Recognizing and Documenting Skin Failure in Wound Care: A Clinical Imperative.
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Understanding Skin Failure: A Distinct Clinical Entity
Skin failure occurs when the body’s physiological reserves are so depleted that the skin and underlying tissues can no longer maintain integrity, leading to spontaneous ulceration. Unlike pressure injuries, which are primarily caused by mechanical forces, skin failure results from systemic factors such as:
- Hypoxia (e.g., shock, respiratory failure, or sepsis)
- Impaired Nutrient Delivery (e.g., malnutrition, critical illness)
- Toxic Metabolic Buildup (e.g., organ failure)
- Severe Inflammatory Responses (e.g., cytokine storm in sepsis)
Recognizing skin failure as a syndrome distinct from pressure injuries is essential for appropriate clinical management and accurate documentation (Langemo & Brown, 2006; Cohen et al., 2017).
Skin Failure can be further classified as
- Acute skin failure is an event in which skin and underlying tissue die because of hypoperfusion concurrent w
- ith a critical illness
- Chronic skin failure is an event win which skin and underlying tissue die due to hypoperfusion concurrent with chronic disease.
- End-stage skin failure is an event in which skin and underlying tissue die due to hypoperfusion concurrent with the end of life.
Differentiating Skin Failure from Pressure Injuries
While both conditions can result in skin breakdown, key distinguishing factors include:
| Feature | Skin Failure | Pressure Injury |
| Cause | Systemic dysfunction (e.g., hypoxia, organ failure) | Local mechanical forces (e.g., pressure, shear) |
| Onset | Sudden, often unavoidable | Gradual, usually preventable with proper care |
| Location | Can appear anywhere, including areas not prone to pressure injuries | Occurs over bony prominences or medical devices |
| Reversibility | Often irreversible despite optimal care | May improve with offloading and intervention |
One critical concept is the Kennedy Terminal Ulcer (KTU)—a type of skin failure occurring at the end of life. It appears suddenly as pear-shaped, purple, or dark wounds, often on the sacrum (Kennedy, 1989; Latimer et al., 2021).
When to Document Skin Failure Instead of a Pressure Injury
Proper documentation of skin failure can prevent misclassification and inappropriate penalties related to quality measures. Consider documenting skin failure instead of pressure injury when:
- The patient has multi-organ failure or a severe systemic illness (e.g., septic shock).
- The wound develops despite optimal pressure relief strategies and care.
- The breakdown occurs rapidly and unexpectedly (within hours to days).
- The wound presents in non-pressure areas, or resembles a Kennedy Terminal Ulcer.
How to Document Skin Failure Accurately
To ensure accurate coding and avoid regulatory issues, documentation should include:
- Clinical Context: Note underlying conditions (e.g., sepsis, shock, organ failure) that contribute to tissue compromise.
- Wound Description: Detail location, shape, color, and progression of the wound.
- Course of Events: Emphasize the rapid, unavoidable nature of the breakdown despite appropriate care.
- Terminology: Use terms like “skin failure,” “Kennedy Terminal Ulcer,” or “end-stage tissue breakdown” rather than “pressure injury” when applicable.
- Multidisciplinary Input: Collaborate with physicians and wound care specialists to ensure consensus in diagnosis and documentation.
Implications for Clinical Care and Policy
Recognizing skin failure as a legitimate clinical entity has broad implications:
- Patient Care: Helps clinicians shift focus from prevention to comfort and palliative measures when appropriate.
- Regulatory Considerations: Can guide policymakers in distinguishing unavoidable wounds from preventable pressure injuries. ( Berkovitz et al.,JAMA 2025)
- Quality Metrics: Avoids inappropriate penalties for facilities when wounds arise due to systemic failure rather than negligence (Black et al., 2011; Delmore et al., 2019).
Conclusion
Skin failure is an under-recognized but clinically significant syndrome. Wound care professionals play a crucial role in differentiating it from pressure injuries, ensuring appropriate documentation, and advocating for policy changes that reflect its unique pathophysiology. By improving awareness and documentation practices, we can enhance patient care and protect healthcare teams from unjust penalties.
References
- Black, J., Edsberg, L. E., Baharestani, M. M., Langemo, D., Goldberg, M., McNichol, L., … & Cuddigan, J. (2011). Pressure ulcers: Avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound Management, 57(2), 24-37.
- Cohen, S. R., Srolovitz, H., Yagudayev, M., Wroblewski, C., & Salles, J. (2017). Skin failure: The final frontier. Advances in Skin & Wound Care, 30(1), 30-34.
- Delmore, B., Cox, J., Rolnitzky, L., Chu, A., & Stolfi, A. (2019). Differentiating a pressure injury from acute skin failure in the adult critical care patient. Advances in Skin & Wound Care, 32(3), 118-127.
- Kennedy, K. L. (1989). The Kennedy Terminal Ulcer. Presentation at the National Pressure Ulcer Advisory Panel Conference. Washington, DC.
- Langemo, D. K., & Brown, G. (2006). Skin fails too: Acute, chronic, and end-stage skin failure. Advances in Skin & Wound Care, 19(4), 206-211.
- Latimer, S., Chuang, S., & Malata, C. M. (2021). Kennedy Terminal Ulcers: A scoping review. Wound Practice & Research, 29(1), 33-42.
- Berlowitz DR, Levine JM. The Evolving Case for Skin Failure-Beyond Pressure Injury. JAMA Intern Med. 2025 Jan 13. doi: 10.1001/jamainternmed.2024.7461. Epub ahead of print. PMID: 39804609.
- Mody L, Rittenberg E, Inouye SK. Pressure Injuries and Skin Failure-Pressure Still Matters. JAMA Intern Med. 2025 Jan 13. doi: 10.1001/jamainternmed.2024.7464. Epub ahead of print. PMID: 39804608.
