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Pressure ulcer stage 1 illustration and photo. Nonblanchable erythema of localized area of skin. Pressure ulcer stage 2 illustration and photo. Partial-thickness loss of the epidermis and some of the dermis. Pressure ulcer stage 3 illustration and photo. Full-thickness loss of the skin and necrosis of subcutaneous tissue. Pressure ulcer stage 4 illustration and photo. Full-thickness loss of skin including the epidermis, dermis, and subcutaneous tissue. Pressure ulcer suspected deep tissue injury illustration and photo. Localized area of discolored skin that is purple or maroon in color. Pressure ulcer unstageable illustration and photo. Full-thickness tissue loss covered by either an eschar or extensive necrotic tissue.
Pressure ulcer stage 1 illustration and photo. Nonblanchable erythema of localized area of skin.
Pressure ulcer stage I illustration and photo. Nonblanchable erythema of localized area of skin.
Pressure ulcer stage 2 illustration and photo. Partial-thickness loss of the epidermis and some of the dermis.
Pressure ulcer stage II illustration and photo. Partial-thickness loss of the epidermis and some of the dermis.
Pressure ulcer stage 3 illustration and photo. Full-thickness loss of the skin and necrosis of subcutaneous tissue.
Pressure ulcer stage II illustration and photo. Full-thickness loss of the skin and necrosis of subcutaneous tissue.
Pressure ulcer stage 4 illustration and photo. Full-thickness loss of skin including the epidermis, dermis, and subcutaneous tissue.
Pressure ulcer stage IV illustration and photo. Full-thickness loss of skin including the epidermis, dermis, and subcutaneous tissue.
Pressure ulcer suspected deep tissue injury illustration and photo. Localized area of discolored skin that is purple or maroon in color.
Pressure ulcer suspected deep tissue injury illustration and photo. Localized area of discolored skin that is purple or maroon in color.
Pressure ulcer unstageable illustration and photo. Full-thickness tissue loss covered by either an eschar or extensive necrotic tissue.
Pressure ulcer unstageable illustration and photo. Full-thickness tissue loss covered by either an eschar or extensive necrotic tissue.

Pressure Ulcer
The following disease information and images of pressure ulcers have been excerpted from VisualDx's Pressure Ulcer Staging module as a public health service.

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Pressure ulcer treatment and therapy, diagnostic pearls, differential diagnosis and pitfalls, best tests, and management pearls, contact us to sign up for a free 30-day trial of VisualDx visual diagnostic decision support system.

Diagnosis Synopsis
A pressure ulcer results when there is localized damage to the skin and underlying tissue as a result of compression between a bony prominence and an external surface. Damage is caused by the forces of pressure, shear, and friction acting individually or in combination with each other.

Pressure ulcers, previously termed as decubitus ulcers, are also commonly referred to as pressure sores and bed sores. Common sites for pressure ulcer formation are the sacrum, over the ischial tuberosity, the trochanter, and the calcaneus. Other locations are the elbow, ankle, scapula, and the occiput. However, the most common sites are the sacrum and the heels. Pressure ulcers affect from 1.5 to 3 million people in the US at an annual cost of approximately $5 billion.

Pressure ulcers occur more commonly in certain subsets of patients, such as the elderly (over the age of 70), patients who have had surgery for hip fracture, and patients with spinal cord injury. Pressure ulcers are also more common in patients who are from nursing homes and assisted living facilities or hospitalized due to some other reason.

Pressure ulcers are classified according to the extent of tissue damage (National Pressure Ulcer Advisory Panel):

  • Stage l: Skin is intact with an area of nonblanching erythema. This is usually over a bony prominence.
  • Stage ll: Partial-thickness skin loss with loss of the epidermis and some of the dermis. It appears as a shallow ulcer with a red-pink color. No slough or necrotic tissue is present in the base. It may also appear as an enclosed or open serum-filled blister.
  • Stage lll: Full-thickness loss of skin with the epidermis and dermis gone and damage to or necrosis of subcutaneous tissues. Damage extends down to but not through the underlying fascia. Subcutaneous fat may be visible, but muscle, tendon, or bone is not seen. Slough may be present but does not hinder estimation of the extent of tissue loss. Tunneling or undermining may be present.
  • Stage lV: Full-thickness loss of skin with extensive destruction, tissue necrosis, and damage to bone, muscle, or other supporting structures that are exposed.

Recently, 2 other stages of pressure ulcer formation have been added:

  • Suspected Deep Tissue Injury: Area of localized, discolored intact skin that is purple or maroon-red in color. It may also appear as a blood-filled blister resulting from damage to underlying soft tissue. Preceding skin changes may include skin that is painful, firm, boggy, or that has a different temperature compared to the surrounding skin.
  • Unstageable Pressure Ulcers: Full-tissue thickness loss in which the base of the ulcer is covered by slough or an eschar and, therefore, the true depth of the damage cannot be estimated until these are removed.

Look For
When examining the ulcer, look for and record the following:

  • Location on the body
  • Staging of the ulcer
  • Size of the ulcer, which should include depth, width, and the length in centimeters
  • Presence of undermining, tunneling, sinus tracts
  • Exudate – if present, the color and amount
  • Wound bed – appearance of the wound bed and the type of tissue visible
  • Presence of necrotic tissue
  • Wound edges – looking carefully at the edge of the ulcer for evidence of induration, maceration, rolling edges, redness
  • Skin around the edges of the ulcer
  • Presence or absence of pain
  • Odor, if present or absent

Dark Skin Considerations:
Erythema can be subtle in darker skin and may appear as a slightly different color, or the skin may be slightly darker than normal. Discoloration, warmth, induration, or hardness of skin may be the only signs of a stage I ulcer in people with darker skin tones.

Medical Disclaimer:
The information contained in this Web page is intended to be an adjunct to traditional medical information sources. It is not intended to be a substitute for professional medical judgment.

Authors and Editors:
Ansa Ahmed MD
Sally-Ann Whelan MS, NP, CWOCN
Lisa Wallin ANP, FCCWS
Art Papier MD