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 and – 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, or 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) and 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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