Pressure ulcers

Pressure ulcers nearly always develop in places where there are bones right under the skin. This includes the tailbone, heels, hips, shoulder blades, ankles, elbows, ears, and the back of your head.

If your body weight constantly “squashes” your skin in these places when you are sitting or lying, not enough blood can get through to provide oxygen and nutrients. The skin becomes thinner, and it may gradually die over time. This creates a wound that is especially painful when you sit or lie on it.

People who are healthy quickly notice pain whenever there is too much pressure on one part of their body. But some diseases can affect how you perceive pain or increase your risk of wounds developing:

• People who are paralyzed often don't sense pressure or pain in the parts of their body that are affected.
• People who have had diabetes for many years sometimes feel less pain and may not notice if there is too much pressure on one part of their body. Diabetes can also affect the flow of blood through the body.
• Circulation disorders, possibly due to narrowed blood vessels (arteriosclerosis), make it even more difficult for blood to reach vulnerable areas of skin.
• Malnutrition is an additional risk factor for people who are bedridden. This is because people who hardly have any body fat and drink and eat very little have thinner and less resistant skin, with poor blood circulation.
• Friction and shear (the forces caused by two layers of skin rubbing against each other) can damage the skin even more. This might happen when people who are confined to their bed are moved, and their skin is pulled over the mattress or sheets. The movement can push the different layers of skin against each other: The top layer is stopped from moving by friction with the sheets, but this doesn't affect the other layers. This can cause redness and superficial skin injuries.
• Incontinence: Skin that is exposed to urine (pee), feces (poop) or sweat for hours is more prone to irritation and damage. This can happen to people who are often in wet diapers for longer periods of time. The skin that has softened up is more likely to become damaged.

If someone has already had a pressure ulcer in the past, they are more likely to develop another one in the same place. This makes it all the more important to try to stop pressure ulcers from developing in the first place.

Pressure ulcers can be painful and emotionally distressing. If treated properly, smaller pressure ulcers can heal within a few weeks. This can take much longer is the wounds are very severe.

Open, poorly healing wounds also act as gateways for germs, which may lead to an infection. If the germs spread further into the body, the wound can’t heal properly, resulting in blood poisoning (septicemia).

Some people are able to check their own skin for early signs of pressure ulcers, for example with the help of a mirror. If they have been in a situation where they could hardly move or were not able to move at all for a longer time, they often know the warning signs. People who are too weak to turn around, sit up or stand up on their own have to rely on help to check any at-risk areas of their body, though. These areas are usually on the back of their body, such as on their shoulder blades or bottom.

Nurses and doctors often use the following classification system to assess the severity of a pressure ulcer:

• Stage 1: The skin isn’t damaged. Lighter skin is reddened, even when no pressure is applied. Darker skin may be somewhat discolored. It might feel warmer or colder, more sensitive to pain, or softer or harder than the surrounding tissue.
• Stage 2: The upper layers of the skin are damaged, and there may be a blister, scrape or bruise, for instance.
• Stage 3: All of the skin layers are damaged and there is a deep wound that may even reach down to the fat layer of the skin. Slough (dead tissue and pus) cover the wound; some parts of the skin may have died (necrosis).
• Stage 4: The skin and much of the surrounding tissue is damaged and has died. The muscles, tendons or bones are visible.

The wound may have slough on it or be covered by a scab, so it’s not immediately clear how deep the wound is. Sometimes the skin is unbroken and has a reddish brown color, but the tissue underneath is damaged.

If doctors think that the sore might be infected it may be necessary to take a swab, blood or tissue sample. This sample is then checked in the lab to see whether bacteria have infected the wound.

If someone has to sit or lie down without moving for a long time – even if just for a few days – it's important to reduce the pressure on the most at-risk parts of their body through regular repositioning and turning. Special supportive surfaces can also help to relieve some of the pressure. For instance, special mattresses or cushions can be used.

Regularly checking the more vulnerable body areas will allow you to react faster if there are any early signs of a pressure ulcer. It is important to take care to avoid friction and shear forces as much as possible when repositioning and assisting someone. For instance, don't pull someone who is bedridden across the mattress or sheets. Cream or lotion can help moisturize very dry skin. Any skin care products you use should be suitable for the person's skin type and its condition. Apply them as gently as possible. There is no scientific evidence that using cream regularly can help to prevent pressure ulcers, though. If the person is incontinent, their incontinence pads or diapers need to be changed regularly too.

It is also important to make sure that the person gets enough to drink and eats a balanced diet: Not getting enough fluids or malnutrition can weaken the skin even more.

The most appropriate treatment will depend on the type and severity of the pressure ulcer. It is important to always prevent the pressure ulcer from being subjected to continuing pressure. Positioning aids, special mattresses, and regular repositioning and movement help to relieve the pressure on the affected parts of the body.

Many different types of wound dressings can be used for pressure sores. The dressings should cover the wound, keep it moist and prevent infection. Every time the dressing is changed, the wound can be cleaned. For stage 3 and 4 wounds, a technique called debridement is used as well to remove dead tissue. Debridement involves a healthcare professional using tweezers or a scalpel to remove dead cells.

Further treatments for poorly healing pressure ulcers include antibiotics or vacuum-assisted closure (VAC). Surgery is sometimes recommended as well, for instance a skin graft.

Proper wound care and the right positioning can prevent pain or at least reduce it. If that isn’t enough, local anesthetics are an option. Some dressings contain painkillers too. Both options can provide short-term pain relief. Oral medication like acetaminophen (paracetamol) or ibuprofen tablets can also help relieve mild to moderate pain. Doctors can prescribe stronger painkillers if needed.

Moving as much as possible can help to prevent pressure ulcers. Caregivers and their family members can keep on encouraging you to do so and help you move the position of your body. It is important to relieve the pressure on at-risk areas of skin quickly and to show them to a doctor or nurse.

People who have pressure ulcers may feel very uncomfortable. In addition to the pain, they may feel embarrassed. So good support is needed on both personal and medical levels.

Family members can also learn various positioning techniques in caregiving courses. In Germany and other countries, health insurers or long-term care insurers cover the costs of many of the aids needed at home or may lend things like nursing beds. Many cities also have information centers for caregivers, offering help and advice concerning issues related to pressure ulcer prevention.

When people are ill or need medical advice, they usually go to see their family doctor first. Information about health care in Germany can help you to navigate the German healthcare system and find a suitable doctor. You can use this list of questions to prepare for your appointment.