Diseases & Conditions

Bedsores (pressure sores)

Bedsores, more accurately 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.

Although people living with paralysis are especially at risk, anyone who is bedridden, uses a wheelchair or is unable to change positions without help can develop bedsores.

Bedsores can develop quickly, progress rapidly and are often difficult to heal. Yet health experts say many of these wounds don't have to occur. Key preventive measures can maintain the skin's integrity and encourage healing of bedsores.

Bedsores fall into one of four stages based on their severity. The National Pressure Ulcer Advisory Panel, a professional organization dedicated to the prevention and treatment of pressure sores, has defined each stage as follows:

• 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 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

When to see a doctor
Contact your doctor right away if you notice any broken skin or open sores. Get immediate medical care if you have signs of infection such as fever, drainage from the sore, a foul odor, or increased heat and redness in the surrounding skin.

Bedsores are usually unmistakable, even in the initial stages, but your doctor is likely to order blood tests to check your nutritional status and overall health. Depending on the circumstances, you may have other tests.

When you have a wound that doesn't improve, even with intensive treatment, or you have chronic pressure sores, your doctor may remove a small sample of tissue. The tissue may be cultured for unusual bacteria or fungi. The tissue may also be checked for cancer, which is a risk in people with long-standing wounds.

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.

Addressing the many aspects of wound care, including the emotional issues, requires a multidisciplinary approach. You're likely to receive care from nurses and your primary care physician, along with help from a social worker and physical therapist. When incontinence is an issue, you may see a urologist or gastroenterologist. And if a wound requires surgical repair, a neurosurgeon, orthopedic surgeon and plastic surgeon may be involved in your care.

Conservative treatment
Although it may take some time, 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. If you're unable to change position on your own, a family member or other caregiver must be able to help. Using sheepskin or other padding over the wound can help prevent friction when you move.

• 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.

  For your mattress, doctors often suggest low-air-loss beds or air-fluidized beds. Low-air-loss beds use inflatable pillows for support, whereas air-fluidized beds suspend you on an air-permeable mattress that contains millions of silicone-coated beads.

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 (debridement). 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.

Surgical repair
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.