Pressure ulcers treatment | 7 Effective treatment strategies

What is a pressure ulcer?

Pressure ulcers – also called bedsores or pressure sores – are a significant clinical and financial burden across UK health and social care. These injuries develop when prolonged pressure or shear forces damage the skin and underlying tissues, most often over bony areas such as the sacrum, heels and hips. They commonly affect people with limited mobility or impaired sensation.

In the UK, more than 700,000 people develop pressure ulcers each year. In 2004, the cost of treating pressure ulcers in the NHS was estimated to be £1.4–2.4 billion annually, representing around 4% of total healthcare spending at the time. These figures highlight the scale of the challenge and the urgent need for effective prevention and management.

Prompt, stage-appropriate intervention is essential to stop progression, reduce complications such as infection or sepsis, and support healing. The National Institute for Health and Care Excellence (NICE) Guideline CG179 sets out a clear framework for assessing risk, classifying severity and guiding treatment across care settings.

Successful care depends not only on technical measures – debridement, dressings and pressure relief – but also on supporting underlying needs such as nutrition, hydration and mobility.

Pressure ulcer stages

Early stages of pressure ulcers may show as non-blanching erythema, while advanced cases can progress to full-thickness tissue loss with exposed muscle or bone. These cases carry a high risk of severe complications.

The NPUAP–EPUAP classification system, endorsed by NICE, provides a standard framework for grading pressure ulcers. It supports consistent assessment and treatment planning. The stages are:

Stage I (category 1) – intact skin with non-blanchable redness, usually over a bony prominence.
Stage II (category 2) – partial-thickness skin loss of the epidermis and/or dermis, often appearing as an open ulcer with a pink wound bed.
Stage III (category 3) – full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon or muscle are not exposed.
Stage IV (category 4) – full-thickness tissue loss with exposed bone, tendon or muscle, sometimes with undermining or tunnelling.
Unstageable – full-thickness tissue loss where slough or eschar obscures the base, preventing depth assessment.
Deep tissue injury – purple or maroon discolouration of intact skin, or a blood-filled blister, signalling damage to underlying tissue.

Recognising the stage is essential: while stage I may resolve with simple offloading (reducing pressure on the affected area) and skincare, stage IV requires complex wound management and multidisciplinary support to avoid sepsis or limb-threatening infection.

Diagnosing pressure ulcers

The importance of early detection and intervention

Identifying pressure damage early is crucial to prevent progression and reduce the physical, psychological and financial impact of chronic wounds. A stage I ulcer, if missed, can deteriorate within days into a stage III or IV lesion, causing complications and extended hospital stays. By contrast, early action at the first signs – such as redness that does not blanch – can halt damage with the right care.

Acting quickly improves patient outcomes and lowers costs for healthcare facilities. Treating advanced ulcers is estimated to be up to 10 times more expensive than managing early-stage damage, once longer admissions, specialist equipment and possible surgery are factored in. Patients who avoid deep tissue injury also have a better quality of life – ulcers often cause reduced physical function, limited mobility and difficulty carrying out self-care.

Routine skin inspection should be part of every nursing assessment, especially for people who are immobile or bedbound. Digital photography can aid monitoring over time, while effective handovers ensure that those at risk are consistently highlighted.

Assessment and grading of pressure ulcers

A systematic assessment forms the foundation of all treatment decisions. It starts with a full skin and tissue evaluation, recording the following:

Ulcer location, size (length, width and depth)
Undermining or sinus tracts
Exudate volume and type
Condition of the surrounding skin
Pain levels

Tools like the Waterlow or Braden Scale for risk and the NPUAP–EPUAP system for grading support consistency and reliable decision-making.

Assessment should account for intrinsic factors (diabetes, vascular disease, nutrition and continence) alongside extrinsic factors (mattress type, repositioning frequency and moisture exposure).

A holistic review considers mobility, cognitive status and the patient or carer’s capacity for self-care. Findings recorded in a standardised pressure ulcer chart improve communication within the multidisciplinary team and provide a baseline for tracking healing.

NICE recommends repeating assessments at least weekly for stage II–IV ulcers, or more often if complications arise or the patient’s condition changes. In each reassessment, include clear measurements or photographs to monitor progress and ensure that care plans are adapted quickly if needed (for example, if an infection develops). Thorough documentation also underpins clinical governance, audit and potential medicolegal review.

Treating and managing pressure ulcers

Wound cleaning and debridement techniques

Preparing the wound effectively is key to creating the right conditions for healing. Cleaning usually begins with gentle irrigation using warm, sterile saline or clean potable water. This removes debris without harming viable tissue. Antiseptics like chlorhexidine are generally avoided unless there is clear evidence of infection, as they can damage regenerating cells.

Debridement is central to wound cleaning because it clears necrotic tissue, slough and biofilm that slow repair. The main approaches are:

Autolytic debridement – uses the body’s own enzymes, supported by moisture-retentive dressings (e.g., hydrogels, hydrocolloids), to soften and break down dead tissue.
Enzymatic debridement – applies topical proteolytic agents (such as collagenase) where surgical methods are unsuitable.
Mechanical debridement – removes debris with monofilament pads or low-pressure irrigation. Clinicians should take care to protect healthy tissue.
Surgical (sharp) debridement – rapid removal of necrosis by a trained clinician, used when tissue is extensive or infection control is urgent.

The choice of method depends on the ulcer’s stage, the type of tissue present and individual factors such as pain tolerance or use of anticoagulants. All procedures should be carried out by clinicians with tissue viability training, with pain relief provided to reduce discomfort and enable effective treatment.

Dressings and topical treatments by ulcer stage

Dressings serve several purposes: they keep the wound moist, absorb excess fluid, protect the surrounding skin and, when needed, deliver active treatments.

NICE advises matching dressing choice to the ulcer’s stage and needs:

Stage I–II ulcers – simple barrier films or foam dressings may be enough to cushion and protect intact or shallow wounds.
Stage II–III ulcers – hydrocolloid or foam dressings that balance moisture with absorption. Alginate or hydrofibre dressings suit wounds with heavier exudate.
Stage III–IV ulcers – advanced dressings with antimicrobial agents (such as silver or honey) or negative-pressure wound therapy (NPWT) for large or complex wounds.
Unstageable or necrotic ulcers – hydrogels or hydrocolloids to support autolytic debridement, sometimes combined with enzymatic agents.

Other topical therapies – such as collagen matrices or growth factor gels – may be used when a wound does not heal despite standard care. Plan dressing changes on a set schedule that allows regular monitoring without disrupting the wound bed unnecessarily. Record the type of dressing, how often it is changed and the patient’s comfort. These details give a clear basis for future treatment decisions.

Managing infection and preventing sepsis

Infection control is vital to prevent complications. Do not swab wounds routinely – take cultures only when there are clear signs of infection.

Local signs – increased exudate, odour, redness or pain
Systemic signs – fever, rapid heart rate or low blood pressure

Treatment options include:

Topical antimicrobials – silver dressings or honey gels to reduce local bioburden.
Systemic antibiotics – guided by severity and culture results; empirical cover may be needed in urgent cases.
Sepsis management – use NEWS2 protocols and escalate rapidly if sepsis is suspected.

Involving microbiology teams and tissue viability nurses early ensures treatment is targeted and avoids unnecessary antibiotic use. Strict hand hygiene, aseptic technique and PPE remain essential across all care settings.

Relieving pressure through repositioning

Relieving pressure is central to both prevention and treatment. Regular repositioning – usually every two hours for bedbound patients and hourly for those at highest risk – reduces sustained pressure on bony points. Repositioning plans should be individualised, taking into account comfort, mobility and skin tolerance, and must be clearly documented.

Common techniques include:

Supine to lateral tilt – using pillows or wedges for a 30° tilt to reduce shear
Prone and semi-recumbent positions – used carefully for sacral relief, ensuring the head of the bed is not raised too high
Dynamic micro-positioning – small shifts every 15–30 minutes, often useful in palliative contexts

Repositioning should fit into daily routines like meals and hygiene, not feel like an isolated task. Training staff in safe handling protects both carers and patients.

Specialist mattresses and seating aids

Specialist surfaces complement manual repositioning and are especially important for those with limited mobility or high risk of deterioration. Options include:

Alternating pressure mattresses – cycle air to shift loading points
Low-air-loss systems – provide constant airflow to reduce heat and moisture
Foam or viscoelastic mattresses – conform to body shape, suitable for lower-risk patients
Specialist cushions – gel, foam or air-filled supports for wheelchair users

Choose the equipment based on individual risk, not cost alone. A good approach is to review the patient’s needs and equipment use regularly, ensuring that it’s properly maintained. Users should be guided on effective – and safe – usage.

Nutrition and hydration in ulcer recovery

Good nutrition is important in ulcer healing to aid collagen production, immunity and recovery. NICE recommends a dietitian’s input for all adults with pressure ulcers, with a focus on:

Calories – usually 30–35 kcal/kg/day to cover needs plus healing
Protein – 1.2–1.5 g/kg/day to support collagen and cell repair
Micronutrients – vitamin A, vitamin C, zinc and iron if deficient
Hydration – 1.5–2 L/day, unless restricted by other conditions

It’s not always possible for a patient to get adequate nutrition through diet alone. In these cases, supplements or enteral feeding may be needed. Regularly monitor the patient’s weight and intake to keep care on track.

Pain management strategies

Tissue damage can worsen pain, and patients may feel particularly uncomfortable during dressing changes or movement.

When pain is managed well, these interventions are not so distressing, which makes it easier for clinical staff to provide care. For instance, patients can better tolerate turning, sitting upright or trying different positions for longer, relieving pressure more effectively and protecting the skin.

Effective pain management also helps maintain trust between the patient and healthcare staff.

Options include:

Analgesics – from paracetamol and NSAIDs to opioids for severe pain
Topical agents – such as EMLA cream or lignocaine patches before procedures
Non-drug techniques – relaxation, guided imagery or TENS where suitable

Treatment considerations in palliative care

In palliative settings, the focus shifts from healing to providing comfort and dignity. Repositioning schedules may be adjusted to patient preference, and dressing changes kept to the minimum needed for comfort.

Moisture-retentive dressings can ease discomfort in shallow ulcers, while non-adherent dressings reduce pain during changes. Pain relief takes priority, and invasive or burdensome interventions are generally avoided unless they are clearly in line with the patient’s wishes.

Shared decision-making with patients and families ensures care remains compassionate and aligned with end-of-life values.

Monitoring healing and adjusting care plans

Regular reassessment keeps treatment on track and helps staff use resources wisely. Healing can be measured through changes in wound size, depth and exudate, as well as by observing granulation tissue and the condition of the surrounding skin.

If progress is limited after four weeks, the care plan should be revised. Adjustments may involve:

Switching dressing type or debridement method
Escalating pressure-relieving devices
Increasing nutritional or pain management support
Referring to specialists for complex wounds

Electronic wound management systems support this process by capturing data, highlighting trends and improving communication between home, community and hospital teams. Multidisciplinary reviews enable different teams to share responsibility and give patients the best chance of recovery.

When to refer to a tissue viability nurse

Tissue viability nurses have specialist skills in complex wound care. They train staff, introduce advanced therapies and coordinate input from the wider team.

A patient may be referred to a tissue viability service when:

Ulcers are stage III, IV or unstageable
Healing has stalled despite four weeks of appropriate care
Infection keeps recurring or complicates the wound
Advanced therapies (e.g., NPWT) are being considered
Comorbidities such as diabetes or vascular disease affect healing

Early involvement enables thorough assessment and tailored care plans. It also gives staff the support they need to provide the best care. This reduces the risk of ulcers becoming chronic or leading to hospital admission.

Support for carers and family members

Carers play a vital role in daily prevention and management. They help with repositioning, check the skin for changes, and provide emotional support. With clear explanations, demonstrations and written guidance, carers feel more confident and able to carry out these tasks safely. Training on using mattresses, changing dressings and spotting early warning signs also helps reduce anxiety and keeps care consistent at home.

Support for carers needs to go beyond training. Community nursing helplines and peer groups can offer reassurance day to day, while respite services give carers the chance to rest and recover. Recognising the emotional strain of caring for someone with a chronic wound is just as important as teaching practical skills. When carers feel supported, they are better able to give steady, good-quality care.

Training for care home and domiciliary staff

Good pressure ulcer management depends on well-trained frontline staff. Care homes and domiciliary services should run structured training programmes that cover risk assessment, skin checks, safe handling, dressing choices and documentation.

Competency checks and refresher sessions keep skills up to date and make sure staff follow policy. Working with local tissue viability teams and joining regional audits encourages continuous improvement.

Embedding pressure ulcer training into induction and mandatory updates means all staff – whatever their role – understand their part in prevention and early action.

Training for care home and domiciliary staff

NHS guidelines and local care pathways

While NICE sets national standards, local NHS trusts and clinical commissioning groups often create tailored care pathways to reflect local resources and patient populations. These pathways link acute, community and primary care services, setting out referral criteria, shared documentation and escalation processes. Aligning them with the NHS Long Term Plan’s emphasis on integrated care systems (ICSs) helps improve continuity and avoid duplication.

Organisations should review pathways regularly, drawing on audit data, patient feedback and emerging evidence – including updates from the 2019 EPUAP/NPIAP/PPPIA Guideline – to make sure practice remains current and effective.

Documentation and communication in multidisciplinary teams

Clear, consistent documentation is vital for safe transitions between care settings. Pressure ulcer charts, nutrition notes, pain management records and device maintenance logs should all be available through electronic health records.

Handover meetings and discharge summaries need to flag the ulcer’s current condition and what treatment has been provided so far. They should also document any changes to the care plan, keeping everyone in the loop.

Regular multidisciplinary team meetings – involving nurses, dietitians, physiotherapists, podiatrists, pharmacists and doctors – support seamless, joined-up decisions. Where possible, patients and carers should be part of these conversations, so they feel included and it is easier to follow through on care plans.

Sources:

Treatment for pressure ulcers

In this article