Skin Failure: An Emerging Concept


Dr Jeffrey M Levine MD

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Skin Failure - what is it?

Skin failure is an emerging concept that ties together current trends in clinical practice and deserves wider acceptance. Wound care providers have long recognized that skin failure exists, but adoption of the name has been limited due to confusion as to its clinical manifestations. Terms such as Kennedy Terminal Ulcer (KTU) and skin changes at life’s end (SCALE) have been advocated to describe the phenomenon of skin breakdown in patients who are dying, however this does not fit wounds that have similar characteristics in patients who do not die. In my opinion the term ‘skin failure’ assembles these clinical observations into an easily understandable and more accurate term.

There is growing recognition that pressure ulcers can occur when risk is recognized and prevention measures are implemented. We now have improvements in life-support technologies in intensive care, hospital, and rehabilitation settings applied to an increasingly high-risk population that effectively prolongs life, negating terminology that implies imminent mortality. I propose clarification of nomenclature through recognition of skin failure as a clinical syndrome that shares similar mechanisms with other organs. This will encourage a broader conceptual framework that some pressure ulcers, whether or not associated with mortality, are unavoidable consequences of skin failure.

A definition

Skin failure is the state in which tissue tolerance is so compromised that cells can no longer survive in zones of physiological impairment that include hypoxia, local mechanical stress, impaired delivery of nutrients, and build-up of toxic metabolic by-products.

When defining skin failure, a logical place to start is the normal function of skin. If skin no longer performs its role maintaining vasomotor tone, body temperature and water balance, and ceases protecting the body from infection and mechanical trauma, it is failing. In this model the Kennedy Terminal Ulcer (KTU) and Slin Changes at Life's End (SCALE) are manifestations of skin failure because the organ can no longer provide these functions. Skin failure can account for the high rate of breakdown in the setting of multi-organ system failure, and unavoidable pressure injury when preventive interventions have been implemented. By folding these observations into the spectrum of skin failure, quality deficit implications are removed and the terminology becomes more accurate and uniform.

Unavoidable pressure ulceration

Skin failure fits neatly into the phenomenon of unavoidable pressure ulceration. Evidence shows that unavoidable wounds occurs frequently in the setting of hypoxia and multi-organ system disease. It is natural to conclude that once skin can no longer survive intact in the setting of severe physiologic and mechanical stress (i.e. nonmodifiable intrinsic and extrinsic risk factors) that it has undergone failure. If a pressure ulcer is an unavoidable result of multi-organ system dysfunction, sepsis, SIRS, or end-of-life conditions, it is incorrect to attribute this outcome to inadequate care when providers have implemented appropriate preventive interventions. Doing so mars the reputations of facilities and practitioners and gives rise to patient and family dissatisfaction.


Recognition of skin failure will lay the foundation for common nomenclature and open new directions for research. From a clinical perspective this terminology builds upon the KTU and SCALE for more accurate classification of an identified disease state that will facilitate data collection for research and improve quality measurement. In an era of data driven, outcomes oriented, value based care, it is time to collaborate with our colleagues and create a unified approach to skin failure – a phenomenon that occurs in the course of acute and chronic illness as well the end of life when the body is shutting down.

Editors note:

This article interested me as skin failure is a concept which seems so logical yet has only really been considered in relation to end-of-life. Logically, skin failure could also manifests as skin tears, bruising and other ‘oddities’ seen on ‘elderly’ skin, as well as a contributory factor to pressure ulceration.

If this concept is accepted, it will make us rethink how PUs, VLUs and other wounds are managed