7 Key Symptoms of Pressure Ulcers (Bedsores) You Should Never Ignore

Introduction

Pressure ulcers, commonly known as bedsores or pressure sores, are injuries to the skin and underlying tissue that result from prolonged pressure on the skin. These wounds typically develop on bony areas of the body, such as heels, ankles, hips, and tailbone. Bedsores are most common in people who are bedridden, use a wheelchair, or are unable to change positions without help. Understanding the symptoms of pressure ulcers is crucial for early detection and prevention of serious complications. This comprehensive guide will walk you through the key symptoms to watch for, helping you recognize bedsores at various stages of development.

1. Skin Discoloration and Color Changes

One of the earliest and most noticeable symptoms of pressure ulcers is a change in skin color in the affected area. The appearance varies depending on skin tone and the severity of the condition.

In people with lighter skin tones, the affected area may appear red or pink and does not blanch (turn white) when you press on it. This persistent redness is a warning sign that the tissue is beginning to break down due to inadequate blood flow.

For individuals with darker skin tones, the area may appear blue, purple, or have a shiny appearance. The skin might also look different from the surrounding areas, appearing darker or having a different texture.

These color changes indicate that the skin cells are being deprived of oxygen and nutrients due to sustained pressure. The discoloration typically appears on pressure points where bones are close to the skin surface, such as the sacrum, heels, elbows, and shoulder blades.

Key indicators:

• Non-blanching redness on light skin
• Purple, blue, or darker patches on dark skin
• Shiny or taut appearance of skin
• Color that differs noticeably from surrounding healthy tissue

2. Skin Temperature Variations

The affected area may feel different to the touch compared to the surrounding skin. This temperature variation is an important early warning sign that many people overlook.

The area developing a pressure ulcer often feels warmer than the nearby tissue. This warmth indicates inflammation as the body attempts to fight the damage. The increased temperature results from the inflammatory response, with more blood being directed to the area in an attempt to heal the damage.

Conversely, in some cases, the affected area may feel cooler than the surrounding skin. This coolness suggests that blood flow to the area has been significantly compromised, which is a serious concern requiring immediate attention.

You can detect these temperature changes by gently touching the suspected area and comparing it to nearby healthy skin. Use the back of your hand, which is more sensitive to temperature differences than your palm.

Temperature signs to monitor:

• Warmth indicating inflammation
• Coolness suggesting poor circulation
• Noticeable difference from surrounding tissue
• Consistency of temperature abnormality over time

3. Changes in Skin Texture and Firmness

As pressure ulcers develop, the texture and firmness of the affected skin undergo noticeable changes that differ from healthy tissue.

The area may feel unusually firm or hard to the touch, a condition known as induration. This firmness occurs because of swelling and inflammation in the deeper tissue layers. The skin might feel tight or taut, similar to the sensation of an overfilled balloon.

Alternatively, the area may become softer and spongier than the surrounding skin. This softening, called boggy tissue, indicates that the tissue underneath is breaking down and becoming damaged. The skin may feel mushy or have a different consistency when you gently press on it.

You might also notice that the skin texture becomes rougher, smoother, or develops a different surface quality. Some areas may develop a leathery appearance as the skin begins to harden and deteriorate.

Texture changes include:

• Unusual firmness or hardness (induration)
• Soft, spongy, or boggy feeling
• Leathery or hardened surface
• Inconsistent texture compared to healthy skin

4. Pain, Tenderness, or Altered Sensation

Pain and sensory changes are significant symptoms of pressure ulcers, though they can vary greatly depending on the individual’s overall health and nerve function.

Many people experience tenderness or pain in the affected area, especially when pressure is applied or when they move. The pain may be described as burning, aching, or sharp. This discomfort occurs because the tissue is being damaged and inflammatory chemicals are stimulating pain receptors.

However, it’s important to note that some individuals, particularly those with diabetes, nerve damage, or spinal cord injuries, may not feel pain in the affected area. The absence of pain does not mean there is no pressure ulcer. In fact, people who cannot feel pain are at higher risk because they lack this natural warning system.

Some people report tingling, itching, or unusual sensations in the area before visible signs appear. These sensory changes can be early indicators that tissue damage is beginning.

Sensory symptoms to watch for:

• Tenderness when touched
• Burning or aching sensation
• Sharp pain with movement or pressure
• Tingling or itching
• Numbness or absence of sensation (in high-risk individuals)

5. Skin Breakdown and Open Wounds

As pressure ulcers progress beyond the initial stages, visible breaks in the skin become apparent. This is a critical symptom requiring immediate medical attention.

The skin may develop blisters, which can be filled with clear fluid or blood. These blisters indicate that the layers of skin are separating and tissue damage is advancing. The blisters may be intact or already ruptured.

As the condition worsens, the skin breaks open, creating a shallow crater or ulcer. The wound may appear pink or red, and you might see the damaged tissue beneath the skin surface. At this stage, the epidermis (outer skin layer) and possibly the dermis (deeper skin layer) have been compromised.

In more severe cases, the wound becomes deeper, exposing fat tissue, muscle, or even bone. The ulcer may have irregular edges and the base of the wound may contain yellowish dead tissue (slough) or black dead tissue (eschar). Deep pressure ulcers are serious medical conditions that can lead to severe complications if not properly treated.

Signs of skin breakdown:

• Blisters (intact or broken)
• Shallow open sores or craters
• Deep wounds exposing underlying tissue
• Yellow slough or black eschar in the wound bed
• Irregular wound edges
• Visible fat, muscle, or bone in severe cases

6. Drainage or Fluid from the Affected Area

The presence of drainage is a significant symptom that indicates tissue damage and possible infection in pressure ulcers.

Once the skin breaks down, you may notice fluid draining from the wound. In early stages or less severe ulcers, the drainage might be clear or slightly yellow (serous fluid). This is the body’s natural response to injury as it attempts to clean the wound and promote healing.

The amount of drainage can vary from minimal moisture to significant fluid that requires frequent dressing changes. Pay attention to the quantity, as increasing drainage may indicate progression of the ulcer or development of complications.

If the drainage becomes thick, cloudy, green, or has a foul odor, this strongly suggests infection. Infected pressure ulcers may also produce pus, which appears as thick, yellowish, or greenish discharge. Any signs of infection require immediate medical evaluation.

Blood-tinged drainage may also occur, especially if the ulcer is deep or if there has been trauma to the area. While some blood-tinged fluid can be normal in deeper wounds, excessive bleeding should be evaluated by a healthcare provider.

Drainage characteristics to monitor:

• Clear or light yellow fluid (normal healing)
• Increased volume of drainage
• Thick, cloudy, or discolored discharge (infection)
• Foul-smelling odor (infection)
• Pus or purulent drainage
• Blood-tinged or bloody drainage

7. Swelling Around the Affected Area

Swelling, or edema, around a pressure point is an important symptom that indicates inflammation and possible tissue damage beneath the skin surface.

The area surrounding the pressure ulcer may appear puffy or swollen. This swelling occurs as part of the inflammatory response, with fluid accumulating in the tissues as the body attempts to respond to the injury. The swollen area may extend beyond the visible area of discoloration or damage.

You can check for swelling by gently pressing on the area with your finger. If an indentation remains after you remove your finger (called pitting edema), this confirms that fluid has accumulated in the tissue. The depth and duration of the indentation can indicate the severity of the swelling.

Swelling may also make the skin appear stretched, shiny, or taut. In advanced cases, the swelling can be quite pronounced and may make it difficult to see the underlying bone landmarks that are normally visible.

Increased swelling, especially if accompanied by warmth, redness spreading beyond the original area, or fever, may indicate infection. This requires prompt medical attention to prevent serious complications such as cellulitis or sepsis.

Swelling indicators:

• Puffy or swollen appearance
• Pitting edema (indentation remains after pressing)
• Shiny, stretched skin
• Swelling extending beyond the discolored area
• Progressive increase in swelling over time

Main Causes of Pressure Ulcers

Understanding what causes bedsores is essential for prevention and early intervention. Pressure ulcers develop when sustained pressure reduces blood flow to vulnerable areas of skin and underlying tissue.

Prolonged Pressure

The primary cause of pressure ulcers is continuous pressure on the skin, particularly over bony prominences. When pressure exceeds the capillary blood pressure (approximately 32 mmHg), blood flow to the tissue is restricted. Without adequate blood flow, skin and tissue are deprived of oxygen and nutrients, leading to cell death and tissue breakdown. This commonly occurs in people who remain in one position for extended periods without relief.

Friction and Shear Forces

Friction occurs when the skin rubs against bedding, clothing, or other surfaces. This repeated rubbing can remove the protective outer layer of skin, making it more vulnerable to breakdown. Shear forces develop when the skin moves in one direction while the underlying bone moves in another direction, such as when a person slides down in a bed or chair. This pulls on blood vessels and can damage deeper tissue layers.

Moisture and Maceration

Excessive moisture from perspiration, urine, or feces can soften the skin (maceration), making it more fragile and susceptible to damage. Wet skin breaks down more easily than dry skin and is more vulnerable to the effects of friction and pressure.

Poor Nutrition and Hydration

Inadequate nutrition, particularly insufficient protein, vitamins (especially C and E), and minerals, impairs the skin’s ability to maintain its integrity and heal damage. Dehydration reduces skin elasticity and makes tissue more vulnerable to pressure injuries. Malnutrition weakens the immune system and slows the healing process.

Reduced Mobility and Sensation

People who cannot move independently or change positions easily are at highest risk. This includes individuals who are bedridden, use wheelchairs, are paralyzed, or are sedated. Those with reduced or absent sensation, such as people with spinal cord injuries, diabetes-related neuropathy, or other neurological conditions, may not feel the discomfort that normally prompts position changes.

Medical Conditions and Risk Factors

Several health conditions increase susceptibility to pressure ulcers, including diabetes (which impairs circulation and healing), vascular disease (reducing blood flow), neurological disorders, advanced age (skin becomes thinner and less resilient), obesity or being underweight, incontinence, smoking (impairs circulation), and conditions requiring extended bed rest or immobilization.

Prevention of Pressure Ulcers

Preventing bedsores is far more effective than treating them. With proper care and attention, most pressure ulcers can be prevented, even in high-risk individuals.

Regular Position Changes and Movement

The most important preventive measure is to relieve pressure regularly. Bedridden individuals should be repositioned at least every two hours, while wheelchair users should shift their weight every 15-30 minutes. When repositioning, avoid dragging the person across sheets, as this creates friction and shear forces. Instead, lift them carefully. Use pillows or foam wedges to keep bony areas from touching each other, such as knees and ankles.

Use of Pressure-Relieving Devices

Specialized mattresses, overlays, and cushions designed to redistribute pressure can significantly reduce risk. These include foam, air, gel, or water-filled devices. The choice depends on the individual’s risk level and mobility. Ensure wheelchair cushions are appropriate for the person’s needs and are used consistently. Avoid using ring-shaped (donut) cushions, as they can reduce blood flow to the area.

Skin Care and Hygiene

Keep skin clean and dry, using mild soap and warm (not hot) water. Pat skin dry gently rather than rubbing. Apply moisturizer to dry skin, but avoid over-moisturizing areas where bone is close to the surface. Protect skin from moisture by promptly cleaning areas exposed to urine or feces, and use barrier creams if necessary. Check skin daily for any signs of redness, changes in color, or other early warning signs of pressure damage.

Optimal Nutrition and Hydration

Ensure adequate intake of protein, calories, vitamins, and minerals to maintain skin health and healing capacity. Encourage sufficient fluid intake unless medically contraindicated. For individuals at risk, consult with a dietitian to develop an appropriate nutrition plan that supports skin integrity.

Minimize Friction and Shear

Use lifting devices and draw sheets to help move and reposition people safely without dragging them. Keep the head of the bed at the lowest safe elevation to prevent sliding down. Use protective dressings or padding on areas prone to friction, such as heels and elbows. Ensure bed linens are smooth and free of wrinkles, crumbs, or other objects that could create pressure points.

Education and Awareness

Educate caregivers, family members, and at-risk individuals about pressure ulcer risks, early warning signs, and prevention strategies. Create and follow a regular schedule for repositioning, skin checks, and care activities. Document skin condition and any changes to identify problems early.

Frequently Asked Questions

What is the difference between a pressure ulcer and a bedsore?

There is no difference—they are the same condition. “Bedsore” is the common term, while “pressure ulcer” or “pressure sore” is the medical terminology. They may also be called “pressure injuries” or “decubitus ulcers.”

How quickly can pressure ulcers develop?

Pressure ulcers can develop surprisingly quickly. In some high-risk individuals, noticeable skin changes can occur within 2-6 hours of continuous pressure. More significant damage typically develops over several days, but the timeline varies based on individual risk factors, pressure intensity, and overall health.

Can pressure ulcers heal on their own?

Early-stage pressure ulcers (Stage 1) may heal on their own if pressure is immediately relieved and proper preventive care is implemented. However, more advanced ulcers typically require medical intervention and proper wound care to heal. Without treatment, pressure ulcers tend to worsen and can lead to serious complications.

Who is most at risk for developing bedsores?

People at highest risk include those who are bedridden or use wheelchairs, individuals with limited mobility or inability to change positions independently, people with reduced sensation or paralysis, elderly individuals with fragile skin, those with poor nutrition or chronic illnesses, and anyone confined to bed following surgery or during illness.

What areas of the body are most commonly affected by pressure ulcers?

The most common sites are areas where bone is close to the skin surface. For bedridden people lying on their back, these include the tailbone (sacrum), heels, shoulder blades, back of the head, and spine. For side-lying positions, the hips, ankles, knees, and ears are vulnerable. For wheelchair users, the tailbone, buttocks, shoulder blades, and backs of arms and legs are at risk.

Are pressure ulcers painful?

Pain levels vary significantly. Some people experience considerable pain and tenderness, while others, particularly those with nerve damage or reduced sensation, may feel little or no pain. The absence of pain does not mean a pressure ulcer isn’t serious—visual inspection and monitoring are essential regardless of pain levels.

Can pressure ulcers lead to serious complications?

Yes, untreated or severe pressure ulcers can lead to serious complications including cellulitis (skin infection), bone and joint infections (osteomyelitis and septic arthritis), sepsis (life-threatening blood infection), and in rare cases, cancer in chronic wounds. Deep ulcers can cause significant tissue damage and may require extensive medical intervention.

When should I seek medical attention for a suspected pressure ulcer?

Seek medical attention immediately if you notice any signs of skin breakdown, persistent redness that doesn’t blanch, blisters or open sores, or any signs of infection such as fever, foul-smelling drainage, pus, increased pain, warmth spreading beyond the affected area, or red streaks extending from the wound. Early intervention significantly improves outcomes.

Can pressure ulcers be prevented in all cases?

While not all pressure ulcers can be prevented, the vast majority can be avoided with proper preventive care. Consistent implementation of prevention strategies—including regular repositioning, use of pressure-relieving devices, good skin care, and adequate nutrition—can reduce the risk by up to 95% in most situations.

References:

• Mayo Clinic – Bedsores (Pressure Ulcers)
• NHS – Pressure Ulcers (Pressure Sores)
• MedlinePlus – Pressure Sores
• Johns Hopkins Medicine – Bedsores
• National Center for Biotechnology Information – Pressure Ulcer