Lesions on the skin that are caused by pressure resulting in tissue damage are often found on the lower limbs, but can occur almost anywhere
Pressure ulcers — better known as bedsores — are lesions on the skin that are caused by unrelieved pressure resulting in tissue damage. they usually develop over bony areas of the body, often in the lower limbs (ankles and hips are common), but they can occur almost anywhere (for example, in the nostrils of patients with feeding tubes, in the corners of the mouth in patients with endotracheal tubes, and between fingers in patients with rheumatoid arthritis).
Pressure ulcers are quite common in hospitals and other institutional settings. in acute care hospitals they occur in about 3-15 percent of patients; (1) (2) (3) (4) they occur in about a third of elderly patients who have had hip fractures; (5) and the number rises to as much as 50 percent in critical care patients. (6) ten to 35 percent of patients admitted to nursing homes have pressure ulcers, though this rate decreases somewhat for patients who have been there longer. (7) (8) (9) (10) because there are other reasons for skin breakdown, it is important to be examined and diagnosed by a doctor so that the appropriate treatment can be determined. in this article, we’ll discuss the symptoms and diagnosis of ulcers, as well as their treatment and tips for prevention.
TYPES OF ULCERS
There are several types of skin ulceration. Pressure ulcers or bedsores occur when the skin is subjected to constant pressure, which is why they happen so frequently in hospitals and in older patients. they generally start as a blister, and then become an open sore, finally ending in a “crater.” in addition to pressure ulcers, areas of skin breakdown may be due to other types of ulcers, having to do with insufficient blood flow or to diabetic neuropathy.
Insufficient blood flow through the veins usually occurs in the lower legs, and can result in venous insufficiency ulcers, which are often chronic and difficult to heal. they can cause pain in the foot and usually appear purplish in color. they are never found above the level of the knee or in the forefoot, and may occur singly or in multiples.
A related condition, caused by insufficient blood flow through the arteries, is known as arterial insufficiency ulcers, which are painful lesions that usually occur over the ankle or other areas of the foot. although they may be seen near bony prominences (i.e., joints), they are distinguished from pressure ulcers by their “punched-out” or star-like appearance. The wound may be pale and dry, surrounded by red and taut skin, and can include an area of dead skin.
Diabetic ulcers occur on the foot, usually over the joints or on the top of the toes. these ulcers often occur on the ball of the foot in diabetic patients, due to neuropathy or repetitive injury. Diabetic foot ulcers are often surrounded by a significant thickening of the skin, and are usually insensitive to touch.
There are other, less common causes of ulcers in the legs and feet, which include connective tissue diseases (e.g., rheumatoid arthritis), sickle cell disease, and certain forms of cancer. One’s doctor should take special precaution to rule out these more serious conditions before arriving at a diagnosis of an ulcer.
CAUSES AND RISK FACTORS OF PRESSURE ULCERS
Internal and External Risk Factors
There are both external and internal risk factors for ulcers. Pressure, friction, shearing (two layers of skin sliding on each other in opposite directions), and moisture (which can cause softening of skin) are considered external (or extrinsic) risk factors. Internal or intrinsic factors have to do with the patient’s state of health: these including underlying medical conditions, immobility, inactivity, fecal and urinary incontinence, malnutrition, decreased consciousness, steroid use, and smoking, which can all influence one’s likelihood of developing an ulcer.
Medical conditions linked to intrinsic risk factors are far-ranging and include anemia, infection, peripheral vascular disease, edema, diabetes, stroke, dementia, delirium, alcoholism, fractures, and malignancies. Simple, age-related factors such as reduced fat and muscle mass with which to dissipate pressure also increase risk. lower levels of Vitamin C as one ages may also increase the risk of pressure ulcers by causing blood vessels and connective tissue to become fragile and reducing the number of blood vessels serving the tissue of the skin, and other factors.
The Underlying cause of Ulcers: Tissue Ischemia
A main cause of pressure ulcers is tissue ischemia, which occurs when there is a loss of adequate blood supply to the tissue (skin) in question, caused by excessive pressure on the skin. Pressure to the skin lasting longer than two hours produces irreversible changes in skin tissue. in patients who tend to develop pressure ulcers post-operatively, there is impairment in skin blood flow over bony areas of the skin during surgery. (11)
When a person sits, their sitting bones bear the greatest pressure, often pressure than your capillaries can technically take. (12) Pressure ulcers can actually occur from the “inside-out” given that the muscle is more sensitive to pressure than is the skin. (13) because the outer layer of the skin shows signs of tissue death relatively late in the development of an ulcer, (14) once the skin starts to show indications of the presence of an ulcer, the ulcer may be even more progressed than meets the eye. Factors such as hypotension (low blood pressure), dehydration, heart failure, or medications may also contribute to pressure ulcer development. (6) (15) (16) (17) (18) (19)
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