Decubitus ulcers or pressure ulcers are a frequently encountered problem in elderly, malnourished, and immobilized individuals, especially those with multiple comorbidities. These injuries typically develop over bony prominences when local pressure-induced hypoperfusion and necrosis can lead to the loss of several or all skin layers. Diagnosis is primarily clinical but laboratory studies and imaging are required to evaluate for complications or risk factors that may delay healing (e.g., uncontrolled blood sugars, hypoalbuminemia). Treatment includes adequate analgesia, pressure relief (e.g., regular position changes, alternating pressure mattresses), frequent wound dressings, and nutritional support. Infectious complications (e.g., osteomyelitis, sepsis) should be treated with appropriate antibiotic therapy. Large, deep ulcers may require surgical debridement, especially if there is an inadequate response to conservative management. Preventive measures should be taken for all at-risk individuals and include pressure relief, rigorous skin care, and treatment of comorbidities and other risk factors such as malnutrition and systemic infection.
Predisposing factors 
- Old age
- Cachexia or malnourishment
- Diabetes mellitus
- Prolonged reduction in any of the following:
- Skin breakdown (maceration) due to urinary or fecal incontinence
- Certain medications (e.g., immunosuppressants, steroids, or vasopressors) 
- Prolonged pressure from medical devices such as feeding tubes, oxygen delivery devices, or tracheostomy tubes 
Pressure ulcers can develop within hours in an immobilized individual. Critically ill patients are at especially high risk and must be monitored carefully. 
Mechanical stress → local hypoperfusion → ischemic necrosis 
- Typical location: over bony prominences, such as the sacrum, heel, greater trochanter, lateral malleolus, elbows
- Initial presentation
- Advanced ulcers: loss of several or all skin layers and/or subcutaneous tissue
- See also “Etiology” for predisposing factors and “Staging of decubitus ulcers” for further information.
- Decubitus ulcers should be staged in order to plan management. 
- The wound bed should be cleaned before staging to ensure accurate assessment.
- The stage is determined by the deepest extent of the ulcer.
Staging of decubitus ulcers
(adapted from the 2016 NPUAP classification system) 
- Identify predisposing factors (see “Etiology”) and assess nutritional status and skin condition, especially in other at-risk areas.
- Confirm that the injury is secondary to prolonged focal pressure. 
- Rule out differential diagnoses of decubitus ulcers.
- Assess the stage of the ulcer (see “Staging of decubitus ulcers”).
- Evaluate for predisposing factors, such as:
- Screen for complications
- CBC, CRP: Leukocytosis and ↑ CRP suggest an infectious complication.
- Wound swab: not routinely recommended ; consider in patients with suspected MRSA infection/colonization. 
- Imaging (e.g., x-ray, CT, or MRI): Consider if underlying bony involvement is suspected.
- For further information see “Skin and soft tissue infections” and “Diagnosis of osteomyelitis” as needed.
The differential diagnoses listed here are not exhaustive.
- Soft tissue infection (e.g., cellulitis, abscess)
- Bacteremia, sepsis
- Marjolin ulcer 
We list the most important complications. The selection is not exhaustive.
- Ensure adequate analgesia (see “Pain management” for details on drugs and dosages).
- Consult a wound care specialist, general surgery, and/or plastic surgery.
- Initiate treatment depending on the stage of the ulcer and whether an infection is present.
- Optimize management of comorbidities that may affect healing (e.g., uncontrolled diabetes mellitus).
- Ensure proper follow-up. 
- The wound should be cleaned and freshly dressed regularly.
- Repeated debridements might be necessary.
Supportive care 
The following are also important preventive measures for patients at risk of developing a decubitus ulcer.
Pressure relief over the affected or vulnerable area is one of the most important aspects of management.
Immobile patients and patients with several or refractory ulcers: 
- Frequent position changes (every 2 hours)
- Alternating pressure mattress
- Mobile patients
- Optimize bedding with a foam mattress or overlay.
- Assist with movement for patients with limited mobility.
- All at-risk patients: pad pressure points on devices such as CPAP masks
Rigorous skin care
- Keep the skin clean and well-hydrated in order to prevent skin erosion and laceration.
- Advise caregivers to regularly inspect other at-risk areas to identify early stages of decubitus ulcers.
- Catheterization and/or a bowel program may be helpful for patients with incontinence.
- Ensure adequate hydration and nutrition in all patients, preferably in consultation with a nutritionist.
- Protein supplementation is recommended. 
- Consider increasing daily calorie requirement and supplementing micronutrients to facilitate healing.
Wound management 
- Dressings: (e.g., hydrocolloids, foam dressings ): Perform frequently to absorb excess exudate while keeping the wound moist
- Adjunctive treatment options: electrical stimulation, negative pressure wound therapy, and administration of platelet-derived growth factor 
Systemic antibiotic treatment 
- Indication: evidence of localized or systemic infection (e.g., cellulitis, underlying osteomyelitis, sepsis)
- The choice of antibiotic should be directed by local microbiological guidance or, if a wound swab was obtained, by the culture results.
- See “Empiric antibiotic therapy for skin and soft tissue infections”, “Treatment of osteomyelitis”, or "Antibiotics for sepsis” as needed.
Surgical management 
Indications and options
- Surgical debridement, ulcer/eschar excision
- Secondary closure (e.g., tissue flap reconstruction): clean, healing ulcers.
- Important consideration: Conservative management may be more appropriate for patients who are not good candidates for surgery (e.g., multiple comorbidities, limited life-expectancy).
- Identify patients at high risk of developing a decubitus ulcer (e.g., use scoring systems such as the Braden scale and Norton scale).
- Initiate measures to prevent decubitus ulcers from forming, such as pressure relief, skin care, regular skin inspection of at-risk areas, and good nutrition. (see “Supportive care” in “Treatment” section above for details).