The scourge of pressure ulcers affects thousands of people worldwide and incurs costs amounting to billions of dollars annually. It is estimated that, at any given time, approximately one-third of patients admitted to hospitals or receiving home-based care will develop pressure ulcers.

Pressure ulcers are wounds affecting the skin and underlying soft tissues, which form as a result of constant, prolonged pressure—particularly over bony prominences such as those found on the hips, buttocks, and feet (e.g., the ischium, greater trochanter, sacrum, heel, or malleolus). Direct pressure on a localized area causes the occlusion of the microcirculation, leading to a lack of oxygen (ischemia) and essential nutrients at the cellular level, while simultaneously causing an accumulation of metabolic waste products. This state of stress forces cells to rely on anaerobic processes, resulting in the buildup of toxic byproducts; these, in turn, cause tissue acidosis, an abnormal increase in the permeability of cell membranes, and, ultimately, cell death.

Individuals over the age of 65 are at a high risk of developing pressure ulcers, as they experience a reduction in subcutaneous fat and capillary blood flow, as well as age-related physiological changes in the structure and function of the skin (namely, a decrease in tactile sensitivity and reduced cohesion between the epidermis and the dermis).

Possible causes and remedies

The term “decubitus” (referring to pressure ulcers or bedsores) stems from the fact that such lesions arise due to prolonged time spent lying in bed, combined with a lack of adequate movement. The most common causes of this type of immobility include anesthesia or deep sedation associated with surgery, neurological disorders, senile dementia, or certain types of fractures—essentially any circumstance that prevents a patient from moving freely or from becoming aware of discomfort, and thus from relieving excessive localized pressure by changing their body position.

Pressure ulcers are a complex condition with a multifactorial origin, involving both intrinsic and extrinsic elements. The former category includes risk factors stemming from pre-existing impairments in the body’s normal functioning, such as vascular diseases, diabetes, or malnutrition. In particular, an individual’s nutritional status plays a vital role in determining the outcome of the wound-healing process; it influences the body’s ability to fight infections, counteract metabolic oxidation, and synthesize the components necessary for tissue repair—most notably proteins, including collagen. In this context, the nutrition of a patient suffering from chronic ulcers is of critical importance, as the presence of such wounds shifts the metabolic balance toward a distinctly catabolic state. This state is characterized by a very rapid consumption of calories, leading to the depletion of glycogen stores (the molecule used to store glucose) and, subsequently, of protein reserves.

The intake of dietary supplements containing proteins (in the form of amino acids), zinc, and vitamins A, C, and E has proven effective in significantly reducing the incidence of pressure ulcers in patients considered to be at risk; this outcome can be attributed to the specific roles these individual components play in wound healing. More precisely, amino acids are essential for cell proliferation, collagen deposition, and the activity of immune system cells. Zinc supports protein synthesis and is necessary for cell growth. Vitamins A, C, and E counteract cellular oxidation and promote skin re-epithelialization, collagen formation, tissue vascularization, and immune function.

Extrinsic risk factors, by contrast, encompass all those environmental variables that trigger specific pathological events at the tissue level, ultimately leading to the development of ulcerative lesions that are particularly difficult to treat. Examples include: (i) either short periods of intense pressure or prolonged periods of mild pressure on a specific area of the body; (ii) friction and rubbing caused by the skin coming into contact with surfaces; (iii) exposure to "shear force" (or "tangential stress"), which occurs when the body slides down against a backrest—a process that does not shift the area of skin in contact with clothing or bed linens, but instead pulls the underlying subcutaneous tissues and muscles downward; and (iv) maceration and the subsequent breakdown of the skin due to moisture accumulation—resulting from sweating, episodes of incontinence, or fluid draining from a surgical wound.

The treatment of pressure ulcers requires a multidisciplinary approach from a team of experts, primarily consisting of physicians specializing in wound care (the branch of medicine dedicated to the study and treatment of chronic skin ulcers), specialized nurses, and physiotherapists. While physicians and nurses focus on the therapeutic management of the wound—for instance, by performing "debridement" (the surgical removal of necrotic tissue, eschar, infected material, etc.) and administering antibiotics and analgesics—the role of the physiotherapist is primarily preventive. To avoid the development, worsening, or recurrence of these lesions, the best strategy involves eliminating or at least minimizing the persistent pressure that causes the ulceration. Beyond the use of specialized medical equipment, such as air-filled anti-decubitus mattresses, the independent or assisted mobilization of the patient is of fundamental importance in preventing ischemic stress to the tissues. Physiotherapists are responsible for assisting patients with repositioning—both by providing practical support during the process (assessing the necessary frequency of movement, ensuring it is carried out effectively and safely, and implementing a program of active and passive exercises for stretching and strengthening the relevant muscles) and by focusing on patient education, ensuring that family members and, whenever possible, the patients themselves are able to correctly and independently carry out the practices required to prevent pressure ulcers.