Pressure ulcers are injuries to the skin or the soft tissue under the skin. Healthcare professionals also call them “bedsores” and “decubitus ulcers.” They occur with long lasting pressure on a specific body area and develop in stages.

People with pressure ulcers need immediate treatment to keep the ulcers from progressing, as they can lead to fatal complications. Doctors describe four stages of pressure ulcers based on their severity. Stage 1 involves mild skin flushing, while injuries at stage 4 can infect muscle and bone.

This article provides an overview of the stages of pressure ulcers. It also details the outlook for people with this type of ulcer and how to prevent them from forming.

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Illustration by Wenzdai Figueroa

The mildest stage of pressure ulcers is stage 1.

According to international guidelines put forth by several organizations including the United States National Pressure Injury Advisory Panel, symptoms at the pressure site may include:

  • an unbroken area of flushed skin
  • nonblanchable erythema, which is a skin discoloration that does not fade when a person presses it
  • changes in skin sensation and temperature
  • loss of skin firmness
  • pain

Nonblanchable erythema may appear differently in people with darkly pigmented skin.

Its presence signifies that a person may develop more pressure ulcers within 4 weeks, which are more likely to be stage 2 ulcers.

Doctors need to start treating pressure ulcers when nonblanchable erythema appears to prevent the progression of the skin condition.


Treatment for pressure ulcers depends on the staging and the location. However, no fixed guideline exists.

The goals of treatment are to:

  • lower the pressure on the skin
  • minimize contact with the ulcer
  • decrease moisture
  • keep the area clean

Usually, stage 1 ulcers do not require surgery.

If pain is present at any stage, doctors may recommend pain relievers. Pain may worsen as the staging increases, and a person may need various pain relievers.

Read more about pressure ulcers here.

According to international guidelines, the epidermis and dermis become thinner in stage 2 pressure ulcers. The epidermis is the visible part of the skin. The dermis is the connective tissue layer located immediately underneath the epidermis.

The guidelines suggest that symptoms of a stage 2 pressure ulcer include the presence of:

  • a discolored wound
  • a moist wound
  • an intact or ruptured blister


In general, pressure ulcer treatment involves wound care and nutritional support.

A person who is at risk of or experiencing malnutrition must receive nutritional support. This involves a protein and calorie-rich supplement with arginine, zinc, and antioxidants. Depending on the severity of the wound, doctors may use different skin dressings for infected and noninfected skin.

Biophysical agents such as pulsed current electrical stimulation may help support healing in some situations. Doctors may prescribe antibiotics to prevent or treat infections.


Recovery from stage 2 pressure ulcers varies based on the location of the wound and the treatments involved. Doctors generally agree that most of the time, people need lifelong treatment and prevention of pressure ulcers.

A stage 2 ulcer progresses to a stage 3 ulcer when the wound extends into the subcutaneous tissue. The subcutaneous tissue lies under the dermis and contains fat cells, hair follicles, neurons, and blood vessels.

Symptoms of a stage 3 ulcer may include:

  • full-thickness loss of the skin
  • visible fat tissue
  • a foul smell

There may also be visible slough or eschar in the wound. Slough is moist, loose, stringy dead tissue that falls off from healthy skin. It appears yellow, tan, gray, green, or brown. Eschar is usually dry and thick and appears tan, brown, or black.


Compared with Stage 2 pressure ulcers, doctors may need to use different wound dressings for stage 3 ulcers. Hydrogel dressings and calcium alginate dressings may help stage 3 pressure ulcers. Platelet-derived growth factor also helps promote the healing of stage 3 pressure ulcers.

Doctors may recommend noncontact low frequency ultrasound therapy or high frequency ultrasound therapy. This treatment is an added treatment for stage 3 pressure ulcer healing.

To lower the size and extent of the ulcer, doctors may treat stage 3 ulcers with negative pressure wound therapy.

Stage 3 ulcers may require surgery.


Recovery from stage 3 pressure ulcers is complicated due to the development of infections at the wound. Infections and complications from stage 3 pressure ulcers can be life threatening. Even after surgery, complications such as abscess formation, blood clotting, and sepsis can occur.

In stage 4 pressure ulcers, the wound extends past the subcutaneous tissue. These pressure ulcers show significant tissue loss. In some situations, stage 4 pressure ulcers affect the underlying muscle, bone, tendon, or joint.

Symptoms may include the presence of slough and eschar in the wound and rolled wound edges.


Similar dressings can treat stage 3 and stage 4 pressure ulcers. Platelet-derived growth factors can also promote the healing of stage 4 pressure ulcers. Different biophysical agents may help aid dressings and growth factors.

These include:

  • pulsed current electrical stimulation
  • noncontact low frequency ultrasound therapy
  • high frequency ultrasound therapy
  • negative pressure wound therapy

Stage 4 pressure ulcers may also require surgery.


Ulcers that require surgery have a high rate of recurrence.

Depending on the ulcer’s location, people may need air-fluid beds when recovering from surgery. Up to 4 weeks after surgery, a person will lie flat on their support surface. After these initial 4 weeks, they can be in a semi-sitting position. At 6 weeks, the person may sit up for 10 minutes at a time.

Doctors will frequently check the surgical site. A detailed skin care routine is necessary.

Doctors cannot measure how deep an unstageable pressure ulcer extends into the tissue because the wound fills with slough or eschar. The presence of slough or eschar indicates the ulcer is either stage 3 or 4.


To determine the best treatment for an unstageable pressure ulcer, doctors must first remove the slough and eschar. Following this, treatment for a stage 3 or 4 ulcer begins.


According to a 2018 study in the British Medical Journal, unstageable pressure ulcers may heal within 10 months of their initial presentation. However, recovery from an unstageable pressure ulcer may become complicated due to other medical conditions, such as diabetes and cardiovascular disease.

Pressure ulcers occur on parts of the body that experience long-term or constant pressure.

They may develop in bony areas such as:

  • the sit bone of the buttocks
  • the outside of the hip
  • the tailbone
  • the heel
  • the outside of the ankle
  • the back of the head

They occur mostly in people with conditions that limit mobility or who must remain in bed for long periods.

However, immobility for as little as 2 hours may be enough to provide the environment for pressure ulcer formation.

Preventing pressure ulcers may be the best way to manage this progressive skin condition. Doctors and nurses can prevent pressure ulcers by maintaining excellent skin care in people with limited mobility. Support surfaces and cushions may help distribute pressure more evenly across pressure points.

Repositioning a person every 2 hours lowers pressure on a specific spot. Some people may need repositioning more or less frequently to prevent pressure ulcer formation.

Depending on the location of the pressure spot, healthcare workers may need to divert urine and stool. Excrement can contaminate and worsen a pressure sore.

Treating and managing pressure ulcers requires efforts from caregivers and healthcare professionals.

An interprofessional team is necessary for treating different stages of pressure ulcers. Surgeons, wound care specialists, and specialty-trained nurses are invaluable for managing pressure ulcers.

A pressure ulcer is a serious skin condition that is complicated to treat. Recurrences are common, and prevention is the best strategy. However, if many risk factors are present, they may still develop in areas of the skin with constant and prolonged pressure.

Staging pressure ulcers help doctors determine the best treatment.