Skin, like other body organs, can fail. But be careful not to confuse skin failure with pressure ulcers, though it can be difficult to determine the difference and can be especially problematic for long-term care facilities facing increasing liabilities, according to one researcher.
“It’s an evolving science,” said Diane Langemo, Ph.D., RN, FAAN, adjunct professor, North Dakota College of Nursing, Grand Forks, ND, and co-author of a 2012 study, “Skin Failure: Identifying and Managing an Underrecognized Condition.”
Langemo and her study co-author Elizabeth Foy White-Chu, MD, an affiliate with the Wound Healing Center with Hebrew SeniorLife at Harvard Medical Center in Boston, Mass., concluded, “Skin failure is not a permissible pressure ulcer and research efforts must, therefore, be focused on a better understanding of this phenomenon.”
Similar to other chronic wound conditions, they believe skin failure necessitates an interdisciplinary approach to care, and in the LTC setting, specialists should be available for consultation.
“Providers, nursing staff, dietitians, rehabilitative therapists, and the resident and family/significant other(s) all play a role in the resident’s care,” the study said. “Whereas pressure ulcer care is aimed at reversing the underlying condition, skin failure care should be focused on resident-centered and caregiver-centered concerns.”
According to Langemo, skin failure – which like pressure ulcers can be very painful – is not a new phenomenon,
“Both are caused by compromised blood flow and waste removal. Skin failure can occur without pressure, but a pressure ulcer isn’t a pressure ulcer unless there is pressure and/or shear involved,” she said.
According to her study, “a pressure ulcer and skin failure can and often do occur together, as an area of skin failure exposed to pressure and/or shear would have greater vulnerability to breakdown. This is not uncommon in an individual with hemodynamic instability, whose position cannot be changed or can only be changed minimally. A pressure ulcer would understandably develop more quickly in an area where the skin has failed.”
In a 2006 article with Gregory Brown, BBA, BSN, RN, CWOCN, Langemo defined skin failure as “an event in which the skin and underlying tissue die due to hypoperfusion that occurs concurrently with severe dysfunction or failure of other organ systems.
Langemo and Brown identified three types of skin failure: acute, chronic and end-stage. They also determined that most episodes of skin failure in LTC settings are either chronic or end-stage and advanced dementia is frequently associated with complications in its last stages.
“As this and other chronic diseases cause organ failure, blood is shunted away from the skin to vital organs, and skin eventually ‘fails,’” the researchers stated.
“In end-stage failure, the resident experiences more rapid skin failure that is concurrent with the end of life. As in chronic skin failure, blood is diverted to the vital organs in an effort to preserve internal organ function,” the wrote.
“The resulting skin breakdown can be shocking to both staff and family members. Honest, open communication about the prognosis is therefore important at this time.”
In 2009, an interdisciplinary panel of 18 experts in wound healing convened to develop Skin Changes at Life’s End (SCALE), a consensus statement on the changes that occur at the end of life. The panel adopted Langemo and Brown’s definition of skin failure in an effort to solidify skin failure as a real condition.
In 2010, the National Pressure Ulcer Advisory Panel’s consensus conference of diverse wound care professionals issued its position that not all pressure ulcers are avoidable.
“The panelists asserted that there are clinical conditions that lead to the unavoidable nature of some pressure ulcers, and they emphasized that skin failure and pressure ulcers are two separate conditions that can occur concomitantly,” the Langemo/White-Chu study said.
Langemo recently said she suspects that both understanding and identifying the two conditions are more of a concern nowadays among healthcare professionals, as the knowledge becomes more generalized and life expectancy grows.
Aging Boomers
In the study, Langemo and White-Chu note the baby boomer generation will represent the oldest group by 2030 and will more than triple in population by 2050.
“Some research suggests that the death rate with continue to decline, which is not surprising given the influx of medical advances that are continuing to prolong life, enabling more people to reach ages beyond which the skin can maintain its integrity. Organ failure is often seen with advanced age and in the setting of a critical illness, and the skin is no exception,” they wrote.
“As we age, our skin becomes dry, thin and prone to damage, leading to a greater risk of injury and prolonged healing time,” Langemo said. “When these conditions are compounded by an acute illness, one can appreciate how skin can fail in frail older adults and critically ill individuals.”
Langemo noted that few studies have addressed skin failure, and currently available data mainly focus on whether certain pressure ulcers can be avoided.
Given that pressure ulcers and skin failure are not the same, Langemo and White-Chu recognized a need to develop tools to predict skin failure.
“With a pressure ulcer, it is only after the ulcer develops that quality assurance initiatives determine avoidability,” they wrote in their study.
Of these tools, the most promising was the Hospice Pressure Ulcer Risks Assessment scale, which evaluates physical activity, mobility and age in its assessment.
Langemo noted that the primary treatment for pressure ulcers is redistributing the pressure and preferably keeping the patient off the area, which often isn’t possible.
As for treating skin failure, she said, “Do whatever you can do to try to improve the circulation, but it’s not always possible.” Repositioning, mobility, hydration, nutrition, and in some instances medication to dilate blood vessels might help, she continued.
Most important is minimizing the pressure and keeping the tissue nourished with creams, lotions or emollients, she said.
Charting the path
Although skin accounts for 10% to 15% of a person’s body weight and is the largest organ of the body, Langemo said, “The general public doesn’t really know skin is an organ. It’s so important to educate patients and families that just like your heart, lungs and your kidneys can fail, so can your skin.”
According to Langemo, it’s equally important to be aware when there is an event to document it on the chart.
Langemo added that much of the knowledge she’s accumulated is the result of clinical observation. As a nursing student she recalls learning about “compromised skin” and pressure ulcers, but she noted, “I don’t remember the term skin failure.”
Langemo’s own “ah-ha” moment came about eight years into her teaching career while assisting in the care of a paraplegic woman in her 40s whose buttock was almost completely covered with pressure ulcers.
It’s the worst case she’s ever seen and to this day, she’s never forgotten it.
“I can vividly remember thinking that I wanted to try to ensure that nothing ever got that bad for anyone again,” she concluded.
Rose Quinn is a freelance writer.
