Skin breakdown is damage to the skin and underlying tissues, ranging from minor irritation to deep wounds. Recognizing and preventing its progression is important.
Defining Skin Breakdown
Skin breakdown involves compromised skin integrity, leading to injury when its natural protective barrier is weakened or overwhelmed. Sustained pressure, friction, or excessive moisture can initiate it.
Causes of Skin Breakdown
Several factors contribute to skin breakdown.
Pressure
Prolonged pressure on specific body areas, particularly over bony prominences, can compress blood vessels. This restricts blood flow and oxygen delivery to tissues, leading to cellular damage and skin injury. Immobility in a bed or wheelchair often causes such pressure.
Shear
Shear forces occur when skin remains stationary while underlying bone and tissue move in opposing directions. This stretching and tearing can damage deep blood vessels, often appearing as an “inside-out” wound. Sliding down in a bed or chair creates shear, pulling tissue layers apart.
Friction
Friction, the rubbing of skin against a surface, strips away outermost skin layers. This mechanical abrasion makes skin more vulnerable to injury.
Moisture
Excessive moisture from sweat, urine, or stool can soften the skin (maceration). Moist skin is more fragile and susceptible to damage from pressure, shear, and friction. This environment also fosters bacterial growth and infection.
Recognizing the Signs
Early identification of skin breakdown is important for timely intervention.
Initial indicators include persistent non-blanchable redness on intact skin. The affected area might also feel warmer, cooler, or exhibit changes in firmness. For darker skin tones, redness may not be visible, appearing instead as a localized area of persistent purple, blue, or darker discoloration.
As skin breakdown progresses, more noticeable signs emerge. These include blisters (intact or ruptured) or changes in skin discoloration like purple or dark patches. Tissue may feel hardened or boggy, indicating deeper damage. Ultimately, open wounds or ulcers can form, exposing underlying tissue.
Skin breakdown frequently occurs over bony areas. Common locations include the heels, sacrum (tailbone), hips, ankles, elbows, and shoulders. Regular inspection of these areas is important, especially for those with limited mobility.
Stages of Severity
Healthcare professionals use a standardized staging system (NPIAP) to classify skin breakdown severity, often called pressure injuries. This system describes tissue damage extent and guides appropriate care.
Stage 1 Pressure Injury
This stage involves intact skin with a localized area of non-blanchable redness. The skin may also be warmer, cooler, firmer, softer, or feel painful or itchy compared to adjacent tissue. No open wound is present.
Stage 2 Pressure Injury
This stage involves partial-thickness skin loss (epidermis and/or dermis). It presents as a shallow open ulcer with a red or pink wound bed, or an intact or ruptured serum-filled blister. Deeper tissues (fat, muscle, bone) are not visible.
Stage 3 Pressure Injury
This involves full-thickness skin loss where subcutaneous fat may be visible. Bone, tendon, or muscle are not exposed. Slough (dead tissue) or eschar (dark, hard dead tissue) may be present; tunneling or undermining (tissue loss under wound edges) can occur.
Stage 4 Pressure Injury
This is the most severe stage, characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present, and undermining and tunneling often occur. Depth varies by anatomical location.
Unstageable Pressure Injury
This classification is used when tissue damage extent cannot be determined because the ulcer’s base is obscured by slough or eschar. Once enough slough or eschar is removed, the injury can be staged as a Stage 3 or Stage 4.
Deep Tissue Pressure Injury (DTPI)
DTPI presents as a persistent non-blanchable deep red, maroon, or purple discoloration of intact or non-intact skin. It can also appear as a blood-filled blister. This injury results from underlying soft tissue damage from pressure and/or shear. The area may be painful, firm, mushy, boggy, warmer, or cooler.
Individuals at Higher Risk
Certain individuals are more susceptible to skin breakdown due to factors compromising skin health and integrity.
Immobility
Immobility significantly increases risk, as prolonged pressure on specific body areas impedes blood flow and leads to tissue damage. This includes bedridden, wheelchair-bound, or those with limited mobility.
Sensory Impairment
Sensory impairment also contributes to risk, as individuals may not feel pain or discomfort signaling the need to shift. Conditions like spinal cord injuries or neuropathies can reduce sensation, allowing damaging forces to persist.
Poor Nutritional Status
Poor nutritional status (malnutrition or dehydration) weakens the skin and impairs healing. Adequate protein, vitamins, and minerals are necessary for healthy skin and tissue repair.
Excessive Moisture
Conditions leading to excessive skin moisture (urinary or fecal incontinence) increase vulnerability. Constant exposure softens the skin, making it more susceptible to damage from friction and shear. This fosters bacterial growth, elevating infection risk.
Underlying Health Conditions
Underlying health conditions like diabetes, vascular disease, and older age also increase skin breakdown likelihood. These often affect circulation, reducing blood flow and nutrient delivery. Older adult skin naturally becomes thinner and less elastic.