Bed sores: Causes, stages, treatment of pressure sores

If someone you care for spends long periods in bed or a chair without being able to shift their weight, their skin is under sustained pressure that can damage tissue before any visible sign appears. Bed sores, also called pressure sores or pressure ulcers, are the result. They’re one of the most common complications for people with limited mobility, and one of the most preventable, yet they can still develop quickly when early signs are missed.

Knowing what to look for, and what to do when you find it, changes the outcome significantly. A sore caught at stage one is a minor problem. But, left unnoticed, it can become a serious wound that takes months to heal and needs specialist nursing care.

What are bed sores?

Bed sores, also called pressure sores or pressure ulcers, develop when sustained pressure cuts off blood flow to the skin, causing the tissue underneath to break down. If you’re caring for someone who spends most of their time in bed or a chair, it’s worth knowing that damage can begin within just a few hours. The NHS describes pressure ulcers as largely preventable, but they remain a common and serious problem for people with limited mobility.

The most vulnerable spots are where bone sits close to the surface with little padding between it and the skin. Heels and hips are the most common sites for this reason, followed by the tailbone, elbows, ankles, and shoulders. For someone who is bedridden, the back of the head and the backs of the knees are also at risk.

What causes bed sores?

Limited mobility is the biggest risk factor. Someone who can’t shift their weight independently relies on others to move them, and the gaps between care visits can easily stretch long enough for damage to begin. Poor circulation compounds the problem. Skin that’s already receiving less blood than it needs has much less tolerance for sustained pressure.

Moisture is another significant factor. Incontinence, sweat, or wound drainage softens and weakens the skin, making it far quicker to break down. Ageing skin is more fragile to begin with and heals more slowly. And when nutrition is poor or someone is dehydrated, the body doesn’t have what it needs to maintain or repair the skin’s surface.

Who is most at risk of pressure sores?

People at higher risk include:

• Older adults with reduced mobility
• People recovering from surgery or illness
• Individuals with spinal cord injuries
• Those living with dementia
• People who are underweight or malnourished
• Individuals with incontinence
• People using wheelchairs or confined to bed

Where do pressure sores commonly develop?

• Heels
• Hips
• Tailbone (sacrum)
• Elbows
• Shoulders
• Ankles
• Back of the head

What are the stages of bed sores?

Healthcare professionals use a four-stage system to describe how serious a pressure sore has become. NICE clinical guidelines provide the framework used across NHS settings.

At stage 1, the skin is intact but looks red or discoloured. It doesn’t turn white (blanch) when pressed, and the area may feel warm or tender. 

Stage 2 involves partial skin loss, typically a shallow open wound or blister that looks raw and pink.

Stage 3 is a full-thickness wound that extends beyond the skin into the tissue below, often with a crater-like appearance. 

Stage 4 is the most severe: the wound reaches muscle, tendon, or bone. At this point, the risk of sepsis is real, and specialist hospital care is often required.

Early signs of bed sores

The earliest sign to look for is a patch of reddened or discoloured skin that doesn’t fade when you press it gently. On darker skin tones, this can be harder to spot. The area may look purple or bluish, or simply feel different in texture. If you’re unsure, check by touch: early pressure damage often feels warmer than the surrounding skin, or slightly firmer.

Other warning signs include tenderness or pain when an area is touched, swelling, and any blistering or broken skin. For someone who can’t easily communicate discomfort, changes in behaviour can be a signal. Becoming unsettled during repositioning, for example, or resisting lying in a position they were previously comfortable with.

Pay particular attention to heels, the tailbone, hips, and shoulders at wash and dressing times, when you already have good access to the skin.

Bed sores treatment

Whatever stage a sore has reached, the first step is the same: get the pressure off. Reposition the person away from the affected area and keep them off it. If the person is at risk more broadly, their GP can refer them for a specialist pressure-relieving mattress or cushion through the NHS, which helps redistribute weight between turns.

If the skin has broken, don’t try to manage it at home with standard plasters or over-the-counter creams. Ordinary dressings can stick to wound tissue and cause damage when removed. Instead, contact the GP and ask for a district nurse referral. A district or community nurse can assess the wound, clean it properly, and apply a clinical dressing suited to the stage it’s at.

Watch for signs the wound is becoming infected: increasing redness spreading from the edges, warmth, a change in smell, or a wound that’s getting wider rather than closing. Contact a GP promptly if any of these appear, as antibiotics may be needed. For complex or non-healing wounds, the GP may refer to a tissue viability nurse, a specialist in difficult wound care. The NHS guidance on pressure ulcer treatment covers the full clinical pathway, including when surgery may be needed.

How to prevent bed sores

Prevention is easier and far less disruptive than treatment. A stage 3 or 4 bed sore can take months to heal and may require hospital admission. 

Reposition regularly

Aim to change the position of someone in bed at least every two hours, or every hour if they use a wheelchair. A pressure-relieving mattress or cushion helps in between, but it’s not a substitute for moving the person. The riskiest period is overnight. If there’s no carer visit between 10pm and 7am, someone can easily spend nine hours in the same position without anyone noticing, and serious damage can start long before morning.

Keep skin clean and dry

After any episode of incontinence, clean and dry the area straight away and apply a barrier cream to protect it. This matters because moisture-softened skin breaks down far more quickly under pressure. When repositioning someone, try to lift rather than drag, as friction can graze and weaken the skin. Wash and dressing times are a good moment for a daily skin check, when you already have access to the most vulnerable areas.

Focus on good nutrition and hydration 

Skin that’s well nourished heals faster and withstands pressure better. Protein helps rebuild damaged tissue, vitamin C supports skin structure, and zinc helps wounds close. If the person you care for has a poor appetite or has lost weight recently, it’s worth mentioning to their GP. Dehydration alone can make skin fragile and slow to recover. Age UK has practical guidance on eating and drinking well in later life if you’re looking for ways to help someone maintain a good diet at home.

Equipment that can help prevent pressure sores

• Pressure-relieving mattresses
• Cushions for chairs or wheelchairs
• Heel protectors
• Profiling beds
• Slide sheets to reduce friction

When to seek medical help

Any pressure sore that has broken the skin warrants a call to a GP or district nurse. Don’t wait to see whether it improves on its own.

Contact a GP or nurse if the wound appears to be getting deeper or wider, if the surrounding skin is becoming increasingly red or swollen, or if there’s a change in smell or discharge. Black or very dark tissue in a wound indicates tissue death (necrosis) and needs urgent attention.

Seek emergency help if the person develops a fever, becomes confused or unusually drowsy, or the wound appears to be spreading rapidly. These can be signs of sepsis. If any of these signs appear, call 999 or 111.

How carers and home care services can help

Professional carers play a direct role in preventing and managing pressure sores. Regular visits create natural opportunities to reposition someone, check skin condition, assist with hygiene, and make sure they’re eating and drinking enough.

For someone at higher risk, perhaps because of limited mobility following a stroke, a serious illness, or advancing dementia, more frequent visits can reduce the gaps when pressure builds undetected. A care plan should include skin checks as a routine part of every visit, not an occasional extra. Care workers can also record observations and flag changes to a district nurse, making them a practical link in a wider support network.

Carers UK has practical support for family carers managing complex needs at home, including guidance on working with professional care agencies.

–As someone’s care needs increase, it can help to have professional support at home before a crisis forces a decision. A care worker who visits regularly will assist with repositioning, skin monitoring, and making sure nutrition and hydration don’t slip. You can search for home care in your area on homecare.co.uk to find regulated providers and read reviews from other families.

In some cases, developing pressure sores may indicate that care needs are not being fully met. If you’re concerned, it’s important to raise this with a healthcare professional or safeguarding team.

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