Skin Failure: Identifying and Managing an Underrecognized Condition : Page 2 of 2

July 19, 2012

Prediction Tools

As pressure ulcers and skin failure are not the same, there is a need to develop tools that can predict skin failure. With a pressure ulcer, it is only after the ulcer develops that quality assurance initiatives determine avoidability.13 Two European studies aimed to develop pressure ulcer risk assessment scales in palliative care settings.18,19 Of these tools, the most promising was the Hospice Pressure Ulcer Risk Assessment (HoRT) scale,19 which includes physical activity, mobility, and age in its assessment. In a study of 85 subjects in a palliative care ward, the HoRT scale had a 100% sensitivity (100% negative predictive value) and 75% specificity (50% positive predictive value) for predicting a pressure ulcer. The scale remains to be validated in other settings, including in frail older adults in LTC.10

Another palliative care study showed that factors such as male sex, an inability to lie flat, catheter use, ostomy care, and an inability to perform activities of daily living are associated with pressure ulcers in home care residents with terminal cancer.20 For those LTC residents who are frail or have chosen a palliative pathway of care, a more sophisticated tool for the prediction of skin failure is needed. Presumably, such a tool would help staff educate residents’ families about the realistic expectations of skin changes during end-of-life care.

Comorbidities and Skin Failure in LTC

Langemo and Brown4 described three types of skin failure: acute, chronic, and end-stage. They reported that most episodes of skin failure in LTC settings are either chronic or end-stage. In chronic skin failure, the resident must have a chronic disease and exhibit a steady decline associated with aging or the progression of his or her disease. Dementia is a common chronic illness in LTC.21 Advanced dementia is frequently associated with complications in its last stages, such as impairment in nutritional status, loss of fat and muscle, pneumonia, and febrile episodes.22,23 As this and other chronic diseases cause slow organ failure, blood is shunted away from the skin, which eventually fails. In end-stage skin 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 as the final effort to preserve internal organ function. 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.

Prior to starting interventions, staff caregivers should be fully aware of residents’ comorbid conditions that may hamper efforts to maintain nutrition and hydration. In the last months of Alzheimer’s dementia, a terminal illness, eating problems will begin.24 Those patients with dementia and skin failure will require a family discussion regarding the use of a feeding tube. No data show, however, that feeding tubes improve nutritional status or resolve pressure ulcers in the setting of end-stage dementia.25 Despite the lack of data, families may find it challenging to watch their loved ones “waste away” with failing skin. Providers and dietary and speech therapists must continue to support families in the decision-making process. Nursing staff, including certified nursing assistants, can educate families about the pleasures of hand-feeding their loved ones.26

Managing Skin Failure in LTC

Similar to other chronic wound conditions, skin failure necessitates an interdisciplinary approach. In the LTC setting, these specialists should be readily available. Providers, nursing staff, dietitians, rehabilitative therapists, and the resident and caregivers all play a role in the resident’s care (Figure). Whereas pressure ulcer care is aimed at reversing the underlying condition, skin failure care should be focused on resident-centered and caregiver-centered concerns.9 

Providers need to have frank discussions with the resident and his or her family, significant other, or caregivers regarding the resident’s prognosis, treatment of symptoms, and goals of care. In turn, residents and caregivers must be willing to clarify the goals of care. Several discussions may be necessary to help them through this process.27 A palliative care or hospice team, if available, can be invaluable in establishing a prognosis, educating the resident and his or her family, and treating the resident’s symptoms. 

Skin failure, like other wounds, will produce significant pain for the resident. Pressure ulcer pain is thought to have both nociceptive and neuropathic mechanisms.28 The provider must assess whether the pain is noncyclic acute (eg,  associated with debridement), cyclic acute (eg, associated with hygiene, turning regimens, dressing changes), or chronic.29 Both pharmacologic and nonpharmacologic means should be used to alleviate the pain, depending on its type and duration. The certified nursing assistant can alert the team to any changes in the resident’s pain experience, such as grimacing or moaning that occurs during the resident’s hygiene or turning regimen. Rehabilitative specialists can educate the team about repositioning the resident as well as recommend off-loading devices to help relieve pressure and pain.

A pressure ulcer will push a resident into a catabolic state, thereby increasing his or her nutritional and hydration needs.30 A dietitian can calculate the necessary amount of calories and fluid that the resident would require for healing, if healing is considered possible. Adequate calories, in addition to protein, are needed to promote collagen and connective tissue synthesis.31 If only protein is supplied without adequate calories, then the protein will be used as an energy fuel.

The mainstay of chronic wound management is moist wound healing. In the case of skin failure, where healing may not be possible, moist wound healing may increase the bacterial burden and risk of infection.32,33 In these situations, povidone-iodine and other antiseptics may be beneficial in preventing wound deterioration or worsening, but these agents have been prohibited in healthcare facilities because of their reported cytotoxic effects. Two systematic reviews, however, have suggested that there is still a role for antiseptics in the treatment of nonhealable wounds.34,35 The resident’s prognosis, goals of care, and ability of the wound to heal must be continuously documented to enable the use of such a controversial product. When antiseptics are used, care must be taken to prevent the wound from overdrying, which can cause increased pain with dressing changes. Wet-to-dry dressings are not recommended,8 as they are especially problematic in patients with skin failure, leading to increased nursing burden and worsening pain for the resident, while providing no bacterial balance.36,37 The recommended dressings are those that are nonadhesive, absorptive, and odor-controlling; prevent desiccation of the wound bed; protect the periwound from maceration; and can be left in place for longer periods. Examples of these dressings include hydrogels, foams, polymeric membrane foams, silicones, and alginates. Odor can be counteracted by removing necrotic debris and using antimicrobials, activated charcoals, and a variety of external odor absorbers.8,38


Because of the dearth of clinical data regarding skin failure, it can be difficult to determine the difference between a pressure ulcer and skin failure. This can be problematic when LTC facilities face increasing liability along with an increasing incidence of pressure ulcers.Skin failure is not a “permissible” pressure ulcer,and research efforts must therefore be focused on a better understanding of this phenomenon. 



1. Centers for Medicare and Medicaid Services. State Medicaid director letter. Published July 31, 2008.
Accessed June 14, 2012.

2. National Quality Forum. Patient safety: serious reportable events in healthcare. National voluntary consensus standards for serious reportable events in healthcare. Accessed June 14, 2012.

3. Federal Interagency Forum on Aging-Related Statistics. Older Americans 2010: key indicators of well-being. July 2010. Accessed June 14, 2012.

4. Langemo DK, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care. 2006;19(4):206-211.

5. Danahy JF, Gilchrest BA. Geriatric dermatology. In: Gallo JJ, Busby-Whitehead J, Rabins PV, Sillman RA, Murphy JB, Reichel W, eds. Reichel’s Care of the Elderly: Clinical Aspects of Aging. 5th ed. Philadelphia: Lippincott, Williams and Wilkins; 1999:513-524.

6. Thomas DR. Are all pressure ulcers preventable? J Am Dir Assoc. 2001;2(6):

7. American Medical Directors Association. Pressure ulcers in the long-term care setting. Clinical practice guideline. Columbia, MD: American Medical Directors Association; 2007:46. Accessed June 22, 2012.

8. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009:21-50. Accessed June 14, 2012.

9. Sibbald RG, Krasner DL, Lutz JB, et al. The SCALE Expert Panel: skin changes at life’s end. Final consensus document. Published October 1, 2009. Accessed June 14, 2012.

10. Kennedy KL. The prevalence of pressure ulcers in an intermediate care facility.
Decubitus. 1989;2(2):44-45.

11. Brennan MR, Trombley K. Kennedy terminal ulcers—a palliative care unit’s experience over a 12-month period of time. World Council of Enterostomal Therapists Journal. 2010;30(3):20-22.

12. Olshansky K. “Kennedy terminal ulcer” and “skin failure,” where are the data? J Wound Ostomy Continence Nurs. 2010;37(5):466-467.

13. Black JM, Edsberg LE, Baharestani MM, et al; National Pressure Ulcer Advisory Panel. Pressure ulcers: avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound Manage. 2011;52(2):24-37.

14. Goode PS, Allman RM. The prevention and management of pressure ulcers. Med Clin North Am. 1989;73(6):1511-1524.

15. Loerakker S, Oomens CWJ, Manders E, et al. Ischemia-reperfusion injury in a rat skeletal muscle assessed with T2-weighted and dynamic contrast-enhanced MRI. Magn Reson Med. 2011;66(2):528-537.

16. Peirce SM, Skalak TC, Rodeheaver GT. Ischemia-reperfusion injury in chronic pressure ulcer formation: a skin model in the rat. Wound Repair Regen. 2000;8(1):68-76.

17. Tsuji S, Ichioka S, Sekiya N, et al. Analysis of ischemia reperfusion injury in a microcirculatory model of pressure ulcers. Wound Repair Regen. 2005;13(2):209-215.

18. Chaplin J. Pressure sore risk assessment in palliative care. J Tissue Viability. 2000;10(1):27-31.

19. Henoch I, Gustaffson M. Pressure ulcers in palliative care: development of a hospice pressure ulcer risk assessment scale. Int J Palliat Nurs. 2003;9(11):474-484.

20. Brink P, Smith TF, Linkewich B. Factors associated with pressure ulcers in palliative home care. J Palliat Med. 2006;9(6):1369-1375.

21. Rhodes-Kropf J, Cheng H, Herskovitz Castillo EH, Fulton AT. Managing the patient with dementia in long-term care. Clin Geriatr Med. 2011;27(2):135-152.

22. Wang PN, Yang CL, Lin KN, Chen WT, Chwang LC, Liu HC. Weight loss, nutritional status, and physical activity in patients with Alzheimer’s disease. A controlled study. J Neurol. 2004;251(3):314-320.

23. Mitchell S, Teno J, Kiely D, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529-1538.

24. Volicer L. Management of severe Alzheimer’s disease and end-of-life issues. Clin Geriatr Med. 2001;17(2):377-391.

25. Finucane TE. Malnutrition, tube-feeding and pressure sores: data are incomplete. J Am Geriatr Soc. 1995;43(4):447-451.

26. Mitchell SL. A 93-year-old man with advanced dementia and eating problems. JAMA. 2007;298(21):2527-2536.

27. Zweig SC, Popejoy LL, Parker-Oliver D, Meadows SE. The physician’s role in patients nursing home care: “She’s a very courageous and lovely woman. I enjoy caring for her.” JAMA. 2011;306(13):1468-1478.

28. Langemo DK, Melland H, Hanson D, Olson B, Hunter S. The lived experience of having a pressure ulcer: a qualitative analysis. Adv Skin Wound Care. 2000;13(5):225-235.

29. Woo KY, Sibbald RG. Chronic wound pain: a conceptual model. Adv Skin Wound Care. 2008;21(4):175-188.

30. Zagoren AJ, Johnson DR, Amick N. Nutritional assessment and intervention in the adult with a chronic wound. In: Krasner DL, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. Malvern, PA; HMP Communications; 2007:127-136.

31. Stechmiller JK. Understanding the role of nutrition and wound healing. Nutr Clin Pract. 2010;25(1):61-68.

32. Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: a systemic
approach to wound management. Wound Repair Regen. 2003;11(suppl 1):S1-S28.

33. Drosou A, Falabella A, Kirsner RS. Antiseptics on wounds: an area of controversy. Wounds. 2003;15(5):149-166.

34. Banwell H. What is the evidence for tissue regeneration impairment when using a formulation of PVP-I antiseptic on open wounds? Dermatology. 2006;212(suppl 1):66-76.

35. Reddy M, Gill S, Kalkar S, Wu W, Anderson PJ, Rochon PA. Treatment of pressure ulcers: a systematic review. JAMA. 2008;300(22):2647-2662.

36. White-Chu F, Flock P, Struck B, Aronson L. Pressure ulcers in long-term care. Clin Geriatr Med. 2011;27(2):247-258.

37. Niezgoda JA, Mendez-Eastman S. The effective management of pressure ulcers. Adv Skin Wound Care. 2006;19(suppl 1):3-15.

38. Schim MS, Cullen B. Wound care at end of life. Nurs Clin North Am. 2005;40(2):281-294.



The authors report no relevant financial relationships.


Address correspondence to:

Elizabeth Foy White-Chu, MD

Hebrew SeniorLife

Department of Medicine

1200 Centre Street

Roslindale, MA 02131