Pressure Ulcers (Bedsores): Stages, Care & Prevention

A pressure ulcer, also called a bedsore, a pressure sore, or a pressure injury, is damage to the skin and to the tissue underneath it, caused by constant pressure on one part of the body. The pressure squeezes the small blood vessels in that spot, so blood and oxygen no longer reach the tissue in the amount it needs, and the tissue begins to break down and die.

What Is a Pressure Ulcer?

Pressure ulcers form when the same area of the body carries constant pressure, most often when a person stays lying or sitting in one position for a long time. They are common in older adults and in anyone whose movement is limited, and they can begin within hours.

They usually develop on skin that lies directly over bone, where there is little muscle or fat to cushion it. The most common sites are:

The hips and outer thighs
The knees, especially where the inner knees press against each other
The ankles
The buttocks
The heels
The spine
The shoulder blades
The tailbone
The elbows
The back of the head
The ears

If you are caring for a relative at home, one point matters more than any other: at the earliest stage the skin is still intact. There is no open sore and no wound yet, only a change in the color, the temperature, or the feel of the skin. Waiting until an open sore appears means missing the one stage at which the damage can still be stopped and reversed completely, with no tissue lost.

So check the pressure points every day, in good light. Because there is nothing to see but a change in the skin, there is one simple check that tells you whether you are looking at a harmless flush or at real damage. Press the discolored area with a fingertip, firmly enough to make healthy skin next to it turn pale but not hard enough to hurt, for about three seconds. Lift your finger and look at once. If the skin goes pale under your finger and then refills with color, blood is still reaching the area. That is not the first stage of a pressure injury, but it is a clear warning that the spot is carrying too much pressure and that the pressure must come off it. If the skin does not go pale and the discoloration stays exactly as it was, that is a stage 1 pressure injury. That is the medical definition of stage 1, not an extra detail. Never do this check on broken skin, on a blister, on a scab, or on a dark purple or maroon patch.

If your relative has darker skin, the color change may not be visible at all, and looking is not enough. Any change may show as an area darker than the skin around it, or as a dull gray or purple cast, rather than as clear redness. The signs that are not about color then matter more, and you find them with your hands: a spot that is warmer than the skin around it, or cooler, either one being significant; skin that feels harder or, on the contrary, boggy and spongy; local swelling; and pain, burning, or itching at the spot. Examine in daylight or under strong light, use touch rather than sight alone, and compare with the matching healthy area on the other side of the body. This is not a cosmetic point: people with darker skin tones are documented to be found at more advanced stages of pressure injury, for the simple reason that the first stage is missed.

One appearance must never be filed under the earliest stage. A patch of persistent deep red, maroon, or purple discoloration, or a blister filled with blood, is a deep tissue pressure injury. It is a separate category, not stage 1 and not an ordinary bruise; the damage has begun deep down where muscle meets bone, and what shows on the surface does not reflect how much tissue is affected underneath. It can get dramatically worse within a few days. Take the pressure off the area immediately and have it assessed by a doctor without waiting to see what happens.

When you find a reddened or discolored area, do not massage it and do not rub it, and do not rub a bony prominence to prevent a sore. Rubbing the spot is common advice among families, and it is wrong and harmful: the tissue there is already receiving less blood than it needs, and rubbing tears the tiny vessels further and adds to the damage instead of improving the circulation. The correct response to redness is always the same, and it costs nothing: take the pressure off it completely and keep it off until the discoloration has gone.

Pressure ulcers can be treated, and how well they respond depends on several things, including the person's other medical conditions and the stage the ulcer has reached. Left untreated, however, infection can spread from the ulcer into the bone, the bloodstream, and the heart, and it can become life-threatening.

What Causes Pressure Ulcers

Constant, unrelieved pressure is the main cause. Lying or sitting on one part of the body for a long period traps the tissue between the bone underneath and the surface pressing from outside, such as a mattress, a chair seat, or a footrest, and the skin breaks down. A cast, a splint, a brace, a tube, or any other medical device resting against the skin can do exactly the same thing at the point where it presses, and a pressure injury caused this way takes the shape of the device. Look at the skin under every device, tube, catheter strap, and elastic band at least once a day.

The damage can come either from high pressure over a short period or from lower pressure kept up over a longer one. Both count. A person left in one position for hours is at risk even when nothing looks tight and nothing feels hard.

Here is what happens inside the body: the tissue and the small blood vessels running through it are squeezed and distorted, circulation to the area falls, the starved tissue dies, and dead tissue can then become infected.

Dragging adds to the damage. Pulling someone across a sheet instead of lifting them creates friction and shear: the skin is held in place while the layers beneath it slide the other way. Shear tears tissue deep below a surface that can still look completely normal. Move the person with a slide sheet or with the help of a second person, and lift rather than drag.

Risk Factors

The following raise the chance that a pressure ulcer will form:

Being unable to move or change position without help. This is the single biggest risk factor.
Older age, because the skin becomes thinner and more fragile.
Urinary or bowel incontinence, which keeps the skin wet and raises the risk of skin damage and infection.
Low body weight, which leaves less padding over the bones.
Certain medical conditions, such as diabetes, which reduces the ability to feel pain and slows wound healing.
Poor circulation.
Reduced alertness or awareness, so the person does not notice discomfort and does not shift position.

Stages of Pressure Ulcers and How They Are Classified

The classification used internationally today has six categories, not four: the four numbered stages, plus an unstageable pressure ulcer and a deep tissue pressure injury. Different sources use the words "stage," "category" and "grade" interchangeably; they all mean the same thing. For someone caring for a patient at home, knowing the category is not a technical detail, because what you need to do changes completely from one category to the next. Stage 1 is the only stage at which the damage can be stopped and reversed completely, with no tissue lost at all, as long as the pressure is taken off in time. At stage 2 some tissue has already been lost, although healing is usually still good. At stages 3 and 4 healing is slower and happens through scar tissue, which does not rebuild the original tissue as it was, and it needs ongoing medical care. The point is not that the later stages will not heal - it is that stage 1 is your only chance to stop the damage before any tissue is lost.

The Fingertip Blanch Test: The Check That Reveals the First Sign

This is the only check that separates passing redness, which means nothing, from the first stage of a pressure injury. It needs no equipment and takes seconds.

Before anything else: only do this check on skin that is intact and unbroken. Wash your hands before and after.
When not to do the test: never press on broken skin, on a blister, on a dark, maroon or purple patch, or on an eschar (a hard crust of dead tissue). Pressing on these areas widens the damage and tells you nothing about the stage.
How to do it: press your fingertip into the middle of the discolored area with steady, moderate pressure - enough to blanch the healthy skin next to it, but not enough to hurt the patient - hold it for about three seconds, then lift your finger and look at the skin immediately. Pressing too lightly gives a false result: the redness looks as though it does not fade, suggesting a stage 1 that is not really there.
Redness that blanches: the skin turns pale under your finger, then its color comes back once you lift it. This means circulation in the area is still working. It is not stage 1 and it is not a reason to panic, but it is a clear warning that the site is taking too much pressure and that the pressure must come off it.
Redness that does not blanch: the discoloration stays exactly as it was and does not go pale under your finger. This is a stage 1 pressure injury, and it is the accepted medical definition of stage 1.
An easier way to see it: press a clean piece of clear plastic with smooth edges onto the skin and look through it while you are still pressing, then clean it afterward or throw it away.
Where to check: the bony prominences in particular - the lower back and the sacrum (the bone at the base of the spine), the crease between the buttocks, the pelvic bones and the sitting bones the body rests on in a chair, the hips, the heels and ankles, the sides of the feet and the toes, the inner knees, the elbows, the shoulder blades, the bumps of the spine, the back of the head, and the outer ear.
Check the skin folds and the places where moisture collects as well, and check them by touch, not by sight alone.
Repeat the check on the same area every two hours until the discoloration has gone completely.

An Essential Caution If the Skin Is Darker

On darker skin the color change may not be visible at all. It may show as an area darker than the skin around it, or as a gray or faint purple cast, rather than as obvious redness.
Signs that have nothing to do with color therefore matter more than color does: a difference in the temperature of the area compared with the skin around it, whether warmer or cooler; firmness, or a boggy, spongy feel; local swelling; and pain or burning when you touch it.
Use touch, not sight alone. Look in natural daylight if you can, or under a strong light, and always compare with the matching healthy area on the other side of the body.
Check for moisture and check the skin folds by touch as well, because moisture trapped in a fold is often invisible on darker skin.
This is not a cosmetic detail. Research shows that pressure injuries are found late in people with darker skin tones, and that they reach more advanced stages more often than in other people. The reason is the difficulty of seeing stage 1, not any difference in the condition itself.

Stage 1: Discoloration That Does Not Blanch, With the Skin Still Intact

The skin at this stage is intact and unbroken, so there is no ulcer and no wound. This is where the most common mistake at home happens: waiting for an open sore to appear before doing anything.
A change in color that does not blanch when you press it: red on lighter skin, and possibly not visible at all on darker skin.
A difference in the temperature of the site compared with the skin around it: it may be warmer and it may be cooler, and both are meaningful signs.
A change in texture: firmness, a boggy spongy softness, or local swelling.
Pain, burning or itching at the site. Pain and a difference in temperature can come before any change in color appears.
Important caution: a dark purple or maroon color that does not blanch is not stage 1. See the section on deep tissue pressure injury below - it is a more dangerous category, and it needs prompt medical assessment.

What the Caregiver Does at Stage 1

This is the stage at which the damage can be stopped and reversed before the body loses any tissue, and none of it needs equipment.

Take the pressure off the area completely and immediately, and keep it off: move the patient so that no part of their weight rests on this site until the discoloration has gone.
Do not massage the area and do not rub it. Massaging a reddened site is common folk advice, but it is wrong and it is harmful: the tissue there is already getting less blood than it needs, and rubbing tears the small vessels further and doubles the damage instead of stimulating circulation. International recommendations explicitly forbid massaging bony prominences or rubbing skin that is at risk.
Reposition the patient regularly, day and night. The practical rule on an ordinary mattress is every two hours, and sooner than that if discoloration appears even while you are keeping to it.
When the patient is sitting in a chair: change their position completely at least once an hour, because pressure on the sitting bones is far higher in a chair than in bed. That said, if the patient can move themselves, have them lean to one side or lift their weight off the seat for a few seconds every fifteen minutes, and it is best that they do not sit continuously for more than two hours.
Use a side-lying tilt of about thirty degrees, propped with pillows behind the back, and do not turn the patient fully onto their side at ninety degrees, because that puts the whole load on the point of the hip bone.
A pressure-redistributing mattress or cushion does genuinely lower the risk, but it does not replace repositioning and it does not excuse you from doing it. Keep the sheet pulled tight and free of wrinkles, and avoid piling up layers or putting plastic covers directly under the patient.
Do not drag the patient across the sheet when you move them. Dragging creates friction and shear forces - the layers of skin sliding one way while the tissue underneath slides the other - and these tear the deep tissue with nothing showing on the surface. Lift the patient with another person's help, or use a slide sheet.
Do not wait for the patient to complain, and do not rely on pain as your alarm, because many people who cannot move have no sensation at the site at all.
Lift the heels clear of the bed: lay a long pillow lengthwise under the leg, from below the knee to above the heel, with the knee slightly bent and not locked straight, so the heel hangs in the air touching nothing and there is no pressure on the Achilles tendon. Do not put the pillow under the knee alone, because that presses on the area behind the knee.
Keep the head of the bed at thirty degrees or less unless there is a medical reason to raise it, because the body sliding downward creates the shear forces that tear the tissue under the skin with nothing showing on the surface.
An exception that must be respected: if the head of the bed has to be raised for a medical reason - tube feeding, breathlessness or reflux, for example - do not lower it on your own and do not go against the doctor's instructions. Work instead on stopping the body from sliding down, make up for it by repositioning more often and by protecting the sacrum and the heels, and raise the problem with the treating team.
Keep the skin clean and dry, and deal with wetness from incontinence as soon as it happens, because constant moisture weakens the skin. Use a gentle cleanser and lukewarm water, and dry by patting, not by rubbing.
Skin barrier products: creams or films put on intact skin that is exposed to wetness, to seal it off from urine and stool. They go on intact skin only. They are not a treatment for an ulcer, they are never put inside an open ulcer, and they are not a substitute for cleaning and drying the wetness.
Do not use ring or donut cushions with a hole in the middle. They concentrate the pressure in a narrow ring around the area and increase the damage instead of relieving it.
Do not put heat on the site: no heat lamps, no hairdryer, no hot water bottles and no hot compresses. Heat increases the tissue's need for oxygen at the very moment its blood supply is already short. Do not apply ice either.
Pay attention to nutrition and fluids, and to protein in particular, because poor nutrition is one of the strongest things that make pressure ulcers worse and hold up their healing.
A caution about nutrition: if the patient has kidney or liver failure, or diabetes, or is on a fluid restriction ordered by the doctor, do not increase protein or fluids on your own. Those amounts are set medically and adjusted within the diet being supervised for them.
Write down what you see: the date, the site and the rough size, with a photograph taken in good light. This lets the doctor or the nurse judge whether things are improving or getting worse, instead of relying on memory.
If the discoloration has not gone within a few hours after the pressure has been taken off completely, treat it as a confirmed pressure injury and ask for a medical assessment.

What the Caregiver Does for Any Open Ulcer (Stage 2 and Above)

These rules apply to every ulcer where the skin has broken open, or where a blister or an eschar has appeared - however small it looks, and before anyone knows its exact stage.

Ask for a medical assessment for every open ulcer. How it is cleaned, which type of dressing is used and how often the dressing is changed are medical decisions that depend on the stage and on the state of the tissue, and no single recipe fits every ulcer.
Take the pressure off the site completely and keep it off, because no pressure ulcer heals while pressure on it continues, however good the rest of the care is.
Do not pop blisters, do not drain them and do not peel off the roof of a blister. The skin covering it is a natural barrier protecting the tissue underneath from infection.
Do not cut away tissue, do not pull off an eschar, do not scrape the base of the ulcer, do not clean it forcefully, and do not pack the ulcer with gauze, cotton or anything else.
Do not put alcohol, hydrogen peroxide, concentrated or colored antiseptics, or home remedies on it. They damage living tissue and hide the color of the wound bed, which gets in the way of the doctor's assessment.
Do not pick a dressing off the pharmacy shelf on your own judgment, and do not change the type of dressing on your own.
Do not stick adhesive tape onto thin or damaged skin, and peel any adhesive off gently and slowly so you do not tear the skin.
Keep up the repositioning, the care of the healthy skin around the ulcer, the nutrition and fluids, and the checks on the other pressure sites, because having an ulcer in one place does not stop another one forming.
Write down the date the ulcer appeared, its rough measurements, and any change in its size, its odor or its discharge, with a photograph in good light. This record helps the doctor judge whether it is improving or getting worse.

Stage 2: Partial-Thickness Skin Loss

Loss of the surface layer of the skin, exposing the dermis underneath - the living pink layer below the skin's surface. The loss is partial and does not go through the full thickness of the skin.
The injury looks like a shallow open ulcer, with a base that is pink or red, moist and living.
It may appear as a blister filled with clear, straw-colored fluid (serous fluid), either intact or burst. An intact blister must never be popped and its roof must never be removed at home, under any circumstances.
Fat under the skin is not visible, and neither is anything deeper than it.
There is no dead tissue: no yellow slough - soft dead tissue that is yellow or gray - and no black eschar. If either one is present, the injury is deeper than stage 2 and has been classified wrongly.
What the caregiver does not do here: do not open the blister and do not drain it; peel medical adhesive off gently and slowly so the thin skin does not tear; and do not put anything of your own choosing on the ulcer.
An important distinction to get right at home: dermatitis caused by incontinence and moisture, thin skin torn when medical adhesive is peeled off, and abrasions, superficial wounds and burns are not stage 2 pressure ulcers, even though they can look similar, and they are prevented and treated in different ways. Confusing them with stage 2 is one of the most common mistakes.

Stage 3: Full-Thickness Skin Loss

Loss that goes through the full thickness of the skin, with the fat underneath visible inside the ulcer.
Granulation tissue may appear in the base - fine-grained red tissue that grows as the wound heals - and the edges of the ulcer may roll inward.
Some slough or eschar may be present, as long as the depth of the injury can still be seen and judged.
There may be undermining beneath the edges - a pocket hollowed out under the rim of the ulcer - or tunneling that runs sideways under skin that looks intact, which is why the real damage can be far wider than the visible opening of the ulcer.
The fascia - the fibrous sheet that wraps the muscles - is not exposed, and neither is muscle, tendon, ligament, cartilage or bone.
A correction to a common description: calling this stage a "crater" is an old and misleading picture if it is taken as the rule. The depth of a stage 3 varies a great deal with where it is on the body. At sites with no fat under the skin - the heel, the ankle, the back of the head, the outer ear and the bridge of the nose - a stage 3 can be completely shallow and look nothing like a crater, while in fatty areas it is very deep indeed. What defines stage 3 is that fat is exposed and nothing deeper than fat is exposed - not the shape of the ulcer, and not its depth.

Stage 4: Full-Thickness Skin and Tissue Loss With Deep Structures Exposed

Full loss of the skin and of what lies beneath it, with fascia, muscle, tendon, ligament, cartilage or bone exposed inside the ulcer, or able to be touched directly.
Slough or eschar may be present, and rolled edges with wide undermining and tunneling under the surrounding skin are common.
Depth varies with the site here too, so an ulcer over a bone that lies close to the surface may be shallower than you would expect and still be a stage 4.
This stage carries a real risk of osteomyelitis - infection reaching the bone itself - and of infection spreading into the blood. It needs specialized medical care and is not managed at home on personal judgment.

Unstageable Pressure Ulcer

What it is: full loss of the skin and tissue, but the base of the ulcer is covered by dead yellow or gray slough, or by a hard black or brown eschar, so the depth cannot be seen and the stage cannot be worked out.
In reality it is either a stage 3 or a stage 4, and there is no way to know which until a specialist removes the dead tissue.
So seeing a black eschar does not automatically mean stage 4. The correct classification is unstageable, until a specialist assesses it.
An exception you should know about: a dry, stable eschar on the heel, or on a limb with a poor blood supply - meaning a dry, firmly attached, intact eschar with no redness around it and no fluctuance (a soft, fluid-filled give under your fingers) - is left alone. Do not soften it, do not remove it and do not wet it, because it is acting as a natural protective cover. Keep it dry, take the pressure off the site, and ask for a medical assessment.
If redness, swelling, discharge or a soft, fluid-filled give under your fingers appears around this eschar, the exception no longer applies and the situation needs urgent assessment.
What the caregiver must never do: do not cut away dead tissue, do not pull off the eschar, do not scrape the base, do not open blisters, do not clean the base forcefully, and do not pack the ulcer with gauze or anything else. Removing dead tissue is a medical procedure with its own indications and contraindications; only a specialist performs it, using sterile instruments.

Deep Tissue Pressure Injury

What it is: a lasting, localized discoloration that does not blanch under pressure - deep red, maroon or purple - on skin that may be intact or broken; or a separation of the outer skin layer revealing a dark wound bed; or a blood-filled blister.
The essential difference from stage 1 is that here the damage started deep down, where muscle meets bone, where the tissue is far more sensitive to pressure, and what shows on the surface does not reflect the size of what lies beneath it.
Pain and a difference in skin temperature often come before the discoloration appears, and the discoloration can be hard to see on darker skin.
Most important in practice: this injury can deteriorate fast, within a few days, and open up to reveal extensive, very deep damage, even though it looked minor and limited at first. It can also sometimes heal without tissue loss. Never take its outward appearance as reassurance.
So if you see a dark or purple patch, or a blood-filled blister, over a pressure site, take the pressure off immediately and ask for prompt medical assessment - do not wait.

Pressure Injuries Caused by Medical Devices

Pressure does not come from the bed alone. Oxygen tubing behind the ears, a nasal feeding tube, a urinary catheter and the strap holding it, splints and braces, and compression stockings all cause pressure injuries, shaped like the device pressing on the skin.
Check the skin under every device, tube and strap at least once a day, and make sure nothing is too tight.
Do not undo, loosen or move a device, tube or splint that the medical team has secured, on your own. If you find a pressure mark, redness or an ulcer under a device, tell the treating team so they can readjust it or move it safely.
Injuries to the mucous membranes inside the mouth or the nose caused by tubes are not classified by the four stages, and they need a medical assessment.

Where Each Role Ends: What the Caregiver Does, What the Nurse Does, What the Doctor Decides

The caregiver at home: relieving pressure and repositioning; checking the skin daily and writing down what you find; cleanliness, drying and managing incontinence; nutrition and fluids within what the doctor has set; protecting the heels; checking the skin under devices and tubes; keeping the dressing clean, dry and in place; and spotting the danger signs and reporting them immediately.
The qualified nurse: assessing the ulcer, measuring it and tracking how it changes; cleaning it with the appropriate solution; choosing the type of dressing and changing it; and teaching the family how to do things correctly.
The doctor: diagnosing infection and deciding on any drug treatment; deciding whether dead tissue is removed and by what method; ordering tests and imaging; and judging the need for surgery or for care inside the hospital.
What the caregiver must never do: cutting, pulling off, scraping, opening blisters or packing the ulcer; picking a dressing from the pharmacy on personal judgment, or changing its type without a plan; and starting any medication for infection on their own.

Common Mistakes in Using the Classification

An ulcer is not reclassified backward as it heals. A stage 4 ulcer that is improving stays "a healing stage 4"; it does not become a stage 3, then a stage 2, then a stage 1, because deep tissue is not replaced by tissue like it, but by scar tissue.
This classification is for pressure injuries only. It is not used for diabetic foot ulcers, nor for arterial or venous leg ulcers, nor for dermatitis caused by moisture and incontinence. Each of those has a different assessment and a different treatment path.
An ulcer whose base you cannot see is not staged. As long as the base is covered by dead tissue or an eschar, it is "unstageable," not a stage 4.

When to Ask for a Medical Assessment Without Delay

Ask for an emergency assessment that cannot wait if any of the following appears:

Redness spreading quickly, with severe pain out of proportion to how the wound looks, or a crackling feeling under the skin when you touch it, or a black patch that is widening fast.
Signs that infection is spreading through the body: a temperature that is raised or that has dropped below normal, shivering, faster breathing or a faster pulse, a fall in the amount of urine, blood sugar going out of control in a diabetic patient who had been stable, confusion, drowsiness or a sudden change in behavior in an older person, or the patient plainly looking unwell with no explanation for it.
Important caution: in older people, the absence of a fever does not rule out infection, and sudden confusion or new drowsiness is often the first and only sign of sepsis. Do not wait for a fever.

Ask for urgent medical care the same day if any of the following appears:

Signs of a local infection that is spreading: redness, warmth and swelling widening around the ulcer, pus-like discharge, a foul odor, increasing pain, or new pain in an ulcer that had not been painful.
A purple or dark maroon patch, or a blood-filled blister, over a pressure site.
Shiny white tissue or bone exposed in the base of the ulcer.
Any pressure injury on the heel or the foot in a patient with diabetes or with a poor blood supply, however small it looks.
Redness, swelling, discharge or a soft, fluid-filled give under your fingers around an eschar that had been dry and stable.

Ask for a medical assessment as well - soon, without waiting, even though these are not emergencies - in the following cases:

Any open wound, blister or black eschar appearing over a pressure site, however small it looks.
Discoloration that does not blanch and has not gone within a few hours after the pressure has been taken off completely.
The ulcer getting wider or deeper, or undermining appearing beneath its edges.
The ulcer not improving over roughly two weeks despite pressure relief and consistent skin care and nutrition, or its improvement going backward after it had begun.

In every case:

Do not start any medication for infection on your own, whether tablets or an ointment, and do not buy medicine without a prescription. Treatment of infection is decided after a medical examination and is followed up medically. Using it at random hides the signs, delays the diagnosis and increases bacterial resistance.
Tell the doctor about pain during repositioning or at dressing changes, so they can decide on the right pain relief and when to give it in relation to the dressing change. Do not use non-steroidal anti-inflammatory painkillers on your own judgment; they are sold without a prescription, but they can harm the kidneys and the stomach and can interact with other medicines, and the risk is greater in older people and in people with kidney or heart disease.
Do not put household substances or folk remedies on the ulcer: no kitchen honey, no flour, no coffee grounds, no henna, no toothpaste, no ash, no oils and no herbal poultices. And do not use alcohol, hydrogen peroxide, or concentrated or colored antiseptics of any kind, including iodine preparations, except on a medical decision. They damage the living tissue that is trying to heal, they hide the color of the wound bed and so get in the way of the doctor's assessment, and they lengthen the time needed for healing.

Treating Pressure Ulcers

Treating a pressure ulcer is never a single step. It is a shared plan between the caregiver at home and the doctor and nursing staff. The most important part of treatment is not what you put on top of the ulcer. It is taking the pressure off the spot where the ulcer sits. An ulcer that stays under pressure will not heal, no matter how good the dressing is.

Pressure ulcers are graded in four stages, according to how deep the damage goes. Two further categories are added to those four. They carry no number, and their depth cannot be judged by looking: an ulcer that cannot be staged, because dead tissue, whether slough or a black eschar, covers its base and hides how deep it goes; and a deep tissue pressure injury, where the skin over it is still unbroken but looks purple or maroon. A black eschar is unstageable, not stage 4. That makes six categories in all, not four. This classification decides who takes charge of treatment and where it is carried out. It is not safe to go by the appearance of the surface alone, because a small opening on the surface can hide extensive damage in the deep tissue underneath it.

The steps below have deliberately been split into three parts, so you know exactly what you may do yourself, what the medical team does, and what must never be attempted at home.

Part 1: What the Caregiver Does at Home

Relieving pressure: reposition the patient regularly, on a schedule set by the medical team, and keep the pressure completely off the site of the ulcer, so the patient is never left lying on it. If no schedule has been set yet, start by repositioning every 2 to 4 hours for a patient lying in bed, and roughly every hour for someone sitting in a chair, then adjust the interval according to what the skin shows at each check and according to what the medical team decides. This is by far the single most important treatment step, and no dressing or ointment can take its place.
A mattress does not replace turning: a pressure-redistributing mattress or cushion helps, but it does not cancel the repositioning schedule and does not let you turn the patient less often. The most common thing that ruins treatment at home is feeling reassured by a special mattress and stopping the turning.
Lying position: it is better to tilt the body onto its side at about a 30-degree angle, propped with pillows, than to lay the patient squarely on the side at a right angle, which puts the weight of the body directly on the hip bone. Keep the head of the bed raised as little as the patient's condition allows, around 30 degrees or less, except at mealtimes or when there is a medical reason, because raising it higher makes the tissue shear over the tailbone.
Avoiding dragging and pulling: do not drag the patient across the surface of the bed when moving them, or when pulling them up toward the head of the bed. Move them with a sheet or a transfer aid, and with another person helping. Dragging and sliding tear the tissue under the skin and widen the ulcer from the inside, even when the surface of the skin still looks intact.
Protecting the heels: lift the heels clear of the mattress by placing a pillow under the full length of the lower leg, from below the knee to above the heel, so that the heel does not touch the bed and pressure is not trapped behind the knee or on the Achilles tendon. Keep the knee slightly bent rather than fully straight.
What must not be used for support: do not use ring or donut cushions, rubber rings, or water-filled gloves under the heel or under the buttocks. These devices concentrate pressure in a narrow ring of tissue around the area, and increase the damage instead of relieving it.
Cleaning the ulcer: clean water that is safe to drink, or sterile saline, is enough. Pour it on gently, without rubbing. Do not put soap, alcohol of any kind (including rubbing alcohol and spirit), cologne, hydrogen peroxide, iodine or any other antiseptic on the open surface of the ulcer on your own, without a medical decision, because these substances damage the new cells and delay healing.
Hand and supply hygiene: wash your hands thoroughly before you go near the ulcer and again afterward, do not touch the face of the dressing that will lie against the wound, use a clean new dressing every time, and never reuse a dressing that has already been taken off, even if it looks clean.
Caring for the surrounding skin: clean the intact skin around the ulcer with a gentle, pH-balanced cleanser, then dry it by patting, not by rubbing.
Controlling moisture and incontinence: every time the skin is wet with urine or stool, clean and dry it without delay, and change the diaper, the clothing or the bed sheets as soon as they are soiled or wet. Skin that stays wet, even for a few hours, is weakened and becomes prone to breaking down, and an ulcer that is already there gets bigger.
Barrier creams: these belong on intact skin that is exposed to moisture from urine, stool or sweat, to protect it from breaking down. They do not go inside the ulcer itself, and they do not go on its open surface.
Nutrition and fluids: provide meals with enough calories and protein, make sure the patient drinks enough fluids unless the doctor has restricted them, and watch for any unintended weight loss or refusal to eat and report it to the medical team.
Daily observation: check all the pressure points every day while changing clothes, in good light: the tailbone, the buttocks, the lower back, the hip bones, the heels, the ankles, the inner sides of the knees, the shoulders, the elbows, the back of the head, and the ears. Also check anywhere medical equipment touches the skin: behind the ear where the oxygen tubing passes, the site of a feeding tube, the catheter, splints, and securing straps.
The blanch test, or how to read a red patch: press the middle of the patch with a fingertip, lightly, for about 3 seconds, then lift your finger and look right away. If the spot you pressed turns pale and its color comes back after a few seconds, that is blanching redness. It means the circulation is still reaching the tissue, and it is a warning that you must take the pressure off that spot and watch it. But if the color stays red and does not go pale under your finger, that is a stage 1 pressure ulcer. At this stage the skin is still unbroken, so there is no open wound yet, but the injury has already begun: take the pressure off the spot completely and tell the medical team. If you wait until you can see an open sore before acting, you have missed the one stage that is still fully reversible. You can use a clear piece of plastic, or the clean bottom of a glass, instead of your finger, pressing with it and looking through it.
If the patient has darker skin: redness may not show at all, and the blanch test alone should not be relied on, because the change in color is hard to see. Compare the spot with the skin next to it, looking for a difference in color: darker, purple, bluish, or a dull gray. Touch it with the back of your fingers, feeling for a difference in temperature, since the spot is warmer than the surrounding skin at first and cooler later on. Feel for firmness, a soft boggy sponginess, or swelling compared with the area around it. Ask the patient whether they feel pain, burning or itching there. Examine in daylight or under strong light, not in a dim room. Here the signs that are not about color matter more than color does: pressure injuries in people with darker skin are known to be found later, at a deeper stage, because stage 1 is missed.
A sign that calls for urgent medical assessment: a purple or maroon patch appearing in skin that has not opened, or a blood-filled blister. This is a deep tissue pressure injury, not stage 1 and not a passing bruise. It can deteriorate within a few days, and it is not managed at home.
No massage: do not massage the site of the ulcer or any reddened patch of skin, and do not rub it with cream or oil. Massage increases the damage to the injured tissue under the skin. The correct response to redness is to take the pressure off it, not to rub it.
Weekly photographs: photograph the ulcer once a week with a phone, from the same distance and in the same light, so that the medical team can see which way it is changing.
Changing dressings: you may change the dressing after you have been trained hands-on to do it, using the type the medical team has specified and without switching to another type on your own. Change it after the pain reliever the doctor prescribed has had time to work. If you find the dressing stuck to the base of the ulcer, moisten it with saline and wait until it loosens, then lift it off gently. Never pull it off forcefully or all at once.
Things that speed up healing: stopping smoking, controlling blood sugar in a patient with diabetes according to the doctor's plan, and encouraging whatever amount of movement the medical team allows.

Part 2: What the Doctor or Nursing Staff Does

Assessing the ulcer and staging it, measuring its dimensions and its depth, and looking for cavities or tunnels running under the edges of the skin.
Assessing the underlying risk factors: general condition, mobility, nutrition, incontinence of urine or stool and the plan put in place for it, anemia, and diabetes control.
Deciding on the appropriate pressure-redistributing surface, whether a mattress or a chair cushion, and reviewing at intervals how well it still suits the patient.
Choosing the dressing that suits the state of the ulcer and the amount of drainage it produces, setting the schedule for changing it, and training the caregiver hands-on to change it.
Assessing the blood supply to the limb before any debridement, especially in heel ulcers. If the blood supply is poor, the dry eschar is left as it is and the patient is referred for a vascular assessment, because removing it from a limb with a poor blood supply opens a wound that the body has nothing to heal it with.
Debridement, meaning the removal of dead tissue: either with dressings that help the body dissolve it on its own, which is the usual first approach, or with enzyme preparations, or with surgical instruments or a high-pressure water jet, inside a medical facility and by a trained specialist. This is a purely medical procedure. It is not done at home, and not with household tools.
Assessing infection: the clinical signs are the basis of the diagnosis, and blood tests or imaging may be ordered when there is a suspicion that the infection has reached the bone.
Treating pain: the doctor may prescribe pain relievers from different classes depending on how severe the pain is, the patient's age, and the state of the kidneys and liver, particularly before scheduled dressing changes. These classes include simple pain relievers; nonsteroidal anti-inflammatory drugs, which are used with caution in older people and in anyone with kidney disease or a stomach ulcer; and opioid pain relievers, which can cause drowsiness and constipation and need monitoring. The type of pain reliever is not switched, and the amount is not increased, at home.
Deciding whether any systemic drug treatment is needed, and determining its type and how long it is given.
Reviewing the plan at regular intervals and documenting the ulcer's measurements, and reviewing the pressure-relief plan and its equipment whenever healing slows, whenever no improvement appears within the expected time, or whenever a new ulcer appears somewhere else.

Part 3: What Must Never Be Done at Home

Cutting away dead tissue or hardened skin, or debriding the ulcer with scissors, a razor, tweezers or forceps, or any sharp instrument.
Packing the ulcer, or pushing gauze or cotton into a cavity or a tunnel inside it.
Opening blisters, or peeling off dry eschar that is stuck down. This applies above all to dry, black, firmly attached heel eschar that is intact and free of redness, swelling and drainage: it is a living cover protecting what lies beneath it, and it is removed only on a medical decision. If it becomes wet, softens, or its edges loosen, or if redness, swelling, drainage or an odor appears around it, that is a reason to ask for urgent medical assessment, not a reason to pull it off at home.
Putting alcohol of any kind (including rubbing alcohol and spirit), cologne, hydrogen peroxide, iodine or any antiseptic on the open surface of the ulcer on your own, without a medical decision.
Putting any household or folk substance on the ulcer, such as ordinary kitchen honey, coffee grounds, henna, toothpaste, flour, powders, ash, ghee, oils, or herbal mixtures. These substances are not sterile, they stick to the base of the ulcer, they hide the signs of infection and the true appearance of the ulcer from the medical team, and they delay treatment.
Aiming tap water or a shower head directly at the ulcer under pressure, or directing any high-pressure stream of water into it.
Warming the area, or drying it with a hair dryer, a hot water bottle, or any source of heat. Sensation is poor at these sites, and a burn can happen without the patient feeling it.
Massaging the site of the ulcer or any reddened patch of skin, because massage increases the damage to the tissue underneath it.
Stopping the repositioning schedule, or stretching out the intervals between turns, because there is a special mattress or because the ulcer looks better.
Buying any antibiotic from the pharmacy and giving it to the patient without a prescription, or applying an antibacterial ointment on your own, or using what is left over from an earlier package.

Antibacterial Creams: An Important Correction

Every chronic ulcer contains bacteria. The presence of bacteria on the surface of the ulcer is called colonization, and it is not an infection. Infection is diagnosed from clinical signs, not from the mere presence of germs and not from a positive culture result on its own.
For this reason, a swab for culture is not taken from an ulcer that shows no signs of infection, because the result will come back positive every time and may push the patient toward treatment that is not needed.
Antibacterial creams and ointments are not used routinely in the treatment of pressure ulcers. They do not speed up healing, they contribute to the emergence of resistant strains of bacteria, and they may cause a contact allergy in the surrounding skin that makes the situation worse.
The greatest practical harm is that relying on them creates a false sense of reassurance, so the ulcer is shown to a specialist later than it should have been, at a point when treatment would have been easier.
Topical antiseptics are used only on a doctor's decision, for a short period fixed in advance, and in specific situations such as a suspected local infection, and are then stopped. Do not start them on your own, and do not extend how long they are used.
Dressings containing silver, iodine or processed medical-grade honey are likewise used on a decision by the medical team and for a set period that is then reviewed. They are not bought straight from the pharmacy and not used indefinitely.
Systemic antibiotics are not prescribed to speed up the healing of an ulcer. They have a role when there is a clear clinical infection, such as spreading cellulitis, infection of the bone, or infection of the blood. Judging whether they are needed, choosing them, and deciding how long they are given is a purely medical decision, and it is not made at home.
A course left over from an earlier illness, or one borrowed from someone else, is not a shortcut. It does not heal the ulcer, and it can mask the signs of a deeper infection so that the infection is found late.

Nutrition: What the Evidence Actually Supports

Malnutrition and a shortage of fluids genuinely do slow healing, which is why the nutritional state of every patient with a pressure ulcer is assessed.
The benefit supported by evidence lies in correcting a nutritional deficiency in someone who has one, or who is at risk of one. Supporting such a patient with enough calories, protein and micronutrients may slightly increase the chances of the ulcer healing, and even that is a low-certainty finding.
As for giving protein, arginine, zinc or antioxidant supplements to a patient whose nutrition is already adequate, there is no reliable evidence that this speeds up healing, and it is not advised for that purpose alone.
Weighing the patient regularly where that is practical, and recording how much the patient actually eats rather than how much is served, are more useful than adding supplements on top of food that is not being eaten.
Assessing nutritional status and prescribing any specialized nutritional support should be done under the supervision of the medical team or a dietitian, not on your own judgment.
One caution: taking zinc supplements in excess over long periods can interfere with the absorption of copper and cause a copper deficiency, so they are not taken without medical supervision.

Surgery

Surgery is considered in deep stage 3 and stage 4 ulcers that do not respond to treatment, when bone or tendon is exposed in the base of the ulcer, when the dead tissue is extensive, or when there is an infection in the bone beneath it.
The surgeon removes the damaged tissue, and may then patch the area with a skin graft, or cover it with a tissue flap taken from a healthy site on the patient's own body.
Surgery is not the right choice for every patient. The decision weighs the patient's general condition, their other illnesses, and their ability to stick to what is required afterward, above all keeping the pressure off the site completely.
The success of a surgical repair depends on keeping the pressure off the site, on improvement in nutritional status, and on stopping smoking. Without these, the ulcer comes back in the same place.

Early-Stage Ulcers and Home Care

Stepping in early, once an ulcer has appeared, does not undo the fact that it happened and does not mean it will go away on its own, but it raises the chances of it healing and keeps it from worsening to a deeper stage. This is an important difference: prevention stops the ulcer from forming, while early intervention limits how deep it goes once it has formed.
Stage 1 ulcers, which are redness that does not turn pale when pressed while the skin is still intact, and stage 2 ulcers, which are a partial-thickness loss of skin appearing as a shallow ulcer with a pink base or as a blister filled with clear fluid, can usually be followed at home. But only after a specialist has examined the ulcer, staged it and set the plan; only with a caregiver who has been trained hands-on; and only with regular nursing follow-up.
A blister filled with blood is not stage 2. It is a sign of a deep tissue pressure injury, and it must be shown to the medical team immediately.
Early redness is not a reason to panic. It often fades within a few days once the pressure is taken off the spot completely. But if it persists, spreads, or the texture of the skin there changes, it means the pressure relief is not enough and the plan needs to be reviewed with the medical team.
It is not true that anyone can treat an early ulcer at home on their own. An ulcer cannot be staged by looking alone, and deep damage may lie under skin that appears intact, or under a small opening on the surface.
Stage 3 and stage 4 ulcers, ulcers that cannot be staged because dead tissue covers them, and deep tissue injuries are managed medically, and home care alone is not enough for them.

When to Seek Medical Help Without Delay

The ulcer getting wider or deeper, or bone or tendon appearing in its base.
Redness spreading around the ulcer, warmth at the site, swelling, or pain that is getting worse.
Pus-like drainage, a foul odor, the base of the ulcer turning black, or a sudden increase in drainage, so that the dressing becomes soaked before it is due to be changed.
Bleeding from the ulcer that does not stop with gentle pressure using clean gauze.
A change in dry, firmly attached eschar: it softens, becomes wet, or its edges loosen, or redness, swelling, drainage or an odor appears around it.
A purple or maroon patch appearing in skin that has not opened, or a blood-filled blister.
A temperature that rises above, or falls below, what is usual for the patient; shivering; faster breathing or pulse; a clear drop in the amount of urine; cold limbs with mottled skin color; or a sudden refusal to eat.
Confusion, unusual drowsiness, or a sudden change in behavior or in the ability to recognize places and people, particularly in older people and in those who have been bedbound for a long time. This symptom on its own may be the first sign of an infection spreading through the body, even if the ulcer itself looks quiet, and the temperature may not rise at all and may in fact fall. Do not wait for a fever before asking for an assessment.
Severe pain out of proportion to how the ulcer looks, together with a rapid deterioration in the patient's general condition. This is a situation that calls for emergency assessment and cannot be put off.
An unexplained rise in blood sugar in a patient with diabetes whose control had been good, since it can come before the rest of the signs of infection.
A new ulcer appearing at another pressure point.
No improvement at all within two weeks, despite full adherence to the pressure-relief and care plan. This waiting period applies only to a quiet ulcer; if any of the signs above appear, do not wait a single day.
Assessment should be sought sooner still in patients with diabetes, poor circulation in the limbs, a weakened immune system, or those taking immunosuppressive medicines, because deterioration is faster in them and its signs are more hidden.

How to Prevent Pressure Ulcers

Almost every pressure ulcer starts the same way: skin over a bone stays pressed against a mattress or a chair for too long, the blood supply to that spot is squeezed shut, and the tissue begins to die. Preventing one means making sure no single spot carries the weight for long, and catching the first warning sign while the skin is still closed. The steps below are the ones that matter most at home.

Take the pressure off, again and again

Change your relative’s position in bed at least every two hours, around the clock. The night hours count — long, unbroken stretches in one position are when many ulcers begin. If a discolored patch appears even though you are turning on time, turn more often, not less.
Sitting up in a wheelchair or an armchair loads the bones you sit on far harder than lying down does. Reposition them completely at least once an hour, and in between — about every 15 minutes — help them shift their weight, lean forward or to one side, or push themselves up briefly if they have the arm strength. Put a pressure-relieving cushion under them instead of letting them sit on a hard seat, and try not to let one stretch of sitting run past about two hours.
Turn them onto alternating sides rather than always the same one. Use pillows or foam wedges to hold the body tilted about 30 degrees onto one side, propped from behind — not lying square on the side at a right angle, which puts the entire weight of the body straight onto the hip bone.
Float the heels clear of the mattress. Place a pillow lengthwise under the calf, from just below the knee to above the ankle, so the heel hangs in the air touching nothing, with the knee slightly bent rather than pushed flat and no pressure on the Achilles tendon. Do not put a pillow under the knee alone — that presses on the back of the knee and leaves the heel down. Heels are one of the most common sites and one of the easiest to protect.
Put a pillow between the knees and between the ankles so bone does not press on bone.
Keep the head of the bed at about 30 degrees or lower whenever it is safe to do so, except at mealtimes. A steeply raised head lets the body slide down, and that sliding drags the skin against the sheet and tears the tissue underneath.
If the head of the bed has to stay raised for a medical reason — tube feeding, breathlessness, reflux — do not lower it on your own and do not go against the treating doctor’s instructions. Work instead on stopping the body from sliding down, reposition more often, protect the tailbone and the heels, and raise the problem with the treating team.
Lift and reposition with a slide sheet, or with two people. Never drag someone up the bed — dragging shears the skin away from the deeper layers even when nothing shows on the surface.
Do not wait for your relative to complain, and do not use pain as your alarm. Many people who cannot move also cannot feel these areas at all.

Check the skin every single day

Look at the whole body once a day in good light, ideally while you are washing or changing them. Check the tailbone and buttocks and the cleft between them, the bones you sit on, the hips, heels, ankles, the sides of the feet and the toes, the inner knees, elbows, shoulder blades, the bumps of the spine, the back of the head, and the ears. Go over the skin folds and any place where moisture collects with your hand — not with your eyes alone.
Check the skin under anything that presses on it: oxygen tubing behind the ears, a feeding tube, a catheter and its securing strap, splints, braces, elastic stockings, a mask strap, and any wrinkled or bunched sheet. Do not loosen, remove, or move a device the medical team has fixed in place. If you find a pressure mark, redness, or a sore underneath one, tell the team so they can adjust or move it safely.
The fingertip test. On intact, unbroken skin only, press the middle of the discolored area with a fingertip for about three seconds, lift your finger, and look right away. Press firmly enough that normal skin beside it would go pale, but not hard enough to hurt — too light a press gives a false result that looks like an injury when there is none. Wash your hands before and after.
Never do this test on broken skin, on a blister, on a scab or a black or brown crust, or on a dark, maroon, or purple patch. Pressing on any of those widens the damage and tells you nothing.
If the skin goes pale under your finger and then refills with color, the circulation is still working — that is a warning to take the pressure off that spot now, not an injury that has set in. If it does not turn pale under your finger, that is a stage 1 pressure injury, and the pressure has to come off that area completely. A clean piece of clear plastic with smooth edges, pressed against the skin, lets you watch the area while you are still pressing.
At stage 1 the skin is still intact — there is no open wound yet. This is the only fully reversible stage. A caregiver who waits for an open sore before acting has already missed it.
On darker skin the color change may not show at all, and the fingertip test on its own cannot be relied on. Trust what your hand tells you: skin that feels warmer or cooler than the area around it, firmer, or oddly soft and spongy, skin that is swollen, or an area your relative says is painful or burning, is a warning sign even when it looks normal. Look in daylight or under a strong lamp, and compare the spot with the matching area on the other side of the body. People with darker skin tones are documented to be diagnosed with higher-stage injuries precisely because stage 1 is missed on sight.
A patch of deep red, maroon, or purple discoloration that does not fade, or a blister filled with blood, is not stage 1. It is a deep tissue pressure injury — damage that began deep down, where muscle meets bone, so what shows on the surface does not reflect how much is hurt underneath. It can break open within days. Take the pressure off immediately and have a doctor look at it without waiting.
Recheck the same spot every two hours until the color change has gone completely. If it has not cleared within a few hours of taking the pressure off entirely, treat it as a confirmed pressure injury and ask for a medical assessment.
Write down what you find — the date, the site, and the rough size — and take a photo in good light, from roughly the same distance each time. That record lets a doctor or nurse judge whether things are improving or getting worse instead of relying on memory.

Surfaces, cushions, and padding

Use a pressure-redistributing mattress. A non-powered (static) high-specification foam mattress is a reasonable first choice for many people at home; a dynamic, or alternating-pressure, mattress runs on a pump that inflates and deflates the air cells in turn, so the pressure points change on their own. Either way, a pressure-relieving surface lowers the risk — it never replaces turning, and it never earns you the right to turn less often. Trusting a special mattress and easing off the turning schedule is the single most common way home care goes wrong.
Pad the pressure points, with foam heel and elbow protectors or soft padding under bony points.
Keep the sheets smooth, dry, and free of crumbs, and do not stack several draw sheets or thick plastic layers under your relative. Wrinkles and stacked layers create ridges that press into the skin.
Avoid tight elastic in socks and clothing, and check that shoes, splints, and braces are not rubbing.

Skin, moisture, and nutrition

Wash with warm — not hot — water and a mild cleanser, and pat the skin dry. Do not scrub.
Change wet or soiled clothing and bedding right away. Skin that stays damp with urine, stool, or sweat breaks down far more easily, and even a few hours of wetness weakens it. A barrier cream or a barrier film protects intact skin that is exposed to urine or stool; barrier products are for closed skin, they do not belong inside or on top of an open ulcer, and they are not a substitute for cleaning and drying the skin.
Moisturize dry, flaking skin, but do not leave it greasy or wet.
Feed the body that has to do the healing. Enough protein, enough calories, and fruit and vegetables all matter; poor nutrition and weight loss are among the strongest risk factors there are. If your relative is eating poorly, losing weight, or being fed through a tube, ask the treating doctor for a nutrition review.
One caution on that: if your relative has kidney or liver disease or diabetes, or a doctor has limited their fluids, do not increase protein or fluids on your own. Those amounts are set medically and have to fit the diet they are already following.
Offer fluids regularly throughout the day unless a doctor has restricted them.
Encourage movement, even in bed. Small movements of the arms, legs, and ankles — whether your relative makes them or you help — keep the circulation going, and any activity out of bed is better still.
Quitting smoking helps, and so does keeping the room free of other people’s smoke. Smoking narrows the small blood vessels the skin depends on to survive and heal.

What not to do

Do not massage or rub a reddened area or the skin over a bony spot. This is common family advice, and it is harmful. That tissue is already short of blood, and rubbing adds mechanical damage to tissue that cannot take it. The right response to redness is to take the weight off it, not to work at it with your hands, with oil, or with cream.
Do not use a ring or donut cushion, a rubber ring, or a water-filled glove under the heel or the buttocks. They do not relieve pressure — they concentrate it in a narrow circle of tissue around the area and cut off the circulation in exactly the place you are trying to protect.
Do not put rubbing alcohol or spirit, cologne, or hydrogen peroxide on the skin or into a wound, and do not use concentrated or colored antiseptics on your own initiative. They damage the fragile new tissue that is trying to heal, they stain the base of the wound so a doctor can no longer read it, and they dry out skin that needs to stay supple.
Do not put home remedies on the skin or a wound — no table honey, ground coffee, flour, powders, henna, toothpaste, ash, ghee, oils, or herbal poultices. They are not sterile, they stick to the base of the wound, and they hide the very signs the medical team needs to see.
Do not cut, peel, scrape, or pack anything. Do not cut away dead tissue, do not pull off a scab or crust, do not scrub or scrape the base of a sore, do not burst or drain a blister, and do not push gauze or cotton into a wound or under its edges. Removing dead tissue is a medical procedure with its own reasons and risks, done by a trained professional with sterile instruments.
Leave a dry black heel scab alone. A dry, hard, firmly attached crust on the heel or on a poorly circulated limb, with no surrounding redness, swelling, or discharge and no soft, spongy feel underneath, is working as a natural protective cover. Do not soften it, wet it, or lift it. Keep it dry, keep the pressure off it, and have it assessed. If redness, swelling, discharge, odor, or a spongy feel appears around it, that needs to be seen urgently.
Do not dry or warm the area with a hair dryer, a heat lamp, a heater, or a hot water bottle, and do not apply ice either. Feeling is often poor at exactly these spots, so a burn can happen without your relative feeling it or being able to tell you, and heat raises the tissue’s demand for oxygen at the moment it is already short of blood.
Do not leave someone sitting in a chair for hours because it seems better than lying down. Sitting loads the tailbone and the bones you sit on harder than lying down does.

Complications

Left untreated, a pressure ulcer does not stay a skin problem. It is an open door into the body, and the complications below are why an ulcer that is not improving needs to be assessed by a doctor rather than managed indefinitely at home.

Spreading skin infection (cellulitis)

A bacterial infection that travels from the surface of the skin into the deeper layers around the ulcer. The warning signs are redness spreading outward from the edge of the wound, increasing warmth, swelling, worsening pain, and discharge that turns thick, cloudy, or foul-smelling. Because feeling is often reduced at these sites, pain may be absent — do not rely on it. Cellulitis can become life-threatening and needs a doctor’s assessment without delay.

Sepsis (blood infection)

If the infection reaches the bloodstream, the body’s own reaction to it can damage organs and cause them to fail. This is a medical emergency, and time matters. Go to an emergency room if you see fever or shaking chills, an unusually low temperature, fast breathing, a racing pulse, low blood pressure, dizziness, mottled or clammy skin, cold hands and feet, a sharp drop in how much urine your relative passes, a sudden refusal to eat, or an unexplained rise in blood sugar in a diabetic whose sugar had been well controlled.

Take confusion seriously. In an older person with a wound, new confusion, disorientation, speech that does not make sense, unusual drowsiness, or a sudden inability to stay awake and answer normally is very often the first sign of sepsis — showing up before any fever, and sometimes with no fever at all, or with a temperature that falls instead of rising. Never wait for a temperature to confirm what a change in alertness is already telling you. Go to an emergency room.

Bone and joint infection

When an ulcer reaches down as far as bone or a joint, the infection can settle there. Bone and joint infection destroys tissue and cartilage and can permanently reduce the movement and function of the limb or joint. It is suspected when a deep ulcer will not heal despite good care, when bone or a hard white structure is visible at the base of the wound, or when there is persistent deep pain or unexplained fever. Judge that by looking only — never open a wound or put a finger inside it to feel for bone, which carries infection deeper in. It is diagnosed with imaging and blood tests, it needs specialist care, and it cannot be assessed or treated at home.

A word about antibiotics

Most pressure ulcers do not need antibiotics at all. Every chronic open wound carries bacteria on its surface — that is normal colonization, not infection, and it is not a reason to treat. A swab taken from a wound with no clinical signs of infection will grow bacteria either way, so a positive result on its own is not permission to start treatment. Antibiotics do not heal a pressure ulcer; relieving the pressure, proper wound care, and good nutrition do.

Starting a leftover course, or one borrowed from a relative or bought over the counter at a pharmacy, does real harm: it can quiet the surface signs while a deep infection carries on underneath, it delays the correct diagnosis, and it breeds resistant bacteria in a wound that may genuinely need treatment later. The same applies to antibacterial creams, ointments, and powders dabbed or sprinkled onto a sore at home: they do not speed healing, they can set off an allergic reaction in the surrounding skin, and their worst effect is the false reassurance that keeps the wound away from someone qualified to look at it. Antibiotics have a role only when a doctor has examined the wound and diagnosed a spreading skin infection, a bone infection, or a blood infection — and it is the doctor who decides which one and for how long.

Frequently Asked Questions

Who is most at risk of pressure ulcers?

Anyone confined to a bed or a wheelchair for long stretches, especially when there is limited movement, poor nutrition, constant moisture on the skin, or reduced sensation.

How do I protect the patient from them?

Change the patient's position regularly (roughly every two hours in bed, and at least every hour when they are sitting), keep the skin clean and dry, use pressure-relieving mattresses and cushions, keep an eye on nutrition and fluid intake, and check the pressure points every day.

When should the patient be seen by a doctor?

If persistent redness appears that does not fade after the pressure has been relieved, or the skin breaks or an open wound forms, or there is discharge, a smell, or fever, these are signs that need medical assessment quickly. And if an older person with a wound becomes confused or unusually drowsy, that is an emergency, even with no fever: they need to go to the emergency department straight away.

Do pressure ulcers heal?

The early stages usually improve with the right care and with pressure relief. At the very earliest stage, while the skin is still intact, the damage is fully reversible, which is why finding it early makes such a difference. Advanced stages need specialized wound care and a lot more time, and sometimes surgery.

What does a pressure ulcer look like, and how do I spot one early?

The first sign is not a wound at all. It is a patch of skin that has changed color compared with the skin around it (red, or darker), on skin that is still completely intact, and it is almost always over a bone: the tailbone, the heel, the hip, the elbow, the shoulder blade, behind the ear, or the back of the head. There is a test you can do with your own hand, on intact skin only, never on a blister and never on broken skin. Press with your fingertip for about three seconds, lift your finger, and look right away. If the skin blanches (goes pale) and then the color comes back, circulation is still working, but that spot is carrying pressure. Take the pressure off it and look again half an hour later; if it has not improved, treat it as damage. If the color does not change at all, if it does not blanch, that is a stage 1 pressure injury, and you need to take the pressure off immediately. On darker skin the redness may not show at all, so look in good light, compare the spot with the skin right next to it, watch for a purple, bluish, or darker tone, and trust your hands: warmth or coolness, firmness, a spongy or boggy feel, swelling, pain, or burning. This is exactly why pressure injuries on darker skin are so often found late, at a more advanced stage. A blood-filled blister, or a deep purple or maroon patch, is not stage 1. It means the damage under the skin is deeper than it looks. That is a deep tissue pressure injury, and it needs to be assessed quickly, not just repositioned. Later you may see a graze or a fluid-filled blister, and then an open sore, which can be shallow or deep depending on the site. If the base of the wound is yellow or black, its depth cannot be judged by eye and it has to be examined. Check the skin every single day, at bath time or when you change your relative.

Treating a pressure ulcer at home: what works and what does not?

What works is anything that removes the cause. Reposition the patient at least every two hours, and every hour if they are sitting in a chair, using a pressure-relieving mattress or cushions, with a pillow under the calf so the heel floats clear of the bed. When you move them, lift them with the bed sheet instead of dragging them, because dragging tears the tissue under the skin, and keep the head of the bed low except at mealtimes. Clean with lukewarm water and a mild soap, dry by patting and not by rubbing, deal with wetness from incontinence right away, and use a barrier cream on intact skin. Food matters as much as turning: enough protein and enough fluids, unless the doctor has set a limit because of the kidneys. What does not work: do not massage or rub a reddened area or a bony spot, because that tissue is already short of blood and rubbing makes the damage worse, and do not use a rubber ring or donut cushion, which concentrates the pressure into a ring around the area. Do not put alcohol or rubbing alcohol, cologne, hydrogen peroxide, antiseptics, colored dyes, coffee, or powder on it, and do not dry the area with a hair dryer or warm it with a hot water bottle: sensation at these sites is poor and a burn can happen without anyone noticing. Do not cut away dead skin and do not pack the wound; the dressing, and the choice of dressing, are a nursing job. And do not buy something at the pharmacy to treat an infection yourself. The patient has to be examined if there is pus or a smell, if the redness is spreading, if the pain is increasing, or if there is no improvement within a week. And if fever or shivering appears, or the older person becomes confused or drowsy or simply not themselves, or their breathing is fast, or they are passing much less urine, that is infection in the blood: emergency care immediately.

What is the treatment for a deep pressure ulcer?

A deep ulcer, one that has reached the fat or the muscle or is close to bone, is not treated with an ointment, and not with something you buy for yourself at the pharmacy. The first and most important step is getting the pressure off the area: the patient must not rest on it, in bed or in the chair, with regular repositioning and a pressure-relieving surface. For as long as the pressure is still there, no treatment will work. Then comes specialist assessment: cleaning the wound and removing the dead tissue by a specialist, never at home, choosing the dressing according to the state of the wound and how much fluid it produces, and measuring the wound every week. If there are signs of infection, or bone infection is suspected: examination, blood tests, sometimes imaging, and treatment on a prescription. There is one exception: a dry, stable black scab on the heel with no redness and no pus. Do not remove it, keep it dry, and do not try to soften it; cover it and have a specialist look at it. Pain is part of the story too, so ask the doctor about a pain medicine suitable for the patient's age and condition before the dressing change. The things that hold healing back are treated as well: anemia, uncontrolled diabetes, low protein, and smoking. Medicines such as steroids and drugs that suppress the immune system slow healing down, but never stop them on your own; that is the doctor's decision. And be realistic: deep ulcers take months, and some of them need surgery to cover and close them. Improvement is slow, but it does come when the pressure is taken off and the nutrition is put right.

What is the best antibiotic for a pressure ulcer?

There is no best antibiotic for a pressure ulcer, and most pressure ulcers do not need an antibiotic at all. Every long-standing wound has bacteria living on its surface; that is normal and it does not mean infection. A swab grows bacteria either way, so the swab result on its own is not permission to treat. An antibiotic is not what closes an ulcer, and it is no substitute for the basics: taking the pressure off, turning the patient, and dressing the wound exactly the way the nurse has specified. And be careful here: taking leftover tablets you have at home, or a relative's prescription, or sprinkling an antibiotic powder or ointment onto the wound, does harm. It makes the bacteria resistant to treatment, and it can mask a deep infection that has already reached the bone. The same goes for the rest: no rubbing alcohol, no hydrogen peroxide, and no antiseptics on the wound; never cut away dead flesh or a black scab; keep a heel scab dry; and do not pack gauze inside the wound, which is the job of the nurse and the doctor. Antibiotics do have a real role in certain situations, and only a doctor decides that after examining the patient, such as when the infection spreads into the skin around the wound, or reaches the bone, or gets into the bloodstream. So if there is fever, or redness and heat that keep spreading, or a bad smell, or pus, or the patient has started to become confused or drowsy, go to the doctor, not the pharmacy.

I found redness on my relative's skin. How do I know it is the start of an ulcer, and what should I do?

Do the pressure test: put your finger on the reddened area, press lightly for about three seconds, then lift it off. If the skin turns white under your finger and then goes red again, that is ordinary redness and it settles on its own, though that spot is still carrying pressure. If it stays red exactly as it was and does not blanch, that really is the beginning of a pressure ulcer, even though the skin is still closed. If your relative has brown or dark skin, the redness may not show at all and this test will not tell you much. Compare the area with the skin around it, using your hand as well as your eyes: a different color (purple, bluish, or darker), extra warmth or extra coolness, swelling, skin that feels harder or softer than the skin next to it, or pain when you touch it. Treat any one of these as the beginning of an ulcer. And the most important thing: do not massage the red area, and do not rub it with oil, cream, or rubbing alcohol. Massaging over a bony spot makes the damage in the tissue underneath worse, because that tissue is already short of blood. What you should do instead is take the pressure off that area completely, tell the nurse or the doctor, and stop using the round rubber ring (donut cushion), because it concentrates the pressure into a ring of skin resting on it and cuts off its blood supply.

How long does a pressure ulcer take to heal?

There is no fixed number, and it varies a great deal from one person to another. If the injury is still at the very beginning, redness that does not blanch with the skin still closed, the area can go back to normal within a few days to a week, as long as the pressure is genuinely taken off. A deep ulcer that has eaten into the flesh takes months, and in a frail patient it may stay open and never close. When a deep ulcer does heal, it closes with scar tissue, which means the area stays weak and breaks down again easily, so prevention continues even after it has closed. The biggest thing that decides how long it takes is not the type of ointment; it is really taking the pressure off. Turn the patient every two hours in bed and at least every hour while they are sitting, tilt them onto their side at an angle rather than straight onto the hip bone, lift the heel off the mattress with a pillow under the calf, and never lay them on the wound. After that comes nutrition, with enough protein and fluids, along with controlling blood sugar and keeping urine and stool off the skin. The skin around the wound has to stay clean and dry, but the wound itself needs the balanced moisture of the dressing the nurse has chosen, so do not leave it uncovered to let it dry out. Your job is to turn the patient, take the pressure off, and report what you see; the dressing and the assessment of the wound are the nurse's job. And if two weeks go by with no improvement at all, that is not a time for patience: the plan has to be reviewed with a doctor.

When is a pressure ulcer dangerous, and when does the patient need a doctor immediately?

Some signs mean the patient has to be seen by a doctor right away, not tomorrow and not at the next dressing change:

Fever, or the opposite: feeling cold and shivering.
Redness, heat, or swelling around the wound that is spreading quickly.
A bad smell, or pus.
A wound that is getting bigger fast, or turning black.
Bone, or something hard and white, visible in the base of the wound (visible just by looking, without opening the wound and without putting your fingers inside it, because that introduces infection).
Pain that has suddenly increased, or severe pain that does not match the way the wound looks.
Fast breathing, a fast heartbeat, very little urine, or a sudden rise in blood sugar.

If the patient has diabetes or a weak immune system, these signs come on mildly or late, so do not wait for them to become obvious. A patient with diabetes or a spinal cord injury may feel no pain at all, so the absence of pain is not reassurance. And the most dangerous sign, the one that is missed most often: an older patient who becomes confused, who talks in a way that does not make sense, or who is drowsy and will not wake up properly. This can be the first sign that the infection has reached the bloodstream, and it appears before fever, sometimes with no fever at all. A change in awareness in a patient who has a pressure ulcer is an emergency: they need to go to the emergency department straight away.