What are pressure ulcers?

People living with paralysis are at high risk of developing skin problems. Limited mobility coupled with impaired sensation can lead to pressure sores or ulcers, which can be a devastating complication.

The skin, the largest organ system in the body, is tough and pliable. It protects the underlying cells against air, water, foreign substances and bacteria. It is sensitive to injury and has remarkable self-repair capabilities.

Skin cannot take prolonged pressure. A pressure ulcer involves damage to the skin and underlying tissue.

Pressure ulcers, also called bedsores, decubiti or decubitus ulcers, range in severity from mild (minor skin reddening) to severe (deep craters that can infect all the way to muscle and bone). Unrelieved pressure on the skin squeezes tiny blood vessels, which supply the skin with nutrients and oxygen. When skin is starved of blood for too long, tissue dies and a pressure ulcer forms.

Causes of pressure ulcers

Sliding around in a bed or chair can cause blood vessels to stretch or bend, leading to pressure ulcers. An abrasion can occur when a person's skin is pulled across a surface instead of lifted. A bump or fall can cause damage to the skin and not show up right away. Other causes of pressure sores are braces or hard objects that put pressure on your skin. Also, people with limited sensation are prone to skin injuries from burns.

Skin damage from pressure usually begins on the body where the bones are close to the skin surface, such as the hip. These bony prominences apply pressure on the skin from within. If there is a hard surface on the outside, too, the skin is pinched off from circulation.

As a result of paralysis, circulation is reduced and less oxygen is available to the skin, lowering the skin's resistance. The body tries to compensate by sending more blood to the area. This may result in swelling, adding more pressure to the blood vessels.

A skin sore begins as a red area on the skin. This reddened area may feel hard and/or hot. For those with darker skin, the area may appear shiny. At this stage, the progression is reversible. The skin will return to its normal color if the pressure is removed. If the pressure is not removed, a blister or scab may form – this means that the tissue underneath is dying. Remove all pressure over the area immediately.

In the next stage, a hole (ulcer) forms in the dead tissue. Frequently, this dead tissue is small on the skin surface, but damaged tissue may extend deep to the bone.

A skin sore can mean several weeks or even months of hospitalization or bed rest in order for the sore to heal. Complex pressure sores may require surgery or skin grafting. All of this can cost thousands of dollars and mean valuable time away from work, school or family.


Skin wound treatment by any means is complicated by hard-to-treat infections, spasticity, additional pressure and even the psychological makeup of the person. In fact, pressure sores have been linked to low self-esteem and impulsive behavior.

It’s an oversimplification to say pressure sores are always preventable but that's almost true. With vigilant care and good overall hygiene, skin integrity can be maintained.

A wide variety of pressure-relieving support surfaces, including special beds, mattresses, mattress overlays or seat cushions are available to support your body in bed or in a chair. Work with your therapists to know what is available.

Search resources like AbleData for specific seating and sleep surface products. For example, FreedomBed offers an automatic lateral rotation system that quietly turns through a 60-degree range of rotation. This is very helpful for people who can't turn at night and who may not have an attendant to do it for them.

Prevention tips

Remember that the first line of defense is to be responsible for your own skin care. Here are few tips to maintain healthy skin:

  • Check your skin daily: use a mirror for hard-to-see areas. Skin stays healthy with good diet, good hygiene and regular pressure relief.
  • Keep the skin clean and dry: skin that is moist from sweat or bodily discharges is more likely to break down.
  • Drink plenty of fluids: a healing wound or sore can lose more than a quart of water each day. Drinking 8 to 12 cups of water a day might not be too much. Beer and wine do not count; alcohol actually causes you to lose water or become dehydrated.
  • Watch your weight: being too thin causes you to lose the padding between your bones and your skin and makes it possible for even small amounts of pressure to break down the skin. Getting too heavy is risky, too. More weight may mean more padding, but it also means more pressure on skin folds.
Don't smoke: research has shown that heavy smokers are more prone to skin sores.

Video: Skin Care

Video: Pressure Relief

Here are a few ways to move your body in your chair to let your skin breathe and prevent pressure sores.


If you are looking for more information on how to treat or prevent skin ulcers, our information specialists are available business weekdays, Monday through Friday, toll-free at 800-539-7309 from 9am to 5pm ET.

Additionally, the Reeve Foundation maintains a skin care fact sheet with additional resources from trusted Reeve Foundation sources. Check out our repository of fact sheets on hundreds of topics ranging from state resources to secondary complications of paralysis. Download our booklet on pressure injuries and skin management.

We encourage you to reach out to support groups and organizations, including:

  • familydoctor.org for more information on the causes and symptoms of pressure sores.
  • Model Systems Knowledge Translation Center offers factsheets on a number of topics, including how to maintain healthy skin.
  • MedlinePlus boasts 750 topics on conditions, diseases and wellness. MedlinePlus brings together authoritative information from NLM, the National Institutes of Health (NIH), and other government agencies and health-related organizations.

Sources: Paralyzed Veterans of America,Craig Hospital,National Library of Medicine,University of Washington School of Medicine/Rehabilitation

This project was supported, in part, by grant number 90PRRC0002, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.