Pressure Ulcers Cannot Be Downstaged
A stage 4 pressure ulcer can never be reclassified as a stage 2 ulcer, even after healing or treatment. Once a pressure ulcer has been staged at its maximum depth, it retains that original stage designation throughout the healing process 1.
Why Downstaging is Not Permitted
Pressure ulcer staging reflects the deepest tissue damage that has occurred, not the current appearance of the wound. The staging system is designed to document the maximum anatomical depth of tissue destruction 1.
- Stage 4 ulcers involve full-thickness tissue loss with exposed bone, muscle, ligament, or tendon 1
- Stage 2 ulcers involve only partial-thickness loss of dermis, presenting as a shallow open ulcer with a viable red-pink wound bed 1
- When a stage 4 ulcer heals, the deep tissue structures (muscle, bone) do not regenerate—instead, the wound fills with granulation tissue and scar tissue 2
Correct Documentation During Healing
As a stage 4 ulcer heals, it should be documented as a "healing stage 4 pressure ulcer" or "stage 4 pressure ulcer with granulation tissue." 2
- The wound may appear more superficial as it fills with granulation tissue, but this does not change its stage designation 2
- If the wound closes completely, document it as a "healed stage 4 pressure ulcer" 2
- This approach maintains accurate medical records and reflects the true severity of tissue damage that occurred 2
Clinical Implications
Understanding that pressure ulcers cannot be downstaged is critical for several reasons:
- Risk stratification: Patients with a history of stage 4 ulcers remain at extremely high risk for recurrence and require intensive preventive measures 2, 3
- Treatment planning: A healing stage 4 ulcer may still require surgical debridement, flap coverage, and management of complications like osteomyelitis 1
- Prognosis: Stage 4 ulcers that become chronic carry significant morbidity and mortality risk, with complications including sepsis and osteomyelitis 1, 3
- Resource allocation: Accurate staging ensures appropriate allocation of wound care resources and specialist consultation 1
Common Pitfall to Avoid
Do not confuse visual improvement with actual downstaging. A stage 4 ulcer that has been debrided and is now filled with healthy granulation tissue may visually resemble a more superficial wound, but the anatomical damage to deep structures has already occurred and defines the permanent stage 1, 2.