Dr DeFloor and the EPUAP have produced a thought-provoking statement on differentiation of pressure ulcers and moisture lesions, which coincides with similar issues raised during the recent consensus conference held by the National Pressure Ulcer Advisory Panel (NPUAP). The EPUAP and NPUAP staging systems for pressure ulcers are essentially equivalent; both use depth of breakdown as the basis for wound "stage," and both include partial-thickness (Stage 2) lesions. Both of these systems were developed when our understanding of the pathology of pressure ulceration and other mechanical injuries was limited; it made sense at that time to classify wounds based on depth of tissue injury. As our knowledge base has grown, however, we have realized that our staging system is frequently problematic. One "problem" is that both partial-thickness and full-thickness lesions are labeled as pressure ulcers, although the current evidence suggests that pressure ulcers are full-thickness injuries and that partial-thickness lesions are generally a result of friction and maceration. These are not just semantic issues; as the EPUAP statement notes, accurate determination of causative factors is critical to the effective management of any patient with skin breakdown, because effective management begins with correction of the causative factors.

This document reflects the EPUAP's recognition of and response to this problem; it effectively highlights the importance of differentiating between pressure ulcers and moisture-related lesions, and it provides helpful guidance to the clinician in conducting a thorough assessment and in accurately interpreting the assessment parameters. As noted, lesions caused by pressure or shear are typically full-thickness lesions with regular borders, whereas lesions caused by moisture or friction are typically partial-thickness lesions with irregular borders. This document, however, also acknowledges that these distinctions are not always as simple as they sound, because a lesion can be caused by a combination of factors.

The NPUAP has also begun to deal with the many complex issues related to pressure ulcer staging. The recent consensus conference posed numerous questions, including: "Are Stage 2 ulcers actually pressure ulcers (are they caused by pressure)?" and "Should lesions caused by factors other than pressure and shear be included in the pressure ulcer staging system?" This conference stimulated lively debate, and the WOCN's contributions to this conference will be highlighted in an article in the January 2006 issue the Journal of Wound, Ostomy, and Continence Nursing.