relaxants that block nerve reflexes in your spine or in the muscle cells themselves.
Even with the best medical care, bedsores may reach a point where they require surgical intervention. The goals of surgery include improving the hygiene and appearance of the sore, preventing or treating infection, reducing fluid loss through the wound, and lowering the risk of future cancer.
The type of reconstruction that’s best in any particular case depends mainly on the location of the wound and whether there’s scar tissue from a previous operation. In general, though, most pressure wounds are repaired using a pad of muscle, skin or other tissue that covers the wound and cushions the affected bone (flap reconstruction). The tissue is usually harvested from your own body. Before the operation, the wound is debrided, although much more extensively than it is in nonsurgical treatments.
Other treatment options
Researchers are searching for more effective bedsore treatments. Under investigation are hyperbaric oxygen, electrotherapy and the topical use of human growth factors. So far, the only therapy that appears promising in early trials is human growth factor, but further studies are necessary.