GPAtlas🧭 When to suspect
A pressure ulcer (also called a pressure sore, bedsore or pressure injury) is localised damage to the skin and/or underlying tissue, usually over a bony prominence or under a medical device, caused by sustained pressure, or pressure combined with shear.
The commonest sites are the sacrum and heels, followed by:
• The ischial tuberosities
• Greater trochanters
• Elbows
• In neonates and infants – the occiput
Suspect pressure damage in anyone with reduced mobility who cannot reposition themselves, with added risk from:
• Reduced sensation (spinal cord injury, diabetic neuropathy, stroke, multiple sclerosis)
• Malnutrition
• Incontinence or moisture
• Friction and shear
• Older age and frailty
• Peripheral arterial disease
• A previous or current ulcer
The earliest sign is non-blanchable erythema of intact skin; in darker skin tones this colour change is easily missed, so judge by warmth, firmness, oedema and reported pain rather than redness alone.
The two core primary-care skills are:
• To categorise accurately (which guides surveillance and wound care)
• To recognise the deteriorating or infected ulcer that needs escalation
Categorisation uses the International NPUAP/EPUAP classification, produced by the European Pressure Ulcer Advisory Panel and partners.
| Category | How it presents |
|---|---|
| Category 1 | • Intact skin with non-blanchable erythema • May be subtle colour change, warmth, firmness or oedema in darker skin |
| Category 2 | Partial-thickness skin loss with exposed dermis – a shallow open ulcer or an intact/ruptured serous blister. |
| Category 3 | • Full-thickness skin loss • Subcutaneous fat may be visible • Slough may be present, but fascia, muscle, tendon or bone are not exposed |
| Category 4 | Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone. |
| Unstageable | • Full-thickness loss where the depth is obscured by slough or eschar • Categorise as 3 or 4 once the base is visible |
| Deep tissue injury (DTPI) | • Intact or non-intact skin with persistent non-blanchable deep red, maroon or purple discolouration, or a blood-filled blister • May deteriorate rapidly |
Source: NICE CG179 · EPUAP/NPIAP/PPPIA 2019 International Classification
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