๐ In This Article
Pressure injuries begin internally โ where you cannot see them start. After SCI, the changes in skin, muscle, and sensation create serious risk over bony areas. This guide explains every stage, every treatment, and what full recovery actually requires.
After spinal cord injury, changes in the skin create the exact conditions for pressure injury. Collagen โ which gives strength to skin โ is decreased, as is blood supply. Muscle size decreases due to immobility and is replaced by an increased fat layer. Sensation is decreased or absent depending on injury type and level.
Normally, bony prominences of the skeleton rest on muscle tissue, which disperses pressure throughout the muscle. As muscle thins, it is less able to do this. Fat tissue condenses under pressure โ creating even more concentrated force over the bony area. This collapses blood vessels so circulation cannot be achieved. Sensation would normally signal you to shift your weight, but after SCI that signal is diminished or gone entirely.
Decreased Collagen & Blood Supply
Skin becomes more fragile and slower to heal. Even minor sustained pressure can cause damage that would not occur in healthy skin.
Muscle Loss โ Fat Increase
Fat condenses under pressure rather than dispersing it โ concentrating force directly over bony prominences and collapsing the tiny capillaries beneath.
Absent or Reduced Sensation
The normal signal to shift position โ which would re-open compressed capillaries โ is gone. Damage occurs silently, from the inside out.
High-Risk Bony Areas
When lying: heels, tailbone, elbows, back of head, shoulder blades. When seated: sit bones, tailbone, back of knees, shoulder blades, feet. Inspect all of these areas at every skin check.
A pressure injury (PI) may also be called a pressure ulcer, skin breakdown, pressure sore, bed sore, or decubitus ulcer. It begins internally โ where you cannot see it start. The first visible sign may be a darkened, red, or ashy spot on the skin due to collapsed blood vessels, most commonly over a bony prominence or cartilage area.
๐ฆด Bony Prominences
The end of a bone where it has a bump โ chin bone, elbow, knee. These points are where pressure concentrates most intensely against skin from below.
๐ Cartilage Areas
The outer ear and tip of the nose are cartilage, not bone โ but equally vulnerable to pressure injury, especially when lying on one side for extended periods.
Injury Is Deeper Than It Looks
Pressure injury is staged by how it looks on the surface โ but the injury is most likely much deeper than what is visible. Never underestimate what you can see on the skin’s surface.
Stage I
Pigmentation Change
A pigmented area on the skin that may be painful if you have sensation. In darker skin, may appear bluish or purplish; in lighter skin, red. Skin may be warm or cool, firm or soft. There may be edema at or beyond the site.
Stage II
Blister or Open Injury
The skin blisters or forms an open injury. The epidermis (top layer) may be open or removed. The injury extends into the dermis. The surrounding area may be red and irritated.
Stage III
Deep Crater
An open, sunken crater extending into the fat layer. Body fat may be visible at the bottom. White patches may indicate infection or decaying tissue. Edges may be hard and rounded inward โ called epibole.
Stage IV
Bone Involvement
The pressure injury has reached the bone. There can be damage to muscle, bone, tendons, and joints. This is the most serious stage and requires immediate medical attention.
๐ซ Unstageable
Covered in eschar โ a yellow, tan, green, or brown dead tissue that makes depth impossible to assess. Eschar keeps germs out but may hide internal infection.
๐จ Never remove eschar yourself โ let your medical professional assess it.
๐ฃ Deep Tissue Injury
Develops in tissue deep below the skin. The area may appear dark purple or maroon, with a possible blood-filled blister.
โ ๏ธ Can rapidly become a Stage III or IV โ act immediately.
You are the first line of defense for your skin. Inspect for rashes, calluses, open areas, pigmentation changes, temperature differences, cuts, tears, or abrasions. If you detect an issue that cannot be simply treated, stay off the area and contact your healthcare professional immediately.
Physical examination with complete skin assessment, focusing on the area of possible pressure injury.
Blood tests to assess for infection and nutritional status.
Wound swab if the area is open, to assess for infection inside the injury.
ADL review โ questions about transfers, turning ability, pressure release frequency, and equipment evaluation.
CT scan or MRI for injuries where depth cannot be assessed โ especially to determine bone involvement or infection.
The Blanch Test
A healthcare professional places pressure on the area with one finger, once. If blood flow is present, the area will empty and immediately refill (blanch). No colour change means blood flow is absent. This test should be done only once, by one professional โ additional testing adds further injury without changing results.
Treatment of pressure injuries takes time. You may need assistance from another person for dressing changes, transfers, and daily activities. Work time and family time may be lost during healing.
๐ Closed Injuries
If the skin is not open, the only treatment is to stay completely off the area. No pressure whatsoever โ not for work, school, hygiene, or any other reason.
Found early โ may resolve within hours. Every hour of delay adds healing time. This is non-negotiable.
๐ฉน Open Injuries
Require a sterile dressing plus complete pressure removal. Clean with prescribed solution or clean water only.
๐จ Hydrogen peroxide is NOT recommended โ it destroys granulation (new cell formation).
Debridement
Some injuries debride spontaneously under an airtight dressing. Enzymes can assist with light debridement at each dressing change. When more intervention is needed, a scalpel, chemical, or โ successfully in some cases โ maggot therapy removes eschar, necrotic tissue, or tissue without circulation. Only performed by a healthcare professional.
Packing
Open injuries require light packing โ healing must happen from the bottom up, with skin closure last. If the skin closes before the wound bed has healed, a pocket forms that can reopen or become a closed infection. As tissue heals, packing reduces. Some packing contains medication or is placed wet and removed dry, providing additional debridement.
Negative Pressure Wound Therapy (NPWT)
Suction-Based
Adds low-pressure suction to the injury, drawing out drainage. A motorised power pack sits at the bedside or on the wheelchair. Special insurance authorisation is required.
Electrical Stimulation
Stage III & IV
Assists healing by increasing blood flow, oxygenation, and granulation of tissue. Used for Stage III or Stage IV pressure injuries.
Hyperbaric Oxygen Therapy
Pressurised Oxygen
Places your entire body or injured part in a chamber delivering 100% oxygen under pressure. The oxygen is thought to significantly speed healing of the wound bed.
Surgical Closure
Stage III & IV ยท Major Commitment
Removes non-healing tissue, may reduce the bony prominence, rotates a flap of healthy muscle for cushioning and blood flow, and closes with healthy skin. Patients remain off the area for six months to one year, then gradually return to seating โ starting at 5 minutes.
๐จ Sepsis โ A Medical Emergency
Infected pressure injuries can become septic. Sepsis spreads throughout the body, affecting major organs. It can be fatal if not treated promptly. Call 911 or go to the Emergency Room immediately if you experience:
Presence of infection or possible infection
Elevated temp > 38.3ยฐC / 101.3ยฐF
Fast heart rate > 90 beats per minute
Fast respiratory rate > 20 breaths/min
Confusion or coma
Edema in extremities, neck, or face
Elevated blood sugar without diabetes
Low temp < 36ยฐC / 97ยฐF
Massage โ adds more pressure, causing further damage.
Alcohol rubs โ do nothing to improve blood flow and add pressure.
Donut cushions โ create a constriction ring that reduces blood flow to the affected area.
Non-medical honey โ only medical-grade honey applied to the wound has evidence; eating it has no effect.
Amputation โ not a treatment for pressure injuries. Healing takes time, but it does happen.
The area of a healed pressure injury is very fragile. Healed skin has no elasticity โ it is essentially a scar. Even if surgically closed, that skin is not accustomed to pressure and has a significantly greater chance of re-injury.
Begin by lying or sitting on the area for no more than 5 minutes.
Stay completely off the area for a minimum of two hours after each session.
Inspect the skin for any pigmentation change after each session before proceeding.
If no change, gradually increase pressure time over days and weeks until normal time is reached.
Continue pressure releases throughout every session โ even during the recovery period.
Any Pigmentation Change = Stop Immediately
If you detect any colour change in the healed area during recovery, remove pressure immediately and contact your healthcare provider. Do not continue increasing time until the area has been re-assessed.
Reeve Foundation Information Specialists
800-539-7309 ยท MondayโFriday, 9:00 am to 8:00 pm ET โ free expert support for people living with paralysis and SCI.
Paralyzed Veterans of America โ Clinical Practice Guidelines
pva.org โ evidence-based clinical guidelines for pressure injury prevention and treatment
National Pressure Injury Advisory Panel (NPIAP)
npiap.com/page/FreeMaterials โ free patient and clinician resources on staging and treatment
Your Rehabilitation or Wound Care Team
Contact your physiatrist, wound care nurse, or occupational therapist at the first sign of any skin change. Early intervention prevents Stage I from becoming Stage IV.
Pressure injuries begin deep inside the body โ what you see on the skin surface is only a fraction of the total damage. Never underestimate any pigmentation change.
For closed injuries, the only treatment is zero pressure on the area โ no exceptions, not for any activity. Found early, pigmentation may resolve within hours.
Never use hydrogen peroxide on open wounds โ it destroys granulation tissue and actively prevents healing. Clean with prescribed solution or clean water only.
Sepsis is a life-threatening emergency. If you have a pressure injury and develop fever, fast heart rate, confusion, or edema โ call 911 immediately.
Recovery requires a gradual return to pressure โ starting at 5 minutes, checking for any pigmentation change, and only increasing time slowly over weeks. Healed skin is scar tissue and has no tolerance for pressure without this process.
๐ SCI Skin Care Series โ 4-Part Series
Article 1
Understanding Your Skin
Article 2
Common Skin Conditions
Article 4
Wound Care & When to Seek Help
