Introduction

As the body's largest organ, skin has multiple functions, causes, and manifestations of failure at end of life.¹ The concept of skin failure was first proposed in 1991 and continues to impact how injuries at end of life are understood.^2-5

Skin failure is often discussed alongside mention of unavoidable pressure injuries, which develop despite implementation of prevention measures, best practices, and monitoring.³ For patients who are critically ill, these pressure injuries may be categorized as acute skin failure depending on the pathophysiological factors that led to their development.⁴ Wound care professionals may find categorizing these injuries, and other injuries concurrent with skin failure, challenging.

WoundSource had a chance to interview Dr. Barbara Delmore and Dr. Jill Cox, thought leaders who have published extensive research on acute skin failure and pressure injuries. Their WoundCon Spring session, “Skin Failure: Will You Know It If You See It?” examined factors that differentiate these injuries. Dr. Delmore and Dr. Cox discuss their motivations for presenting this session and their hopes for future research in the field.

1. What inspired you to participate in the creation and presentation of this session?

   As researchers and wound care experts, our clinical experience was an important driver for this session. We have many years of experience in wound care in the acute setting and had similar experiences with regard to what we were seeing in our critically ill patients. Patients were developing wounds, particularly in the sacral region, that appeared as rapid onset deep tissue pressure injuries. However, we asked, "Are these really pressure-related wounds based on the patient presentation?” Looking at the literature, we found minimal research in this area that would help us explain or confirm our similar anecdotal experiences. That lack of data led us to initially conduct a primary, multisite investigation into the factors associated with acute skin failure, published in 2015. We subsequently conducted a second study using a larger, more diverse dataset to validate our previous findings. This study was published in 2020.

2. What do you feel are the leading innovations in the field regarding skin failure?

   Skin failure and its subtype, acute skin failure, have been conceptually defined for some time in the literature. Currently, the issue is two-fold. First, there are no technologies deemed capable of differentiating skin failure from other wound types. Second, there are no diagnostic criteria established to validate this concept as a true condition. Innovation in this area will occur when either or both above are definitively established and available in everyday clinical practice.

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3. What one thing do you feel clinicians can do tomorrow to improve how they assess skin for failure or pressure injury?

   Clinicians can improve assessment by identifying the risk factors that the patient possesses, in addition to what they are visually and tactilely assessing on the skin. The risk factors can help the clinician determine if factors, such as other organ failures, might be occurring simultaneously. This finding might lead the clinician to suspect that pressure may not be the most significant etiologic cause in the wound they are visualizing.

4. Ultimately, what do you hope readers/clinicians will take away from this session?

   We hope that participants will come away with a better understanding of risk factors that may predict skin failure and its subtypes. We also hope this presentation will spark future researchers to clarify this concept further.

Conclusion

Investigation into the prevalence of acute skin failure continues. Experts have found that patients with severe COVID-19 are at risk for acute skin failure. In a 2023 article, it was reported that one patient repositioned every 2 hours still developed a butterfly-shaped injury in the gluteal area.⁵ Although, in the case of this patient, the ulceration was relatively healed after around 4 months of treatment with best practices, diagnosis of acute skin failure is essential.⁵ Underdiagnosis of acute skin failure impacts management, healing trajectory, and litigation regarding current and future patients, further complicating care in a time where the health care system is strained.⁵

References

1. Levine JM, Delmore B, Cox J. Skin Failure: Concept Review and Proposed Model. Adv Skin Wound Care.2022;35(3):139-148. doi:10.1097/01.ASW.0000818572.31307.7b
2. Irvine C. ‘Skin failure’ - a real entity: discussion paper. J R Soc Med. 1991;84:412-413. https://journals.sagepub.com/doi/pdf/10.1177/014107689108400711
3. Pittman J, Beeson T, Dillon J, et al. Hospital-Acquired Pressure Injuries and Acute Skin Failure in Critical Care: A Case-Control Study. J Wound Ostomy Continence Nurs. 2021;48(1):20-30. Accessed March 3, 2023. doi:10.1097/WON.0000000000000734
4. Delmore B, Cox J, Rolnitzky L, et al. Differentiating a Pressure Ulcer from Acute Skin Failure in the Adult Critical Care Patient. Adv Skin Wound Care. 2015;28(11):514-524. doi: 10.1097/01.ASW.0000471876.11836.dc
5. Panahi A, Couch K, White P, et al. Acute Skin Failure Associated with Severe COVID-19. Plast Reconst. 2023;151(1):185-186. doi:10.1097/PRS.0000000000009748