Welcome to Wound Clinical Solutions Investigation (CSI). See if you can make the diagnosis.
Q. A 64-year-old resident in a long-term care facility presented with the following discoloration on the gluteal area. What is the correct diagnosis?
A. The male resident is incontinent of stool and urine, and is totally immobile. He is unable to swallow and is reliant on enteral feeding to maintain adequate nutritional and fluid intake. He is placed in an upright position for most of the day to prevent aspiration. Given the resident's history and risks for pressure injury, one would presume that deep tissue injury (DTI) is the most likely diagnosis.
According to the most recent National Pressure Ulcer Advisory Panel guidelines, DTI refers to an area that exhibits persistent, nonblanchable, deep red, maroon, or purple discoloration. A DTI may also manifest itself as a darkened wound bed or blood filled blister. There are 2 possible outcomes; a DTI may evolve rapidly to a wound revealing the actual extent of tissue injury, or it may resolve without tissue loss. This purple discoloration on the skin has existed for more than 12 months. Would this injury fit into the definition of DTI?
There are other differential diagnoses that should be considered. Since there is no consensus on the direct and accurate determination of DTI, it is important to rule out other conditions that may mimic this condition. The person is incontinent; thus, moisture-associated skin damage, incontinent dermatitis, or contact irritant dermatitis should be considered as an alternative diagnosis. In the literature, people who are immobile may also develop venous congestion in the sacral area. Venous congestion may promote local inflammation and skin changes similar to those documented for venous leg disease. Other conditions may include post-inflammatory pigmentation, scarring, ecchymosis, infection, and inflammatory skin diseases, such as psoriasis.
As the name DTI implies, what is evident on the skin surface or wound bed indicates that the injury has likely occurred from the inside out—from deep tissue. When a darkened wound bed is caused by dressing material, it is confusing whether DTI is the appropriate diagnosis. If the injury is caused from the "outside-in," it may only involve superficial tissue. There is a need to clarify this important concept that is evidence based. Further dialogue will help move this issue forward to achieve a better consensus.