University of Southern California Mrs. T.H. Chan Division of Occupational Science and Occupational Therapy
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Stages of Pressure Ulcers

You probably learned at some point during your first stay in the hospital or during rehabilitation that pressure ulcers (which means the same thing as "pressure sores" or "bedsores") have four stages. These stages start out small and easy to treat, and progress to very serious, probably needing months of bed rest, hospitalization or even surgery to help heal. One of our participants, Chris, described his own learning process about the stages of pressure ulcers this way:

They show you videos [at the rehabilitation facility] before you leave. "This is what a pressure ulcer can do. This is how you get it. It can start off as a bruise. It could start as a scratch. It can start as a mere abrasion. You know, like a skid mark. And then, eventually, turn into Stage 1. Stage 2, the skin breaks. Stage 3, muscles. Stage 4 is bone. And it happens very quickly." They show you a quick film before you go.

In a nutshell, medical descriptions of the four stages of pressure ulcers are 1 2:

  • Stage 1: Nonblanchable erythema (redness that doesn't quickly fade) of intact (unbroken) skin; could also include warmth, swelling. Dark skin might appear discolored instead of red.

    Stage 1 pressure ulcer
  • Stage 2: Superficial (not very deep) ulcers with loss of epidermis (outer layers of skin), dermis (underlying, still developing skin tissue) or both. Might look like a scrape, blister, "zit" or crater.

    Stage 2 pressure ulcer
  • Stage 3: Skin loss to both outer and underlying layers of skin tissue, with damage all the way down to fascia (connective tissue of body).

    Stage 3 pressure ulcer
  • Stage 4: Skin loss to both outer and underlying layers of skin tissue, with a great deal of damage and dead tissue in the fascia, muscle, bone, tendon or joint capsule.

    Stage 4 pressure ulcer

If you want to use the Internet to learn more about what pressure ulcers are or see illustrations (that is, pictures) of them, there are a number of websites that talk about the stages of pressure ulcers. Some of these online pages have a more "medical" or technical point of view, and some have a more relaxed style, the way you might describe a pressure ulcer (which you can also call a "pressure wound," "decubitus ulcer" or "bedsore") to a friend or family member. An extremely informative website with great illustrations of the stages of Pressure Sores, Pressure Ulcers or Decubitus Ulcers - the site's full-color drawings even show where the bone is under the pressure wound and under the skin surface - is Apparelyzed, a website created by Simon, a man in England who received a spinal cord injury at C-5/C-6 in a car accident in 1992. The site has two goals: first, it contains information about spinal cord injury and related conditions like pressure wounds, autonomic dysreflexia, and spasms. It is also a clothing store that sells T-shirts with positive messages and other clothing designed by Simon; the profits from selling clothes help to pay for the expenses of maintaining the website.

More websites with good information about pressure ulcers include the excellent ad-free website maintained by the University Health Care System, in Augusta, Georgia. The information on this website is written in a "relaxed" style; it's provided by Healthwise, which also supplies information to WebMD, a website run by the publicly-traded company WebMD Corporation, which displays ads along with health information. Taking Care of Pressure Sores, on the Northwest Regional Spinal Cord Injury System website, is maintained by the University of Washington. The illustrations on this page are black-and-white drawings, and the point of view is more "medical" than "relaxed."

If you are interested in information that is in the same style you might see in a hospital or rehabilitation facility, an excellent resource is Pressure Ulcers: What You Should Know, created by the Consortium for Spinal Cord Medicine, which is supported financially by the Paralyzed Veterans of America (PVA). This 45-page guide is easy to read and to use. You can also download a free copy in PDF format. Úlceras por Decúbito: Lo Que Usted Debe Saber Una Guía para Personas con Lesiones Medulares ha sido producida en Español de parte del PVA por el Consorcio de Medicina de la Médula Espinal. Usted puede llamar a 1-888-860-7244.

You can also try this Spinal Cord Injury Manual. The manual was prepared for consumers by the Regional Spinal Cord Injury Center of the Delaware Valley, which is part of Thomas Jefferson University Hospital in Philadelphia, PA. Also try Prevention of Pressure Sores through Skin Care, on the Spinal Cord Injury Model System, maintained by the University of Alabama at Birmingham.

Whatever "tool" you decide to use, whether it is a picture, a description, or a slide show, use that "tool" to teach yourself how to stop a pressure ulcer from hurting you and your health!

1 Dharmarajan, T. S., & Ahmed, S. (2003). The growing problem of pressure ulcers. Postgraduate Medicine, 113, (5), 77-90.

2 Consortium for Spinal Cord Medicine. (2000). Pressure ulcer prevention and treatment following spinal cord injury: A clinical practice guideline for health-care professionals. Washington, DC: Paralyzed Veterans of America.

3 Kirshblum, S. C., House, J. G., & O'Connor, K. C. (2002). Silent autonomic dysreflexia during a routine bowel program in persons with traumatic spinal cord injury: A preliminary study. Archive of Physical Medicine and Rehabilitation, 83, 1774-1776.