Wound Care

Pressure Injury

Manage pressure injury by immediately removing pressure and shear, correctly distinguishing mimics, characterizing tissue loss and exudate, identifying necrosis or deep infection, and selecting debridement, moisture-balanced dressings, negative-pressure therapy, or surgical management when indicated.

Clinical question: How should physicians assess, stage, treat, and monitor pressure injuries while identifying mimics and complications requiring escalation?

Updated September 15, 20266 minute readWound Care

What matters in practice

Treat pressure injury as a pressure-and-shear problem first: institute an individualized repositioning and support-surface plan while reassessing skin and wound evolution. The 2025 international guideline permits either 2-hour or 3-hour repositioning intervals in relevant settings rather than a universal 2-hour rule. Wolters KluwerWolters KluwerPressure Injury Scientific Evidence for Practice... : Advances in Skin & Wound Care
A purple or maroon area, blood-filled blister, or rapidly evolving eschar may represent deep tissue injury, but bruising, hematoma, arterial insufficiency, venous engorgement, necrotizing fasciitis, incontinence-associated dermatitis, skin tear, and terminal skin changes are important alternatives. PubMedPubMedDifferential diagnosis of suspected deep tissue injury - PMC
For wounds with necrotic tissue, assess for debridement before negative-pressure wound therapy; necrotic tissue, untreated osteomyelitis, unexplored fistula, and suspected malignancy are contraindications to NPWT. PubMedPubMedComplex Wound Management - StatPearls - NCBI Bookshelf
Exposed or palpable bone and increasing exudate should trigger evaluation for infection and osteomyelitis rather than reflexive dressing escalation alone. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆
During NPWT, monitor seal integrity and drainage volume and character; pain, bleeding, infection, retained foam, maceration, and loss of suction require prompt correction or treatment reassessment. PubMedPubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf

First Encounter

Prioritize pressure relief, tissue viability, and urgent mimics

The initial decision is whether the lesion is pressure-related and whether rapid tissue loss reflects an emergency.

Immediately eliminate sustained pressure and shear at the involved site, document location, wound-bed visibility, necrosis, exudate burden, periwound condition, and whether bone is exposed or palpable. Repositioning should be individualized; the current international guideline supports either 2-hour or 3-hour intervals in applicable care settings rather than a fixed universal schedule. Wolters KluwerWolters KluwerPressure Injury Scientific Evidence for Practice... : Advances in Skin & Wound Care

Treat a rapidly progressive lesion with disproportionate pain, expanding violaceous discoloration, systemic illness, or concern for necrotizing fasciitis as an urgent diagnostic branch rather than routine pressure-injury care. Necrotizing fasciitis is among the recognized deep-tissue-injury mimics, and delayed distinction risks inappropriate conservative management. PubMedPubMedDifferential diagnosis of suspected deep tissue injury - PMC

For patients with spinal cord injury, incorporate sensory loss, limited mobility, and spasticity into prevention and surveillance planning because these factors increase pressure-injury risk and may reduce symptom-based detection. Digital feedback systems that provide real-time pressure-distribution data and self-management technologies are emerging adjuncts for this population. NatureNatureSelf-managed digital technologies for pressure injury prevention in individuals with spinal cord injury: a systematic scoping review | Spinal Cord

Reassess pressure exposure from bed, chair, medical devices, moisture, and shear whenever a lesion enlarges or new nonblanching discoloration appears. Wolters Kluwer+1Wolters KluwerPressure Injury Scientific Evidence for Practice... : Advances in Skin & Wound Care PubMedDifferential diagnosis of suspected deep tissue injury - PMC
Document darkly pigmented skin using palpable and textural findings as well as color; classic purple or maroon discoloration may be less readily recognized, increasing misclassification risk. PubMedPubMedDifferential diagnosis of suspected deep tissue injury - PMC
Escalate urgently for a lesion suspected to be necrotizing fasciitis rather than classifying it as deep tissue injury. PubMedPubMedDifferential diagnosis of suspected deep tissue injury - PMC

Bedside features that redirect a suspected deep tissue pressure injury diagnosis. PubMedPubMedDifferential diagnosis of suspected deep tissue injury - PMC
Finding	Interpretation	Next action
Localized purple or maroon intact skin or blood-filled blister after pressure or shear exposure	Compatible with deep tissue injury from underlying soft-tissue damage. PubMedPubMedDifferential diagnosis of suspected deep tissue injury - PMC	Remove pressure and shear, document evolution, and reassess frequently for tissue loss or eschar development. PubMedPubMedDifferential diagnosis of suspected deep tissue injury - PMC
Purple skin without a convincing pressure/shear pattern	Consider bruise, hematoma, venous engorgement, or arterial insufficiency. PubMedPubMedDifferential diagnosis of suspected deep tissue injury - PMC	Re-evaluate vascular, traumatic, and anticoagulation-related explanations before staging as pressure injury. PubMedPubMedDifferential diagnosis of suspected deep tissue injury - PMC
Macerated or superficially denuded skin in a moisture-exposed distribution	Consider incontinence-associated dermatitis or skin tear rather than deep tissue injury. PubMedPubMedDifferential diagnosis of suspected deep tissue injury - PMC	Address moisture exposure and skin protection; do not infer deep tissue pressure damage from superficial appearance alone. PubMedPubMedDifferential diagnosis of suspected deep tissue injury - PMC
Rapid evolution with concerning clinical features	Necrotizing fasciitis is a critical alternative diagnosis. PubMedPubMedDifferential diagnosis of suspected deep tissue injury - PMC	Obtain urgent surgical assessment and manage as a possible soft-tissue emergency. PubMedPubMedDifferential diagnosis of suspected deep tissue injury - PMC

Diagnosis

Classify visible tissue loss without forcing a stage through obscuring tissue

Accurate classification determines whether local wound care is sufficient or whether debridement and infection evaluation are needed.

When necrotic tissue completely covers the wound bed and prevents visualization of the deepest tissue loss, classify the injury as unclassifiable rather than assigning a lower stage. The immediate management question is whether necrosis requires debridement and whether infection, exudate, or osteomyelitis is present. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆

Stage 4 pressure injury involves full-thickness tissue loss affecting muscle and/or bone. In this branch, evaluate granulation tissue, necrosis, exudate, wound edges, and bacterial burden; exposed or palpable bone should heighten concern for osteomyelitis. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆

Do not equate all purple periwound tissue with deep tissue injury. Purple tissue can occur around other ulcerations, and deep tissue injury can be mistaken for stage 2 injury, skin tear, or incontinence-associated dermatitis. A history of pressure or shear, lesion morphology, distribution, and serial evolution should determine the working diagnosis. PubMedPubMedDifferential diagnosis of suspected deep tissue injury - PMC

Use serial examinations when the depth is initially indeterminate; deep tissue injury may blister or evolve into eschar. PubMedPubMedDifferential diagnosis of suspected deep tissue injury - PMC
For high or increasing exudate, reassess for local infection, necrotic tissue, and osteomyelitis rather than selecting a more absorbent dressing alone. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆
Protect wound edges from exudate-related damage with barrier cream when exudate is moderate or high. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆

Wound-bed findings that determine local management priorities. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆
Pattern	Primary concern	Management priority
Necrotic tissue obscuring wound depth	Unclassifiable pressure injury; deepest tissue loss cannot be visualized. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆	Assess for debridement and manage bacterial burden; reassess after obscuring tissue is removed. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆
Stage 4 injury with low or moderate exudate	Loss extending to muscle and/or bone; necrosis and bacterial burden may impede healing. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆	Maintain granulation tissue, assess for debridement, and manage bacterial balance or biofilm. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆
Stage 4 injury with high exudate	Increased exudate may indicate infection; osteomyelitis and maceration require attention. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆	Assess for necrosis and osteomyelitis, protect edges with barrier cream, and use a high-absorption strategy. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆
Exposed or palpable bone	Possible osteomyelitis. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆	Evaluate for bone infection before advancing local therapy or NPWT. PubMed+1PubMedComplex Wound Management - StatPearls - NCBI Bookshelf PubMedPressure Injuries: prevention, treatment, and complications – Part II؆

Treatment

Match debridement and dressing function to the wound bed and exudate

Local therapy should address nonviable tissue, bacterial burden, moisture balance, and periwound protection while pressure relief continues.

For necrotic tissue, make debridement the first procedural decision. Necrosis obscures staging, can require removal to permit wound-bed assessment, and is a contraindication to NPWT until the wound bed has been appropriately prepared. PubMed+1PubMedComplex Wound Management - StatPearls - NCBI Bookshelf PubMedPressure Injuries: prevention, treatment, and complications – Part II؆

For moderate exudate, foam dressings and gelling-fiber dressings are listed options; if local infection is a concern, antimicrobial alternatives described include silver-containing foam or gelling-fiber dressings, polyhexamethylene biguanide gel, or cadexomer iodine. Dressing selection should follow exudate level, wound-bed status, and periwound vulnerability rather than a single product preference. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆

For high exudate, use a high-absorption approach such as polymer foam, silver dressings, alginate, collagen, or NPWT when the wound is otherwise suitable. Protect wound edges with barrier cream and reassess increasing drainage for infection, necrosis, or osteomyelitis. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆

Use antimicrobial gels containing polyhexamethylene biguanide when local infection is present. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆
Avoid iodine-based dressings in pregnancy and in patients with thyroid disorders. PubMedPubMedComplex Wound Management - StatPearls - NCBI Bookshelf
Reassess dressing strategy when exudate changes because new high drainage may signal infection or inadequate source control. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆

Local treatment selection by wound feature. PubMed+2PubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf PubMedComplex Wound Management - StatPearls - NCBI Bookshelf PubMedPressure Injuries: prevention, treatment, and complications – Part II؆
Wound feature	Reasonable local approach	Do not miss
Necrotic wound bed	Assess for and perform indicated debridement before considering NPWT. PubMed+1PubMedComplex Wound Management - StatPearls - NCBI Bookshelf PubMedPressure Injuries: prevention, treatment, and complications – Part II؆	Necrosis prevents adequate wound-bed assessment and contraindicates NPWT. PubMedPubMedComplex Wound Management - StatPearls - NCBI Bookshelf
Moderate exudate	Foam or gelling-fiber dressing; consider silver-containing options or PHMB gel when local infection is present. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆	Assess for necrosis and bacterial burden rather than treating drainage alone. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆
High exudate	High-absorption foam, silver dressing, alginate, collagen, or suitable NPWT; protect edges with barrier cream. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆	Increasing exudate may indicate infection or osteomyelitis. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆
Suitably prepared exudative wound receiving NPWT	Monitor drainage, seal, tubing, and device function routinely. PubMedPubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf	Pain, bleeding, infection, maceration, foam retention, or loss of suction require intervention. PubMedPubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf

When negative-pressure wound therapy is appropriate

Consider NPWT for an appropriately prepared, exudative pressure injury when removal of excess exudate and support of granulation are desired. NPWT applies subatmospheric pressure through a foam and semi-occlusive dressing and has been used to remove exudate and debris while promoting granulation tissue formation. PubMedPubMedComplex Wound Management - StatPearls - NCBI Bookshelf

Do not initiate NPWT over necrotic tissue, untreated osteomyelitis, unexplored fistula, or a wound suspicious for malignancy. These findings require diagnostic clarification or source control before negative-pressure treatment is used. PubMedPubMedComplex Wound Management - StatPearls - NCBI Bookshelf

At each NPWT assessment, inspect seal integrity, tubing position, drainage volume, and drainage character. PubMedPubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf
Respond promptly to device alarms or loss of suction by reinforcing the seal or replacing the dressing; persistent interruption can leave heavily exudative wounds saturated and increase periwound breakdown. PubMedPubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf
Stop and reassess for pain, bleeding, infection, retained foam, hypersensitivity, maceration, erosion, or injury to underlying vessels or bowel. PubMedPubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf

Complications

Escalate when osteomyelitis, uncontrolled necrosis, or therapy failure changes the treatment path

The key escalation trigger is a wound whose apparent local problem may represent deeper infection or inadequate source control.

In a stage 4 or heavily exudative pressure injury, exposed or palpable bone and rising drainage should prompt focused evaluation for osteomyelitis. Do not proceed with NPWT if osteomyelitis remains untreated; this is a stated contraindication. PubMed+1PubMedComplex Wound Management - StatPearls - NCBI Bookshelf PubMedPressure Injuries: prevention, treatment, and complications – Part II؆

If local infection is suspected, pair bacterial-burden management with reassessment for nonviable tissue and deeper extension. Antimicrobial topical choices described for local infection include silver dressings, polyhexamethylene biguanide gel, and cadexomer iodine, but cadexomer iodine should be avoided in pregnancy and thyroid disease. PubMed+1PubMedComplex Wound Management - StatPearls - NCBI Bookshelf PubMedPressure Injuries: prevention, treatment, and complications – Part II؆

Escalate to procedural or surgical wound management when necrosis requires debridement, when the wound cannot be adequately evaluated because tissue obscures its base, or when a suspected deep infection precludes NPWT. Continue to monitor nutritional status and comorbid conditions during wound treatment because they materially affect healing outcomes. PubMedPubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf

Suspected malignancy in the wound bed is a contraindication to NPWT and requires diagnostic evaluation before device treatment. PubMedPubMedComplex Wound Management - StatPearls - NCBI Bookshelf
An unexplored fistula is a contraindication to NPWT; define the anatomy before applying suction. PubMedPubMedComplex Wound Management - StatPearls - NCBI Bookshelf
For wound deterioration during NPWT, check mechanical causes first: inadequate seal, malpositioned or blocked tubing, battery failure, or full canister. PubMedPubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf

Findings that should interrupt routine local management. PubMed+3PubMedDifferential diagnosis of suspected deep tissue injury - PMC PubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf PubMedComplex Wound Management - StatPearls - NCBI Bookshelf PubMedPressure Injuries: prevention, treatment, and complications – Part II؆
Trigger	Why it changes care	Immediate next step
Exposed or palpable bone	Raises concern for osteomyelitis. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆	Evaluate for bone infection; do not use NPWT if osteomyelitis is untreated. PubMed+1PubMedComplex Wound Management - StatPearls - NCBI Bookshelf PubMedPressure Injuries: prevention, treatment, and complications – Part II؆
Necrotic tissue covering the wound bed	Depth cannot be classified and NPWT is contraindicated. PubMed+1PubMedComplex Wound Management - StatPearls - NCBI Bookshelf PubMedPressure Injuries: prevention, treatment, and complications – Part II؆	Assess for debridement and reassess the wound bed after appropriate removal of obscuring tissue. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆
NPWT alarm or loss of suction	Therapy may be ineffective and exudate may saturate wound and periwound skin. PubMedPubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf	Reinforce the seal or replace the dressing; check tubing, battery, and canister. PubMedPubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf
Rapidly evolving violaceous lesion with clinical concern for soft-tissue emergency	May be necrotizing fasciitis rather than pressure injury. PubMedPubMedDifferential diagnosis of suspected deep tissue injury - PMC	Seek urgent surgical assessment. PubMedPubMedDifferential diagnosis of suspected deep tissue injury - PMC

Follow-up

Monitor trajectory and prevent recurrence through individualized pressure redistribution

Healing surveillance must detect worsening pressure exposure, infection, device failure, and periwound injury early.

At each wound review, compare wound-bed visibility, necrosis, exudate quantity, drainage character, granulation, wound edges, and periwound maceration with the prior examination. A shift to high exudate should restart the infection and osteomyelitis assessment pathway, whereas preserved granulation supports continuation of a moisture-balanced plan. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆

For patients receiving NPWT, routinely record drainage volume and character and verify that the device is delivering therapy. Loss of suction is most often due to an inadequate dressing seal; prompt seal reinforcement or dressing replacement limits interruption and uncontrolled exudate exposure. PubMedPubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf

Prevention requires a reproducible repositioning plan linked to the patient’s mobility, sensory function, tissue tolerance, and care environment. The international guideline recommendation allowing either 2-hour or 3-hour repositioning intervals reinforces individualized scheduling rather than undocumented routine turning. Wolters KluwerWolters KluwerPressure Injury Scientific Evidence for Practice... : Advances in Skin & Wound Care

Inspect skin and device-contact areas serially in patients with impaired sensation, restricted mobility, or spasticity after spinal cord injury. NatureNatureSelf-managed digital technologies for pressure injury prevention in individuals with spinal cord injury: a systematic scoping review | Spinal Cord
If periwound skin breaks down during NPWT, assess for maceration, excessive moisture, adhesive hypersensitivity, or poor seal and modify the dressing interface. PubMedPubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf
Monitor nutrition and comorbid conditions throughout NPWT and chronic-wound care because both influence healing. PubMedPubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf

Follow-up actions based on change in wound trajectory. Wolters Kluwer+2Wolters KluwerPressure Injury Scientific Evidence for Practice... : Advances in Skin & Wound Care PubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf PubMedPressure Injuries: prevention, treatment, and complications – Part II؆
Observed change	Interpretation	Action
Increasing exudate	May indicate infection and warrants attention to osteomyelitis, necrosis, and wound-edge protection. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆	Reassess wound bed and bone exposure; increase absorption strategy as appropriate and protect edges with barrier cream. PubMedPubMedPressure Injuries: prevention, treatment, and complications – Part II؆
New periwound maceration	Excess moisture or dressing-system failure may be present. PubMed+1PubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf PubMedPressure Injuries: prevention, treatment, and complications – Part II؆	Protect wound edges, reassess absorbency, and if using NPWT inspect seal and drainage function. PubMed+1PubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf PubMedPressure Injuries: prevention, treatment, and complications – Part II؆
NPWT seal failure	Negative pressure is not being delivered effectively. PubMedPubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf	Reinforce adhesive seal or replace dressing and check tubing, power, and canister. PubMedPubMedNegative Pressure Wound Therapy - StatPearls - NCBI Bookshelf
New lesion in a patient with persistent immobility	Current pressure redistribution is inadequate. Wolters KluwerWolters KluwerPressure Injury Scientific Evidence for Practice... : Advances in Skin & Wound Care	Revise individualized repositioning and support-surface plan; document interval and adherence. Wolters KluwerWolters KluwerPressure Injury Scientific Evidence for Practice... : Advances in Skin & Wound Care