My first clinical experience as a student nurse in community health nursing back in the 1980s was visiting a gentleman older than 80 years who lived with his octogenarian wife. Mr J. had chronic obstructive pulmonary disease. I vividly remember Mr J's wife complaining that he endlessly sat in his easy chair while awake. He refused to get up except to go to the bathroom, and he ultimately developed a rash on his buttocks. Mr J was a retiree from a steel mill, continent, cognitively intact, and overweight. He said he preferred to sit in his easy chair during waking hours because it made it easier to breathe. My nursing preceptor and I convinced him to turn over so that we could take a look at his rash. Much to my horror, we observed an enormous purplish area over the lower portion of his buttocks that resembled a deep dark purple bruise. My preceptor in a very matter of fact tone exclaimed that this phenomenon was referred to as "bruised butt syndrome," or contemporarily known as "recliner butt" and was caused by prolonged sitting in a semirecumbent position. After taking a more in-depth history, Mr J said he had no pain in the area and was unaware of any falls or other trauma that contributed to the bruise. Over the next 6 weeks, we checked the bruise weekly and found it never changed in size, color, or shape. I could not believe something so purple could last so long and not turn into something much worse. What exactly was this dark purple discoloration and how could something that appeared to be a traumatic insult fail to deteriorate to a partial or full-thickness wound? Was the causative factor related to pressure, friction, shear, or a combination of all 3?

In this issue of JWOCN, WOC nurses Mary Mahoney and Barbara Rozenbloom describe multiple cases that challenge us to consider a new form of skin injury by labeling this unique phenomenon chronic tissue injury (CTI), defined as a purple-maroon discoloration of the fleshy part of the buttocks found predominantly in homebound patients. They further distinguish the condition from other known skin injury categories such as pressure injury, deep tissue pressure injury (DTPI), skin failure, friction skin injuries (SFIs), and moisture-associated skin damage (MASD). These labels are more closely aligned with their causative factors and are more descriptive than the more broad pressure injury diagnosis.

Chronic tissue injury is not described in the current wound care literature, making it difficult to describe its characteristics or natural history based on evidence. However, Mahoney and Rozenbloom carefully depict 2 major distinguishing features of CTI: discoloration of affected skin and chronicity without deterioration or improvement. These features were noted in a review of medical records and reported anecdotally by hundreds of wound nurses with whom the authors conversed. Overwhelmingly, a consensus was noted between documentation and verbal accounts of the presence of purplish-maroon discoloration that did not progress to a partial- or full-thickness skin injury, fade or diminishing in color or size.

One may argue CTI is a subcategory of DTPI due to similarities between the 2, chiefly color. However, unlike DTPI, CTI does not progress to a wound; instead, the hallmark feature of CTI is its chronic deep purplish maroon color that does not dissipate over time. To fully appreciate the clinical differences among the various skin injuries and damage and DTPI in particular, I suggest reading the article by Black and colleagues, who provide an in-depth clinical differential diagnosis of suspected DTPI and other skin disorders and aptly conclude that many skin problems have a purplish presentation.1 They further suggest nurses need a working knowledge of the underlying pathology that affects tissue and vascular structures to accurately diagnose DTPI and distinguish it from other skin conditions for appropriate treatment.

Over the past several years, numerous articles have been published in the Journal of Wound, Ostomy and Continence Nursing to further distinguish various skin conditions. Berke's case series and literature review and Brienza and colleagues' white paper on SFI suggest a very different source of skin damage.2,3 Berke asserts that wounds located on the fleshy medial buttocks and/or posterior thighs, not located over bony prominences, and exposed to friction not pressure, have unique clinical characteristics that differ from those of pressure injuries and thus require different treatment approaches. Brienza's group further espouses that injuries to the superficial layers of tissue caused by friction are not pressure injuries and should not be categorized or managed as such. Their conclusions support those by Black and colleagues that suggest effective wound management is dependent on accuracy when identifying and correcting causative factors specific to the type of injury. I also recommend reading the landmark article by Gray and colleagues on MASD who present the unique defining features such as skin inflammation occurring with or without erosion or infection and associated with prolonged exposure to various sources of moisture.4 The collective message from these articles underscores the need for a strong understanding of the distinct clinical characteristics of each of these skin injury types.

I advocate scholarly efforts continue among our WOC and other wound colleagues to progress the work of definitively diagnosing and subsequently staging of these skin injuries. For example, the initial development of a psychometrically sound instrument for assessing the severity of DTPI by Honaker and colleagues5 continues to be advanced. Nursing leader and WOC nurse LaBlanc and colleagues have contributed tremendously to the skin tear literature and specifically proposed an enhanced staging model that drives a more focused treatment plan for each type of skin tear.6

There is much to be done to further develop a better understanding of the distinct pathophysiology and physical attributes of CTI. Unfortunately, several barriers exist to specifying a new type of skin injury. For example, the lack of International Classification of Diseases codes for skin damage that fall outside of standard pressure injury definition may suggest that skin conditions such as CTI, SFI, skin tears, and MASD are perceived as less significant. I challenge WOC and other nurses who care for "recliner-bound" patients to carefully consider CTI as a separate category of skin injury to prevent its occurrence and provide treatment that is based on its causative factors and specific pathology. As this article points out, additional research is needed to advance our understanding of the epidemiology, etiology, prevention, assessment, and management of chronic skin injuries across the lifespan.

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