Symptom Management

Contrary to popular belief, it is not multiple sclerosis, but immobility, that creates an increased risk for pressure sores. Pressure sores (also commonly known as “bedsores,” “pressure ulcers,” “dermal ulcers” and “decubitus ulcers”) are the result of breakdown of the skin because of the effects of friction.
 
Think of a blister that develops on your foot when wearing a new pair of shoes for the whole day. The blister is caused by the constant rubbing of the skin against the inner surface of the shoe. In fact, that blister is characterized as a stage II pressure sore. (I will explain staging a little later.) But pressure sores also develop on different areas of the body and usually occur when mobility is impaired.
 
Where Do Pressure Sores Develop?
 
Pressure sores are usually seen over bony prominences, including the coccyx (tailbone), buttocks, heels, elbows, and other areas. In such areas, the skin is pressed and rubbed between the bone underneath and the clothes or bedsheets above. The clothes and sheets act like sandpaper, rubbing away the layers of the skin. If this goes undetected, which may happen in an area of numbness, the skin can erode all the way down to the muscle, or even the bone. The exposed tissues may become infected and begin to decay from lack of blood circulation. In some cases, this can be life-threatening. Fortunately, pressure sores are preventable.
 
What Causes Pressure Sores?
 
While immobility is a primary cause, other factors also increase the risk of pressure sores. These include paralysis or spasticity, which can decrease mobility; numbness and loss of sensation, which can result in the inability to feel the friction or irritation; advanced age, which is often accompanied by decreased mobility; poor nutrition, which hinders healing of the skin; and incontinence, because moist, wet, or soiled skin can exacerbate the irritation. To avoid developing pressure sores and lower your overall risk, practice the simple strategies that follow on a regular basis. If you have an aide or care partner, be sure to share these strategies with them.
 
Strategies To Avoid Pressure Sores
 
To avoid pressure sores, the first strategy is vigilance. If you are a wheelchair user, check your skin for changes in color every day, particularly over the pressure points. While pressure sores can be painful, some people with MS may lack intact pain sensation and therefore be unaware of the sore. This is where visual inspection comes in. If you are doing a self-inspection, use a mirror for hard-to-see areas. If mobility or vision is impaired, have someone else help with the visual inspection. Whatever your situation – you can fight back. Vigilance is the first line of defense.
 
If a red or dark spot appears in a vulnerable area, it’s time to take the pressure off. Don’t lie on the side of the sore. Use foam pads and pillows to shift the weight away from the red or dark area. Try to have your weight resting on the fleshy part of your rear, rather then on a bony prominence. Change position every two hours. Frequent turning, or sitting upright if possible, is essential to alleviate pressure and promote healing.
 
If you are unable to move yourself easily in your wheelchair, it may be worthwhile to have a physical therapist evaluate you and your wheelchair. Simply tilting the back or adding a new cushion may provide significant benefit. Special gel cushions and other modifying devices are available to help keep the pressure off vulnerable areas. These devices can be used in bed, in a wheelchair, or other seating arrangement. Ensure that your wheelchair is comfortable and avoid chafing. If you use a brace, make sure that you aren’t exposing any areas of your body to chafing. Check all strapped areas, as well as your ankles and feet.
 
Regular skin care is critical in preventing pressure sores. Keep your skin clean and dry, as free as possible from urine, stool, drainage, or perspiration. Use a mild soap with moisturizer and wash with warm – not hot – water. Use a hypoallergenic moisturizer sparingly to prevent dry skin. Avoid talcum powder, which tends to accumulate in skin folds. Use mild, nonirritating, unscented soap and detergent.
 
Watch for fluid accumulation in areas such as the feet, ankles, shins, and lower back. Fluid accumulation in these areas is called “edema.” If persistent swelling occurs, be sure to tell your doctor. Over the long term, diabetes and smoking can decrease circulation to the limbs, which may impair healing and also increase your risk of developing pressure sores.
 
Nutritional Healing
 
If a pressure sore has developed, proper nutrition is necessary for your body to heal. If you don't get enough calories, protein and other nutrients, your body won't be able to heal, no matter how well you care for the pressure sore. Both protein deficiency and dehydration are linked to skin breakdown, impaired integrity of the skin, and delayed healing. On the other hand, proper nutrition and adequate hydration can help prevent pressure sores altogether. If you need help to modify or assess your diet, talk to your doctor, nurse or dietitian. Always inform your doctor if you experience unintentional weight loss.
 
In the earliest stage of a pressure sore, relieving pressure from the affected area may suffice. However, once the skin integrity has been breached, professional help is needed. Special dressing may be required and self-treating is not advised. Infected sores may need antibiotic therapy. Sometimes, the sores need to be cleaned of all dead tissue, a process called debridement. Serious pressure sores may require skin grafting or surgery.
 
It is important to realize that a pressure sore can quickly escalate from what appears to be a Stage I to what appears to be a Stage III or IV, although the stages may not be readily observed. Pressure sores do have the potential to worsen rapidly, so seek medical care promptly.
 
Prevention is always the best treatment and can help you avoid long-term and costly medical treatment. Remember, the skin is our primary barrier of protection from a world full of harmful bacteria. So, take care of it!
 
Pressure sores, as well as burns and other types of wounds, are categorized according to the degree of tissue damage:
 
Stage I: This stage is characterized by a dark area or a reddening of the skin that does not blanch on contact, which means that when lightly pressed with a finger, the skin does not turn white. This is the beginning of a pressure sore, an indication of a problem. Preventive action is needed.
 
Stage II: The skin develops a blister, which may be broken or unbroken. The deeper layer of the skin is still intact. With immediate attention, a stage II wound can heal rapidly. The area must be covered, protected and kept clean and dry.
 
Stage III: The wound looks like a crater that has eroded through all layers of the skin, down to the underlying tissues. Serious infection can occur and medical care is needed. Adequate nutrition and hydration are vital.
 
Stage IV: The wound has penetrated down to muscle, bone, or tendons and may also have injured these tissues. The depth of the wound is generally more significant than the diameter. This is very serious and can produce a life-threatening infection. Medical care by a wound care specialist is required.
 
Dr. Daniel Silverman serves as the vice -president for Medical Affairs for Samaritan Hospital in Troy, N.Y. He is board-certified in neurology and is a member of the American Academy of Neurology, Consortium of MS Centers, and the American Stroke Association. Previously, he served as medical director of the MS Care Center and the Center of Disability Services in Albany, N.Y.
 
(Last reviewed 1/2024)