Pressure Ulcers (Pressure Sores)

NICE CKS Pressure ulcers. Last revised: Jan 2024.

NICE Clinical guideline [CG179] Pressure ulcers: prevention and management. Published: Apr 2014.

Article Last Updated:18/05/2026

Pressure Ulcers (Pressure Sores)

Pressure ulcers, also known as pressure sores, are localised injuries to the skin and/or underlying tissue caused by sustained pressure, or pressure combined with shear.

This updated UKMLA guide ot pressure ulcers is based on NICE CKS and NICE CG179, which covers causes, risk factors, diagnosis, classification, complications, prevention, and management.

Causes and Risk Factors

Incidence and prevalence increases with age (>60% cases occur in >70 y/o)

Key risk factors of developing pressure ulcers (however, note that anyone can develop a pressure ulcer):

Category	Risk factors
Prolonged pressure exposure	Immobility and inability to reposition independently (e.g. spinal cord injury, motor neuron disease, advancing age, frailty) Prolonged bed / chair use Use of non-pressure-relieving mattresses / chair / bed
Reduced pain / pressure perception	Loss of sensation Neurological impairment Cognitive impairment
Skin integrity factors	Urinary and/or faecal incontinence Excess skin moisture or dry skin Poor general skin condition
Circulatory / systemic disease	Diabetes Peripheral vascular disease Heart failure Malnutrition / nutritional deficiency

Risk Assessment

Who should have a pressure ulcer risk assessment

All people being admitted to secondary care or to care homes in which NHS care is provided
All people receiving NHS care in other settings (e.g. primary and community care, and emergency departments) who are at risk

Consider carrying out an assessment of pressure ulcer risk for all people in their own homes or in social/nursing care settings

Pressure ulcer risk assessment

Consider using a validated risk assessment scale to support clinical judgement.

Recommended risk assessment scales include:

Reassess pressure ulcer risk, particularly if there is a change in clinical status (e.g. after surgery, on worsening of an underlying condition, or with a change in mobility)

Assessment and Diagnosis

Pressure ulcers most commonly occur over bony prominences:

Sacrum
Heels
Ischial tuberosities
Elbows

Clinical features and classification of pressure ulcer (NPUAP-EPUAP system):

Stage	Description
1	Non-blanching erythema
2	Partial thickness skin loss
3	Full-thickness skin loss with visible subcutaneous fat
4	Full-thickness tissue loss with visible muscle / tendon / bone
Unstageable	Base obscured by slough / eschar, preventing accurate depth assessment

Pressure ulcers are a clinical diagnosis, investigations are NOT used to confirm the diagnosis.

Do NOT routinely take a wound swab, only perform a wound swab if an infected pressure ulcer is suspected.

Complications

Pain and distress
Infection (e.g. cellulitis, osteomyelitis)
Longer hospital stay
↑ Mortality and morbidity
Reduced quality of life

Pressure ulcers are costly to healthcare providers: treating pressure ulcers costs the NHS over £1.4 million every day.

Management

Prevention of Pressure Ulcers

Offer a skin assessment by a trained healthcare professional.

Patient repositioning

Encourage the person to reposition at least every 4-6 hours (depending on the risk level)

If the patient is unable to reposition themselves → offer assistance in repositioning (e.g. instructing carers to reposition the patient regularly)

Pressure redistributing devices

High-specification foam mattress
For those who sit for prolonged periods → consider a high-specification foam or pressure redistributing cushion
If the person is at risk of developing a heel pressure ulcer
- Elevate the heels (with heel suspension device, pillow / foam cushion) to prevent contact between the heel and the bed
- Constant low-pressure devices (e.g. gel or foam heel pads / cups and booties) to distribute the pressure
- Low-friction devices (e.g. dressings, booties) to reduce friction and shear when the patient moves their foot

Pharmacological management

Consider a barrier preparation (e.g. cream, films) in those at risk of developing a moisture lesion or incontinence-associated dermatitis (e.g. those with oedema or incontinence)
Consider an emollient if the skin is dry or inflamed

Do NOT offer the following:

Subcutaneous or intravenous fluids specifically to prevent pressure ulcers in adults whose hydration status is adequate
Nutritional supplements specifically to prevent pressure ulcers in adults whose nutritional intake is adequate
Skin massage or rubbing to prevent pressure ulcers

Management of Active Pressure Ulcers

Initiate and/or reinforce preventive measures (see above)

Also:

Perform a nutritional risk assessment (if at risk of deficiency → refer to dietitian)
Offer pressure redistributing devices (if not already used as part of preventive measures)
Apply an appropriate wound dressing
- Consider using a dressing that promotes a warm, moist, wound-healing environment (e.g. hydrocolloid dressing)
Assess the need for wound debridement
Offer systemic antibiotics ONLY if there is clinical evidence of infection (specifically sepsis, spreading cellulitis, or underlying osteomyelitis)

Do NOT routinely offer systemic antibiotics to heal a pressure ulcer or if there is a +ve wound culture but NO clinical signs of infection.

Do not routinely use topical antiseptics or antimicrobials to treat a pressure ulcer.

Do not offer electrotherapy or hyperbaric oxygen therapy to treat pressure ulcers.

Do not routinely offer negative pressure wound therapy to treat pressure ulcers, unless it is necessary to reduce the number of dressing changes (e.g. in a wound with a large amount of exudate)