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A Review of the Skin Failure Concept

My colleagues, Barbara Delmore PhD, RN, CWCN, MAPWCA and Jill Cox PhD, RN, APN-c, CWOCN, and I have written a paper,1 available electronically ahead of print, that reviews the skin failure concept, defines related controversies, and proposes a model for its pathogenesis. Like all other organs, skin can fail; however, experts continue to grapple with definitions, causative factors, and manifestations.

By defining contributing factors that apply to other organ systems, providers establish skin failure as an entity and thus are able to recognize and address it in practice. This also enables providers to assist regulators by incorporating these pathophysiologic factors into modification of quality measurement criteria. Unifying the concept across the health care continuum—from the intensive care unit to long-term care—will bring a common sense understanding of skin failure and related entities, including unavoidable pressure injuries and terminal ulceration.

Skin Failure: Concept Review and Proposed Model

Written from an interdisciplinary standpoint, the paper is titled “Skin Failure: Concept Review and Proposed Model.” It reviews barrier functions of skin and defines specific pathophysiologic factors that lead to skin disruption. These factors include hypoperfusion, hypoxia, increased vascular permeability, and edema, all of which act in synergistic fashion to impair skin’s barrier function.

The article further defines acute and chronic conditions leading to these pathophysiologic aberrations, including multiple organ dysfunction syndrome, protein-calorie malnutrition, and immunocompromised states. Also addressed are critical contributing factors, such as age-related skin changes, frailty, sarcopenia, cytoskeletal and external forces, pharmacologic contributors, and the dying process. There is a pressing need to define skin failure as a clinical syndrome because of its implications for both clinical care and health care policy. The proposed model assembles a variety of overlapping nomenclatures into a unified mechanism for understanding skin failure and, most significantly, places terminal ulceration within its spectrum of manifestations. The full paper can be accessed in the Reference section of this blog.


1. Levine JM, Delmore B, Cox J. Skin failure: concept review and proposed model. Adv Skin Wound Care. Published online November 1, 2021. doi:10.1097/01.ASW.0000798464.03618.d9

About the Author

Dr. Jeffrey Levine is a board-certified internist and geriatrician with over thirty years of experience in wound care in hospitals, nursing homes, and home care environments. He is Associate Professor of Geriatrics and Palliative Care at the Icahn School of Medicine at Mount Sinai. He received his fellowship training in geriatrics at the Mount Sinai Medical Center where he began his interest in chronic wounds. He is an alumnus of the National Pressure Ulcer Advisory Panel (NPUAP). Dr. Levine's interest in pressure ulcers began in the 1980s during his geriatric training when he noticed that many of his nursing home patients had pressure ulcers but there was little reliable information on treatment methods. This motivated him to study not just prevention and treatment of chronic wounds, but to delve into the rich history of wound care over the centuries. He has since published a number of articles on historical topics ranging from wound care in ancient Egypt through the 20th Century. 

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.