Secondary Logo

Words on Wounds

A forum to discuss the latest news and ideas in skin and wound care.

Wednesday, May 1, 2019

Mona is a 73-year-old woman who was admitted to the hospital with urosepsis and delirium. She was confused and agitated, constantly moving to get out of bed. She developed a heel ulcer on her left leg. How should we describe this?
Heel Ulcer 5-1-19.png
1. What is the etiology? 
This is a large blister over the heel area. The most likely cause of this type of superficial skin damage is related to friction secondary to agitation with excess leg movements rubbing against the bed sheets. The area may also be vulnerable to pressure damage and pressure injury should not be ruled out, because the blister occurred over a the bony prominence.
2. What stage is this? 
According to the National Pressure Ulcer Advisory Panel (NPUAP), a blistered area resulting in the epidermis separating from the dermal layer is a stage 2 pressure injury or ulcer. However, the correct staging will depend on the type of fluid inside the blister. Mona developed a blister filled with murky fluid that is not pus or blood, but providers could not visualize the wound base to determine the level of tissue involvement. This conundrum is not clearly addressed in the NPUAP guideline. Either necrotic tissue or a full-thickness wound were possible and have been seen on the base of similar blisters, prompting providers to call this is a nonstageable wound.
3. What should be done? 
The subject of whether this blister should be drained is highly debatable. Because Mona is mobile, she may choose to have it drained, because the blister may impair ambulation and could burst during a heel strike. It is always better to drain the blister in a controlled environment than having it to rupture accidentally, especially in an unhygienic surrounding. Efforts to offload the heel will be crucial to promote healing and prevent further damage.

Monday, April 15, 2019

CSI 4-15-19.png

Matt is a 62-year-old male with a history of musculoskeletal degenerative disease. Recently, he was treated with antibiotics for a urinary tract infection and developed diarrhea

Upon assessment, his skin in the coccyx area is extremely fragile because of exposure to moisture from incontinence and accumulated heat secondary to immobility. The skin is irritated and inflamed from chemical irritants in the fecal matter and mechanical trauma from frequent cleansing. Small, discrete skin tears, attributable to frictional force from the washcloth, are apparent in the injured area, evidenced by partial skin loss. Over the next week, the area continues to deteriorate and acquires a dark, purplish appearance with evidence of tissue necrosis and deep tissue injury. 

His care team knows that in combination, excess moisture and increased heat and subsequent metabolic demand of the skin create a favorable microclimate for skin breakdown, so several interventions are implemented. Matt's standard hospital mattress is replaced with a low air loss mattress, and he is frequently turned to provide pressure redistribution and minimize shearing

It is a clinical challenge for healthcare professionals to identify and classify skin tears when they occur in areas of the body where pressure injuries also typically occur, such as over bony prominences. Skin tears and superficial stage 2 pressure injuries may be precipitated by similar risk factors. According to the updated definition proposed by the International Skin Tear Advisory Panel in 2018, a "skin tear is a traumatic wound caused by mechanical forces, including removal of adhesives. Severity may vary by depth (not extending through the subcutaneous layer).” 

Proper description of the skin lesion is important for care planning to address primary causative factors. However, as illustrated in this case, skin tears can rapidly evolve into pressure-related tissue injury because to skin fragility including skin atrophy, loss of elastin, and weakening of the epidermal junction.
Bundled approaches to care allow healthcare professionals to prevent and manage wound etiologies (pressure injuries, moisture-associated injuries, and skin tears) with one prevention program. This can potentially save money and time, but more importantly, also enhances patient comfort. The prevention and management of skin tears in frail older adults is available and can be accessed online here.

Wednesday, March 27, 2019

The March 2019 CE/CME article, Reexamining the Literature on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries, is an excellent review of evidence that attempts to differentiate pressure injury from what is commonly known as 'skin failure' in patients who are critically ill or approaching death. During critical medical crises and at life's end, a failing heart may not be able to maintain adequate perfusion to vital organs, leading to multiorgan failure, including the skin. Skin changes are inevitable when metabolic demand outstrips supply of oxygen and vital nutrients. The early signs that herald skin breakdown were initially described by Kennedy and further validated by the SCALE expert panel. Skin breakdown may be unavoidable when prevention strategies are deemed futile or even precarious. 

While skin failure and pressure injuries are separate entities, they are intimately linked and share many common risk factors. In a retrospective study of data from 2,062 patients at the end of life,1 a history of pressure injuries, cancer, incontinence, activity/mobility, and skin circulation were predictive of pressure injuries.

Another retrospective cohort study2 evaluated 766 patients in 9 intensive care units of 2 university hospitals. The overall pressure injury incidence was 18.7%. The likelihood of having a pressure injury increased by 7.8 times in palliative care and 2.3 times in patients who were between 60 and 84 years old. The chances also increased 10% for each day of hospitalization and 1.5% for each point of the Nursing Activities Score.

In an examination of 154 patients receiving palliative care, all had evidence of pressure injuries during hospitalization.3 Interestingly, improvement of pressure injuries was observed in 74% of patients; specifically in 75% of those with sacral ulcers, 50% of those with heel ulcers, and over 80% of those with ischial pressure injuries. These findings suggest that pressure injuries in palliative care patients can be improved with appropriate care regardless of whether skin failure exists.

Last, the risk factors for pressure injury were explored in patients who had a life expectancy of 6 months or fewer and received home palliative care.4 The prevalence of pressure injuries was 13.1%. Pressure injuries were more common among patients who were female, of older age, and those with a low body mass index, low Braden score, and poor physical functioning. Patients with more than one caregiver at home were also at higher risk, perhaps because of inconsistency in care. 

The relationships among pressure injuries, SCALE, terminal ulcers, and skin failure are complex and requires further evaluation. If you'd like to weigh in on this thorny issue, please take the Advances in Skin & Wound Care Survey on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries, available until June 30, 2019 at



1. Li HL, Lin SW, Hwang YT. Using nursing information and data mining to explore the factors that predict pressure injuries for patients at the end of life. Comput Inform Nurs 2019;37(3):133-41. 

2. Strazzieri-Pulido KC, S González CV, Nogueira PC, Padilha KG, G Santos VLC. Pressure injuries in critical patients: incidence, patient-associated factors, and nursing workload. J Nurs Manag 2019;27(2):301-10.

3. Dincer M, Doger C, Tas SS, Karakaya D. An analysis of patients in palliative care with pressure injuries. Niger J Clin Pract 2018;21(4):484-91.

4. Artico M, Dante A, D'Angelo D, et al. Prevalence, incidence and associated factors of pressure ulcers in home palliative care patients: a retrospective chart review. Palliat Med 2018;32(1):299-307.

Friday, March 8, 2019

The NPUAP 2019 annual conference took place Friday, March 1 and Saturday, March 2 at the St. Louis Union Station Hotel in St. Louis, Missouri. The conference, titled Innovative Research & Practice Across Populations: Connecting Science to Practice, featured nationally and internationally recognized experts focusing on pressure injury prevention and treatment across the spectrum of special populations. The NPUAP also annouced the 2019 International Guideline for Prevention and Treatment of Pressure Injury, scheduled to be launched November 15-16, 2019 in Los Angeles, California. Advances in Skin & Wound Care would like to extend our most enthusiastic congratulations to the conference's award winners:

Barbara Braden, PhD, FAAN, winner of the JoAnn Maklebust Lifetime Achievement Award


Joyce Black, PhD, RN, FAAN, winner of the Kosiak Award


William Padula, PhD, MS, MSc, winner of the Thomas Stewart Founder's Award


Michelle Deppisch, PT, CWS, FACCWS, winner of the President's Recognition Award 


Thursday, February 14, 2019

​Recently we asked you whether you think there is a reliable and objective way to evaluate dry skin. Clinical evaluation of the hydration status of the superficial skin is indirect, based upon visual and tactile evaluation of clinical observable signs. For example, the Overall Dry Skin Score according to the European Group on Efficacy Measurement of Cosmetics and other Topical Products for dry skin assessment categorizes clinical signs of dryness from 0 (absent) to 4 (large scales, roughness, redness, cracks/fissures). However, the highly subjective nature of visual assessment and unstandardized taxonomy to describe skin dryness often yields inconsistencies, poor reproducibility, and miscommunication. What seems to be dry skin to one clinician may not be consistent with another clinician's assessment. Evaluation is more challenging with darker skin, eczematous conditions, and aging frail skin.  

With recent advances in computer science and artificial intelligence, computerized metrics to discriminate and calibrate skin pathology are gaining popularity, and numerous computerized diagnostic systems have been reported in the literature for the evaluation for melanoma with satisfactory accuracy. Wound care researchers are working on a specific tool for the evaluation of dry skin. These coomputerized algorithms are created by many layers of artificial neurons to automatically extract clinical features of dry skin from data including scales, crack/fissures, redness, skin thickness, and eczematous changes. In other words, the computer program is trained to figure out a problem rather than having the answers programmed into it. The algorithm can be made more or less sensitive, allowing the researchers to tune its response depending on what they want it to assess. We hope to see the results soon!