I would like to compliment Dr Jeffrey M. Levine's "Commentary" article in the May 2017 issue, titled "Unavoidable Pressure Injuries, Terminal Ulceration and Skin Failure: In Search of a Unifying Classification System."

I totally agree that as clinicians we are in the dark not only about how to classify skin failure but also how to diagnose it. The dermatology specialty and literature define skin failure completely different than do most clinicians in the wound care community. Dr Levine issues the challenge to try and obtain consistency in defining skin failure.

In his article, Dr Levine states, "[horizontal ellipsis]the literature is unclear as to whether 'terminal ulcers' are different from pressure-related injuries, even though they commonly appear over bony prominences." He also states, "Given the large surface area it (skin) covers, it may fail regionally, as well as systemically."

I would like to discuss each of these statements separately because they, in many ways, are the difficult issues that we are presented with as clinicians. As a plastic surgeon who treated many chronically ill patients and end-of-life patients, I was well aware how challenging it was to prevent pressure injuries. Skin failure to me was what Dr Levine described: "[horizontal ellipsis]there are other skin changes such as blistering, mottling, and gangrene that occur concomitantly to the dying process[horizontal ellipsis]." Whenever I saw these signs, they rarely, if ever, were isolated to just over a bony prominence. Therefore, no one can say with certainty that skin failure does not occur regionally (over a bony prominence), but the challenge is: How does one accurately diagnose regional skin failure from systemic skin failure? My concern is that clinicians have fallen into a trap that assumes if other organs are failing, and the skin is also an organ, then it must be failing as well, and in total body organ failure, an ulcer over a bony prominence must be a result of skin failure. I think it is important to make sure that there is a unified understanding of the effects of hypoperfusion on the skin and how it relates to skin failure and pressure injuries. I believe it is accepted that hypoperfusion makes the skin extremely susceptible to pressure injuries. However, is the definition of skin failure a physiologic "nonvisible" diagnosis of hypoperfusion that can make the skin susceptible to injury, or is it a "physical" diagnosis where one visually can see actual skin "failure" (necrosis, ulceration, blistering, mottling, and gangrene) and not just over bony prominences? Other organ failures can be documented with laboratory tests, such as in renal and liver failure, cardiac output studies with heart failure, and oximetry readings in lung failure. Unfortunately, skin failure is too often diagnosed as a catchphrase when other organs are failing and a patient sustains a pressure injury.

I hope Dr Levine's challenge will be a clarion call to finally develop a coherent classification system, with distinct clinical signs and symptoms, as well as any diagnostic tools to assist in a diagnosis. This is important for many reasons. Is a skin breakdown avoidable or unavoidable, and can it pass legal challenges? Will it be reimbursed? As Dr Levine summarizes in his article, "Achieving this goal will require agreement and collaborative effort from the entire interprofessional wound care community" (and I would add the National Pressure Ulcer Advisory Panel and dermatological community).

-Kenneth Olshansky, MD

Clinical Professor Plastic Surgery (Ret)

Virginia Commonwealth

University/Medical College of Virginia