A pressure ulcer can begin quietly: a patch of skin that stays red after pressure is relieved, an unexplained sore spot, or a change in skin colour over a bony area. So, what is a pressure ulcer? It is damage to the skin and underlying tissue caused by sustained pressure, often combined with friction, shear or moisture. It is also commonly called a pressure injury, pressure sore or bed sore.
For a person with limited mobility, a pressure ulcer can affect comfort, independence and confidence as well as physical health. Early action matters. The right seating, mattress, cushions, repositioning routine and clinical advice can help reduce risk and support healing.
What is a pressure ulcer and why does it develop?
Pressure ulcers develop when pressure reduces blood flow to an area of skin for too long. Without sufficient blood flow, the skin and deeper tissue do not receive the oxygen and nutrients they need. Damage can then occur, sometimes beneath the surface before it is easy to see.
They are most likely to form over bony areas, including the tailbone, hips, heels, ankles, elbows, shoulder blades and the back of the head. For people who use a wheelchair or spend long periods in a recliner, pressure may also build under the sitting bones, thighs or along the spine.
Pressure is usually the main cause, but it is rarely the only factor. Friction can occur when skin rubs on bedding or a chair surface. Shear occurs when the skin stays in place while the body slides, such as when someone gradually slips down in bed. Moisture from perspiration or incontinence can soften skin and make it more vulnerable to damage.
Who is at greater risk?
Anyone who cannot change position easily can be at risk. This may include older people, people living with disability, those recovering from surgery or illness, and people with spinal cord injury, neurological conditions or reduced sensation.
Risk can also increase with poor circulation, diabetes, dehydration, weight loss, fragile skin, fever, infection or inadequate nutrition. A person does not need to be completely bed-bound to develop a pressure ulcer. Long periods in one position, whether in bed, a wheelchair or a lift and recline chair, can be enough when other risk factors are present.
For family members and care teams, a change in mobility is often the moment to review pressure care. For example, someone who has recently returned home after hospital, is spending more time in bed, or is finding transfers harder may need a different support surface or a more structured repositioning plan.
Early signs to watch for
A pressure ulcer may first appear as skin that is red, purple, blue or darker than the surrounding area, depending on the person’s skin tone. The area may feel warmer or cooler, firmer, softer, painful, itchy or tender.
On lighter skin, redness that does not fade after pressure is removed is a warning sign. On darker skin, look closely for a change in colour, shine, texture, temperature or tenderness instead of relying on redness alone. Regular skin checks are particularly helpful for heels, hips, the sacrum and areas hidden by clothing or continence products.
If skin is broken, blistered, weeping, blackened, unusually painful or showing signs of infection, seek advice promptly from a GP, wound care nurse or treating health professional. Signs of infection can include increasing redness around the wound, swelling, heat, odour, pus, fever or feeling generally unwell.
Understanding pressure ulcer stages
Health professionals use staging systems to describe the extent of a pressure injury and guide care. A wound should be assessed by a qualified clinician, as the depth of damage is not always obvious.
Stage 1: Intact skin with persistent changes
The skin remains intact but shows a persistent colour change or feels different from nearby skin. This stage can often be reversed when pressure is relieved quickly and the area is protected.
Stage 2: Partial-thickness skin loss
There may be a shallow open wound, abrasion or blister. The wound bed is generally pink or red. It can be painful and requires careful pressure relief, moisture management and appropriate clinical wound care.
Stage 3: Full-thickness skin loss
The ulcer extends through the skin into the fatty tissue beneath. The wound may have deeper edges or drainage. A stage 3 injury needs timely clinical assessment and a tailored treatment plan.
Stage 4: Deep tissue damage
A stage 4 pressure ulcer involves extensive tissue loss and may expose muscle, tendon, cartilage or bone. These wounds require specialist management and can carry a serious risk of infection.
Some wounds are described as unstageable when the base is covered by slough or dead tissue, meaning the true depth cannot yet be confirmed. A deep tissue pressure injury may look like persistent dark red, purple or maroon discolouration and can deteriorate rapidly.
Prevention is a daily plan, not one product
A pressure care mattress or cushion can be an important part of prevention, but equipment works best as part of a broader care plan. The correct approach depends on the person’s mobility, weight, skin condition, sitting time, ability to reposition and clinical risk level.
Repositioning reduces the time pressure is concentrated in one area. The appropriate schedule varies from person to person, so it should be guided by a treating clinician rather than a one-size-fits-all timetable. Some people can complete regular weight shifts independently in a wheelchair, while others need assistance with turns in bed and transfers.
Skin should be kept clean, dry and protected from prolonged moisture. Continence care, gentle cleansing and suitable barrier products may be recommended where moisture is an issue. Avoid rubbing fragile skin and take care when moving someone in bed. Transfer aids, slide sheets and good manual handling techniques can reduce friction and shear for both the person receiving care and the carer.
Nutrition and hydration also contribute to skin health and wound healing. If appetite is poor, weight is changing or a wound is slow to heal, a GP, dietitian or clinical team may recommend a nutritional review.
Choosing pressure-care equipment
The best pressure-care setup is the one that meets the person’s needs in their actual daily environment. A cushion suited to occasional comfort is not necessarily suitable for a person spending most of the day in a wheelchair. Similarly, a mattress overlay may be appropriate for one person, while another needs a higher-level pressure redistribution mattress and a clinical assessment.
Wheelchair cushions can help distribute pressure more evenly and improve sitting comfort, but correct sizing and positioning are essential. A cushion that is too small, incorrectly placed or used with poor posture may not provide the intended benefit. Seating assessment is particularly valuable for people with altered posture, asymmetry, reduced sensation or a history of pressure injuries.
In bed, pressure care mattresses and overlays are designed to redistribute pressure across a larger surface area. Some use foam, while alternating air systems change pressure across different sections of the mattress. There are trade-offs: more complex equipment may offer a higher level of pressure redistribution, but it must be properly set up, maintained and compatible with the person’s transfer needs, bed frame and care routine.
Heel protection can also be necessary, especially where a person spends long periods lying down and cannot reposition their feet independently. The aim is usually to relieve pressure from the heel rather than simply add padding directly beneath it.
For people arranging equipment after discharge, it can help to ask practical questions before purchasing or hiring: How many hours will the equipment be used each day? Can the person reposition themselves? Is there an existing wound? Who will set up and monitor the equipment? Will the support surface affect transfers, bed rails or hoist use?
When a clinician should be involved
Any suspected pressure ulcer deserves timely professional assessment, particularly when skin is broken or the person has diabetes, poor circulation, reduced sensation or a weakened immune system. Wound dressings should be selected for the wound and the person, not simply because they worked for someone else.
Occupational Therapists, physiotherapists, nurses, GPs and wound specialists can help identify the causes of pressure, review seating and mobility, and develop a plan that is realistic for home, aged care or community settings. For providers and care teams, documenting skin checks, equipment use and changes in condition supports consistent care across shifts and services.
Pressure ulcers are often preventable, but prevention needs to match the person rather than the product brochure. If comfort has changed, mobility has reduced or a sore area is developing, arranging an assessment and the right pressure-care support early can protect skin, reduce complications and make day-to-day care more manageable.