The Four Stages Of Pressure Ulcers

By Delialah Falcon. May 7th 2016

Many individuals develop pressure ulcers as a result of experiencing prolonged pressure to the skin. Also known as bedsores or pressure sores, these ulcers usually occur in bony parts of the body, such as the hips, ankles or heels. The prolonged pressure results in damage to the skin and the tissues beneath the skin. They can develop rather quickly and once they occur, they can be difficult to treat.

Here is a complete guide to the four different stages of pressure ulcers, including an overview of possible symptoms for each stage.

The Four Stages Of Pressure Ulcers

The type of symptoms associated with pressure ulcers depends largely on the stage in which the sores are in. In individuals who are confined to wheelchairs, common sites where pressure ulcers may develop include the shoulder blades, the spine, back of the legs or arms, the tailbone or the buttocks.

In individuals who are confined to a bed, common sites may include the shoulders or shoulder blades, the lower back or tailbone, the hips, heels or ankles, the back or sides of the head and the skin behind the knees or on the rims of the ears.

There are four stages of pressure ulcers:

Stage One

The skin at the site of a developing pressure ulcer is still intact during stage one. Individuals with lighter skin tone may notice that the skin has a slightly reddish tint to it. When gentle pressure is applied to the skin, no lightening of the area occurs.

Individuals with darker skin tone may not notice any change to the color of their skin when left alone or when touched. However, there may be a bluish or ashy look to the skin. When compared to the skin surrounding the area, the ulcer site may either be softer or firmer, cooler or warmer. It may be also painful.

Stage Two

When a pressure ulcer reaches stage two, the skin is no longer intact and an open wound is present. The top epidermal layer of skin is gone and a portion of the underlying dermal layer of skin is either damaged or gone. The sore itself may be pink to red in color and may have a basin-like shape. Alternately, the sore may resemble a fluid-filled blister that is either intact or has ruptured.

Stage Three

In stage three, the pressure ulcer resembles a crater, with yellowing dead tissue present at the bottom of the wound. There is often some fat exposed, resulting from skin damage at the wound site. The damage may spread below the site of the sore into underlying, healthy layers of skin.

Stage Four

During this stage, the pressure ulcer has progressed to a deep wound. There is a significant amount of skin loss, often with fat being exposed. Muscles, tendons and bones may also be exposed. Areas of crusty, darkened, dead tissue are often present at the bottom of the wound. The damage is extensive and generally spreads below the site of the sore into underlying healthy layers of skin.

Overview Of Symptoms By Stage

Stage one bedsores are relatively minor because the skin remains intact. Characteristics include:

  • Reddish color (in people with light skin color) that doesn’t lighten briefly when touched.
  • Skin may be bluish or ashen (in people with dark skin color) or there may be no color change at all.
  • The site could be painful.
  • The site may be warm or cold, soft or hard.

Stage two bedsores are a bit more serious. Skin is broken and the underlying tissue may be damaged or lost. Characteristics include:

  • A shallow basin-shaped wound.
  • May also appear initially as a blister that is either fluid filled, or has ruptured.

Stage three bedsores are quite serious. A deep wound is present that is deep enough to expose some of the layer of fat that is found under the skin.

  • The wound looks like a crater.
  • Yellowish colored dead tissue may be visible at the bottom of the wound. This is called slough.
  • The damage may begin to spread outward under the surface of the skin.

Stage four bedsores are very serious and can have some dire consequences. The wound is very deep and could expose underlying muscle, tendon or even bone.

  • The bottom of the wound likely contains slough and possibly dark, crusty dead tissue called eschar.
  • The damage will extend beyond the wound under the healthy surface skin.


The most effective way to prevent pressure ulcers is by frequently changing positions. Individuals confined to a wheelchair or on bed-rest should change positions every 15 minutes on their own, if possible. If assistance is needed to change positions, it should be given every 1-2 hours.

Individuals with limited mobility should always check their skin for the development of pressure ulcers. Earlier detection will lead to early treatment. The skin should always be washed and dried thoroughly and well-cared for.

(For more information on prevention, treatment and care for pressure ulcers, see Protecting Yourself And Your Loved Ones From Bedsores.)


Managing pressure ulcers can be stressful for both the affected individual and those people who are involved in his care. Speak with the doctor and inquire about additional support services such as community support groups and palliative care specialists.


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