Pressure injuries are preventable and treatable — but only when the cause is addressed. The cause is pressure. The intervention is off-loading. Wound care without off-loading is treating the symptom while the cause continues. Staging guides dressing selection, but no dressing heals a wound that is still under pressure.
CLINICAL PRINTABLE
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A one-page Pressure Injuries / Wounds clinical reference is on the way.
1 · Recognition / Staging
- Stage 1: Non-blanchable erythema of intact skin over a bony prominence. Skin is intact. May be painful, firm, soft, warmer, or cooler than adjacent tissue. Difficult to detect in darkly pigmented skin.
- Stage 2: Partial-thickness skin loss with exposed dermis. Presents as a shallow open ulcer with a pink/red wound bed, or an intact/ruptured serum-filled blister. No slough or eschar.
- Stage 3: Full-thickness skin loss. Subcutaneous fat may be visible. Slough and/or eschar may be present. Depth varies by anatomical location — areas with minimal subcutaneous tissue (bridge of nose, ear, occiput, malleolus) may be shallow.
- Stage 4: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. Slough and/or eschar often present. Undermining and tunneling common.
- Unstageable: full-thickness skin and tissue loss where the extent of tissue damage cannot be confirmed because the wound base is obscured by slough or eschar. Debridement is required to determine true stage.
- Deep tissue pressure injury (DTPI): persistent non-blanchable deep red, maroon, or purple discoloration, or epidermal separation revealing a dark wound bed. May evolve rapidly to expose actual tissue loss.
2 · Differential / Wound Types
Venous leg ulcer
Located on the medial lower leg/gaiter area. Associated with venous insufficiency, edema, lipodermatosclerosis, and hemosiderin staining. Irregular borders, shallow, painful. Compression therapy is the cornerstone of treatment.
Arterial (ischemic) ulcer
Located on distal extremities, toes, and pressure points. Punched-out appearance, pale wound bed, minimal exudate. Associated with absent pulses, ABI <0.9, claudication. Compression is contraindicated.
Diabetic foot ulcer
Plantar surface of the foot over pressure points. Associated with peripheral neuropathy and peripheral arterial disease. Callus formation around the wound. Requires off-loading, infection management, and vascular assessment.
Moisture-associated skin damage (MASD)
Skin breakdown from prolonged exposure to moisture (incontinence, wound exudate, sweat). Diffuse, irregular borders, not over a bony prominence. Distinct from pressure injury — treatment is moisture management, not off-loading.
3 · Treatment Pathway
Off-loading — the essential intervention
Reposition every 2 hours for bed-bound patients. Use pressure-redistribution mattresses (foam, alternating air) for all at-risk patients. Heel protection devices for heel ulcers. Off-loading is the intervention — wound care without off-loading will fail.
Stage 1 — Intact skin
Eliminate pressure over the area. Protect with transparent film or thin foam dressing. Moisturize dry skin. Do not massage over bony prominences — this increases tissue damage.
Stage 2 — Partial thickness
Moist wound healing: hydrocolloid, foam, or transparent film dressing. Change every 3–7 days or when soiled. Avoid wet-to-dry dressings — they damage granulation tissue and are painful.
Stage 3–4 — Full thickness
Debridement of necrotic tissue (autolytic, enzymatic, sharp/surgical). Moist wound environment with appropriate dressing (alginate for heavy exudate, foam, hydrogel for dry wounds). Negative pressure wound therapy (NPWT/VAC) for large wounds with adequate perfusion.
Infection management
Wound colonization is expected — treat only clinical infection (increased pain, erythema, warmth, purulent exudate, fever, elevated WBC). Topical antiseptics (silver-containing dressings, cadexomer iodine) for critically colonized wounds. Systemic antibiotics for cellulitis, osteomyelitis, or sepsis.
Nutrition
Malnutrition impairs wound healing. Assess nutritional status (albumin, prealbumin, weight). Protein 1.2–1.5 g/kg/day for wound healing. Vitamin C and zinc supplementation if deficient. Dietitian referral for significant malnutrition.
4 · Expected Response
- Stage 1–2 injuries should show improvement within 1–2 weeks with consistent off-loading and appropriate dressing. Lack of improvement suggests inadequate off-loading or unrecognized infection.
- Stage 3–4 injuries heal slowly — weeks to months. Track wound dimensions (length, width, depth) at each assessment. A wound that is not progressing after 2–4 weeks of optimal care requires reassessment.
- Wounds should not be staged in reverse (e.g., 'Stage 4 healing to Stage 3') — once a wound is full-thickness, it heals by scar formation, not by regeneration of lost tissue layers.
5 · Escalation
- Osteomyelitis: bone exposed in wound base, or failure to heal despite optimal care. MRI is the most sensitive imaging. Bone biopsy for culture-directed antibiotic therapy. Orthopedic or infectious disease consultation.
- Sepsis from wound source: systemic signs of infection (fever, hypotension, tachycardia, elevated WBC) with a pressure injury as the likely source — blood cultures, broad-spectrum antibiotics, source control.
- Wound care specialist or plastic surgery referral for Stage 3–4 wounds not progressing, wounds requiring surgical debridement, or consideration of flap closure.
- Vascular surgery referral if arterial insufficiency is contributing to wound non-healing — revascularization may be required before wound healing is possible.
Apply It · Change One Detail
APPLY IT
An 82-year-old nursing home resident has a Stage 3 sacral pressure injury with yellow slough covering the wound base. The wound has not improved in 3 weeks despite daily dressing changes. The problem is not the dressing — it is that the patient is being repositioned only every 4 hours and is sitting in a chair for 6 hours daily. Off-loading is the intervention. No dressing will heal a wound that is still under pressure.
CHANGE ONE DETAIL
Change one detail — the same wound now has surrounding erythema, warmth, purulent drainage, and the patient has a fever of 38.8°C. This is now a clinically infected wound. Wound culture, systemic antibiotics, and assessment for osteomyelitis (MRI if bone is visible or palpable) are required in addition to off-loading.
Bottom Line
Off-loading is the intervention. No dressing will heal a wound that is still under pressure. Wound care without off-loading is treating the symptom, not the cause.
EVIDENCE & REFERENCES
- National Pressure Injury Advisory Panel (NPIAP). Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. 2019. https://npiap.com
- Berlowitz D. Epidemiology, pathogenesis, and risk assessment of pressure-induced skin and soft tissue injury. UpToDate. 2024.