Following a spinal cord injury, the skin becomes more susceptible to damage due to reduced mobility, sensation, circulation and the inability to regulate body temperature below the level of injury. Our skin is a vital component of our bodies and maintaining healthy skin is vital in protecting against germs and bacteria getting into our bodies.

What is a pressure sore/ulcer?

The definition of a pressure ulcer is “localised damage to the skin and the deeper layers of tissue under the skin, usually over a bony prominence, resulting from sustained pressure” – NHS Improvement 2018. The pressure cuts off the blood supply to the area, resulting in oxygen and nutrients being unable to keep the skin healthy which can lead to the skin and tissues dying, as well as damage to the muscle or bone underneath.

A pressure ulcer begins as a reddened area on the skin, which may feel hard or hot when touched. This is referred to as Stage 1. If you have a dark complexion, the site may be shiny or look like a purplish-coloured bruise rather than reddened. At this stage, it is possible to stop the pressure ulcer from developing further by ensuring there is no pressure on this area. Depending on where the ulcer is, this may involve a period of bed rest. You should avoid applying pressure to the area until your skin returns to its usual colour and state. Continuing to put pressure on the area can lead to a blister, pimple or scab quickly covering the affected area, known as Stage 2. When the skin becomes hard and red, the tissue underneath is dying. If the pressure ulcer gets to this stage, the pressure must be removed, and you should see a doctor as soon as possible. An ulcer reaches Stage 3 once the skin has broken down to become a deep wound that not only affects the skin but also the fatty tissue and sometimes muscle. The sore looks like a crater with dark patches around the edges. An ulcer is categorised as Stage 4 when it becomes a severe wound that may reach the bone, tendons, ligaments, or joints. The sore may have dead tissue, infection, or odour.

If a pressure ulcer is left untreated, it can lead to several weeks or months of bed rest. This can have long-lasting implications on a person’s health (physical and mental) and finances (inability to work). 

The good news is that pressure ulcers are almost always preventable. 

Risk factors 

The three most important risk factors are:

• Pressure on the skin
• Damage to the skin
• Poor self-care

Pressure on the skin

Sustaining a spinal cord injury will usually result in the loss of movement and may require the use of a wheelchair. Sitting or lying in the same position for prolonged periods can put pressure on the skin, which can cause damage. It’s important to relieve the pressure when sitting in a wheelchair by changing position regularly. Bony areas, such as the ischial tuberosities (the sitting bones in your bottom), tend to be the first places where damage occurs from staying seated, and as muscles are likely to waste away following SCI, there is less padding to protect the skin, so the bones press against it, putting pressure on it from the inside.

It's also important to avoid pressing against any hard surfaces which may cause unwanted pressure. Buttons, studs and thick seams can all be the cause of pressure ulcers, as can objects put in trouser pockets (coins, keys etc.) or even catheter connectors or clamps.  

It’s also important clothing fits properly. Trousers, socks or shoes that are too tight can apply pressure and cut off the blood circulation. Too loose, and folds in material can also cause pressure issues. 

Relieving pressure

As someone with a spinal cord injury, it’s important to change your position regularly to relieve pressure and allow better blood circulation. 

If you are a wheelchair user, it’s essential you use the correct cushion to help relieve pressure, and to maintain it so that it continues to provide you with pressure relief. There are lots of different types of wheelchair cushion and choosing the one most suitable for your needs can be done with the help of your local wheelchair services centre. Ask a GP, physiotherapist or hospital staff to refer you. 

When sitting in a wheelchair it’s important to maintain good, even posture as slouching or sitting lop-sided can increase pressure on the skin. Relieving pressure when sitting in a wheelchair can be done in several different ways. It’s important to find a way that works for you and/or your caregivers. Leaning from side to side, leaning forward, and tipping back can all be effective ways of relieving pressure in a wheelchair.

Relieving pressure when lying down in bed is also important. Choosing a good pressure-relieving mattress can help, as will having a regular turning schedule. A turning schedule usually involves changing the position you’re lying from side to back to the other side, or front, or a similar pattern. Depending on your skin’s tolerance, it’s recommended to turn from one position to another every 2 to 5 hours. It’s worth checking your skin for red marks every time you turn, and gradually building the time between turns if no red marks are found. Whatever position you’re lying in, it’s important to use pillows or foam padding to support your body and prevent pressure on vulnerable areas such as ankles, heels, knees, hips, and elbows.

Damage to the skin

If your skin becomes damaged, it’s more susceptible to pressure ulcers. Damage can occur through things like friction, wetness or burns.

If your skin is rubbing against hard or rough surfaces it may break down and become damaged. 

If your skin is exposed to moisture for prolonged periods it sheds layers, becoming thinner and weaker. Sweat, urine and faeces are common sources of moisture on the skin. Managing bladder and bowel incontinence is not only an important part of maintaining good skin health but essential in leading a fulfilled life after spinal cord injury. See our guide on managing incontinence after spinal cord injury.  

Checking your skin

Checking your skin on a regular basis helps to identify any problems early, preventing pressure ulcers from developing. If you are unable to check your skin, it’s important you train someone to check on your behalf. Not doing so puts your health at risk. 

Using a mirror or mobile phone camera, you should check all pressure hot spots twice daily, once in the morning before getting dressed and once at night when undressing.  Look for changes to the look or feel of the skin. Red marks, blisters, cracks, bruises, swelling and flaky skin can be the result of too much pressure, as can changes in temperature (warmer spots) or lumps that feel hard or jelly-like.

As well as seeing a change in the look or feel of the skin, increased spasms or raised temperature can also be a sign of a pressure ulcer.

Poor self-care

Taking care of your general health can help prevent pressure sores. 

Exercise: regular exercise can help keep the body healthy and is also good for managing weight and mental health.

Nutrition: eating a healthy, balanced diet ensures your skin receives the vitamins and minerals it needs to stay healthy. Drinking around 2 litres of water each day ensures your skin stays hydrated and it helps your vital organs to function properly. 

Weight: maintaining a healthy weight is important. Being overweight adds pressure to the bony areas suspectable to skin breakdown, increasing the likelihood of a pressure ulcer and potentially increasing the time it takes for one to heal. Being underweight can also put more pressure on bony areas as there is less tissue and fat to act as ‘padding’. Someone who is underweight might also lack the nutrition to ensure any skin problems heal quickly.

Smoking: nicotine causes the blood vessels to contract, restricting the flow of nutrients and oxygen to the skin. Smoking is a primary cause of vascular disease, resulting in the narrowing of blood vessels, and decreasing the blood supply to the skin.

What to do if you notice a red mark

• Take bed rest and keep pressure off the affected area 

• Take pictures of the pressure mark and send them to a healthcare professional specialising in skin care so progress can be monitored 

• Speak to a healthcare professional such as a district nurse, GP or outpatient department nurse at your spinal injury centre and put a treatment plan in place

• Eat a high protein diet and take plenty of healthy fluids 

Further help and advice are available from tissue viability nurses (TVN) – your GP can refer you to your local service. The SIA support line and SCI nurse specialists can also help. 

Tips for healthy skin

Check your skin for unusual marks twice daily, once in the morning before you get out of bed and on getting into bed in the evening.

Keep your skin clean and moisturised to help it become more resilient to damage.

Eat a balanced diet and drink about 2 litres of fluids a day.

Avoid smoking because it affects your circulation, which can slow down the healing process of any wounds and dry out your skin.

Additionally, if you have sustained a spinal injury that was someone else’s fault, you can get in touch with the legal experts at JMW Solicitors. We can help determine who was responsible for the incident - whether you are making a personal injury or medical negligence claim - and help you claim the compensation you will need to help you finance any future care and lifestyle changes you may need.