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Pressure Ulcers: Diagnosis, Treatment, and Prevention
Dr. Pignolo is Assistant Professor and Director, Ralston-Penn Clinic for Osteoporosis & Related Bone Disorders, Department of Medicine, Division of Geriatric Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA.
Pressure ulcers – better known as bedsores – are lesions on the skin (and/or underlying tissue) that are caused by unrelieved pressure resulting in tissue damage. They usually develop over bony areas of the body, often in the lower limbs (ankles and hips are common), but they can occur almost anywhere (for example, in the nostrils of patients with oxygen tubing, in the corners of the mouth in patients with endotracheal tubes, and between fingers in patients with rheumatoid arthritis).
Pressure ulcers are quite common in hospitals and other institutional settings. In acute care hospitals they occur in about 3-15% of patients;(1)(2)(3)(4) they occur about a third of elderly patients who have had hip fractures;(5) and the number rises to as much as 50% in critical care patients.(6) Ten to 35% of patients admitted to nursing homes have pressure ulcers, though this rate decreases somewhat for patients who have been there longer.(7)(8)(9)(10) Because there are other reasons for skin breakdown, it is important to be examined and diagnosed by a doctor so that the appropriate treatment can be determined. In this article, we’ll discuss the symptoms and diagnosis of ulcers, as well as their treatment and tips for prevention.
Types of Ulcers
There are several types of skin ulceration. Pressure ulcers or bedsores occur when the skin is subjected to constant pressure, which is why they happen so frequently in hospitals and in older patients. They generally start as a blister or superficial crater, and then become a deeper open sore. In addition to pressure ulcers, areas of skin breakdown may be due to other types of ulcers, having to do with insufficient blood flow or to diabetic neuropathy.
Insufficient blood flow through the veins usually occurs in the lower legs, and can result in venous insufficiency ulcers, which are often chronic and difficult to heal. They can cause pain in the foot and usually appear purplish in color. They are never found above the level of the knee or in the forefoot, and may occur singly or in multiples.
A related condition, caused by insufficient blood flow through the arteries, is known as arterial insufficiency ulcers, which are painful lesions that usually occur over the ankle or other areas of the foot. Although they may be seen near bony prominences (i.e., joints), they are distinguished from pressure ulcers by their “punched-out” or star-like appearance. The wound may be pale and dry, surrounded by red and taut skin, and can include an area of dead skin.
Diabetic ulcers occur on the foot, usually over the joints or on the top of the toes. These ulcers often occur on the ball of the foot in diabetic patients, due to neuropathy or repetitive injury. Diabetic foot ulcers are often surrounded by a significant thickening of the skin, and are usually insensitive to touch.
There are other, less common causes of ulcers in the legs and feet, which include connective tissue diseases (e.g., rheumatoid arthritis), sickle cell disease, and certain forms of cancer. One’s doctor should take special precaution to rule out these more serious conditions before arriving at a diagnosis of a pressure ulcer.