Understanding pressure ulcers

What is a pressure ulcer?

A pressure ulcer is localised damage to the skin and the underlying soft tissue. The injury is usually over a bony prominence or related to a medical or other device due to unrelieved pressure.

The pressure ulcer can:

  • Present as intact skin or as an open wound
  • Be painful
  • Occur as a result of intense and/or prolonged pressure
  • Occur as a result of pressure in combination with shear

A number of contributing or confounding factors are also associated with pressure ulcers: The primary of which are impaired mobility and impaired sensation

Who is at risk of developing pressure ulcers?

A number of risk factors can lead to the development of pressure ulcers.

Intrinsic factors

  • Malnutrition or dehydration
  • Vascular disease
  • Circulatory abnormalities
  • Multiple co-morbidities
  • Previous history of pressure ulcer
  • Neurological conditions
  • Sensory impairment 
  • Acute illness
  • Level of consciousness 
  • Extremes of age

Extrinsic factors

  • Surface the patient is nursed on
  • Reduced mobility or immobility
  • Moving and handling aids/ techniques 
  • Medication – sedation
  • Length of surgical procedures
  • Devices used i.e oxygen , plaster of Paris, intubation 
  • External influences on the skin such as Urine, Faeces, Excess talcum powder, perfume, starch or over use of soap and massage or rubbing
How are pressure ulcers classified?

This illustrations below show the total of 6 descriptors that describe the depth of a pressure injury. The first four are described as “stages” or categories ranging from one to four. The last two additional stages are called “unstageable” and “Deep tissue injury.”

Category 1 pressure ulcer: Non-blanchable erythema in fair skin Category 2 pressure ulcer:
Partial thickness skin loss

Stage 1 pressure ulcer

Stage 2 Pressure Ulcer

Category 3 pressure ulcer:
Full thickness skin loss
Category 4 pressure ulcer:
Full thickness skin and tissue loss

Stage 3 pressure ulcer

Stage-4 pressure ulcer

Unstageable pressure ulcer:
Depth unknown
Deep tissue injury:
Depth unknown

Unstageable pressure ulcer

Deep tissue pressure ulcer

What is Moisture Associated Skin Damage (MASD)?

One of the commonest reporting errors is around moisture lesion. Clinicians can associate this damage with pressure and grade these lesions Category II to IV

  • Often caused by incontinence associated dermatitis (IAD) due to exposure to urine of faecal matter, but can be caused if excess exudate or perspiration present
  • Most commonly present in natal cleft
  • Loss of epidermis and skin appears macerated, red, broken and painful
  • Presents as a ‘kissing’ ulcer or a superficial red diffuse skin break
  • Irregular shape
  • Without necrosis
  • Not directly over a bony prominence

Moisture Associated Skin Damage (MASD)

What are the key risk factors for Incontinence Associated Dermatitis (IAD)?

The increase in moisture resulting from episodes of incontinence, combined with bacterial and enzymatic activity, leads to the breakdown of vulnerable skin, particularly in those who are very young or elderly.

Intrinsic factors

  • Faecal incontinence (diarrhoea/formed stool)
  • Double incontinence (faecal and urinary)
  • Urinary incontinence
  • Frequent episodes of incontinence (especially faecal)
  • Poor skin condition (e.g. due to aging/steroid use/diabetes)
  • Diminished cognitive awareness
  • Pain
  • Raised body temperature (pyrexia)
  • Medications (antibiotics, immunosuppressants)
  • Poor nutritional status
  • Critical illness

Extrinsic factors

  • Use of occlusive containment products
  • Poor manual handling resulting in increased friction
  • Inability to perform personal hygiene
  • HCP and social care involvement
  • Concordance
  • Type of cleansing products used and method adopted
What's the difference between pressure ulcers and MASD


  Pressure Ulcer MASD (incl moisture lesions)


Pressure and/or shear forces internal or external

Moisture( MASD): incontinence (incontinence associated dermatitis), sweat( intertrigininous dermatitis/Intertrigo, peristomal(stoma), periwound(wound exudate and friction


Usually bony prominence, occuring in a defined area

Sacrum, perineum, stoma, wound edges, skin folds, any part of the body exposed to moisture


Superficial to full thickness

Superficial to partial thickness


Defines edges, often circular or irregular shape

Diffuse area (moisture uncontained). ‘Kissing’ ulcers may be present


Possible necrosis

No necrosis

Colour of wound bed

Non blanching erythema, Slough, Necrosis

Red, pink or white. Not equal

Did you know?

200,000 people have chronic wounds in the UK of which pressure ulcers are the single most costly chronic wound to the NHS1

Pressure Ulcers account for up to 4% of the UK healthcare budget, or £2,1 billion/year2

Pressure ulcers in older patients are associated with a fivefold increase in mortality, and in-hospital mortality in this group is 25% to 33%3

View the pathway here
Pressure Ulcer Pathway

Pressure Ulcer Pathway

Using the Coloplast 3 Step Approach, we've broken down the process for Assessing, Preparing and then treating pressure ulcers into a simplified pathway.

Stop Pressure Injury Day

At Coloplast we are supporting the worldwide goal to Stop Pressure Injuries.

In this video we explore some of the key challenges and what we should do to stop pressure injuries.

Skin care: Incontinence interventionsĀ 

Skin exposed to urine and stool increases the risk for incontinence associated dermatitis (IAD) and pressure ulcer development.14

Cleanse the skin promptly following episodes of incontinence.14,15 

Cleanse, moisturise and protect:

  • Skin should be cleansed with a pH-balanced cleanser to maintain the acid mantle
  • Consider using a skin moisturiser to hydrate dry skin
  • Protect the skin from exposure to urine, stool and excessive moisture with a moisture barrier

Consider the use of urinary catheters or faecal containment devices for high risk individuals.

Evolution of deep tissue injury examples

In these 3 clinical pictures you see how a sacral pressure injury fairly rapidly can progress.

Day 1 – The skin is intact but discolored, this stage is to be classifies as a Deep Tissue Pressure Injury

Day 3 – The skin is still discolored with epidermal blistering. The stage is still a Deep Tissue Pressure Injury

Day 10 – The Deep Tissue Injury (DTI) has become necrotic and covers the pressure injury, therefore it is now classified as an Unstageable Pressure Injury

Deep Tissue Injury - Day 1

Deep Tissue Injury - Day 1

Deep Tissue Injury - Day 1

Deep Tissue Injury - Day 3

Deep Tissue Injury - Day 10

Deep Tissue Injury - Day 10

Browse our educational E-learning courses

Access HEAL
Pressure Injury Management

Pressure Injury Management

In this course you will learn about how to assess and manage pressure injuries.

Access HEAL
Pressure Injury Prevention

Pressure Injury Prevention

In this course you will learn how to classify pressure injuries, how to examine and assess the patient's skin as well as get techniques for preventing pressure injuries.

Bite sized education

Bite sized education

Educational module on pressure ulcers,  their impact and implications.  What causes them and some of the most common locations.

Patient cases

Learn more
Pressure Ulcer on the right lower limb

Pressure Ulcer on the right lower limb

Read how the pressure ulcer was treated, leading to granulation tissue in 56 days.

Learn more
Treatment of recurring pressure ulcer over the left ischium with a silicone foam dressing

Treatment of recurring pressure ulcer over the left ischium with a silicone foam dressing

Read how the pressure ulcer was treated, leading to granulation tissue in 56 days.

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