The detection of erythema (stage I pressure ulcers) in patients with darkly pigmented skin is especially challenging. The significance of accurate assessment is made even more relevant, given the emerging body of evidence that suggests that patients with darkly pigmented skin are disproportionately more likely to die from pressure ulcers. Given the "browning" of the US population, clinicians must increase their awareness of the disparity that exists in skin assessments between patients with light and darkly pigmented skin.

The health disparity related to skin assessments will increase in the United States if we do not address this inequity. This is evident by the fact that the minority population is growing faster than the majority. In fact, the US Census Bureau reported in 2007 that over 100 million Americans were from ethnic/racial backgrounds.1 About 1 in 3 US residents is from a minority group. There are now more minorities in the United States today than there were people living in the United States in 1910.1 Hispanics and blacks comprised over 80% of the ethnic/racial minority population. A large number of these individuals have darkly pigmented skin.

Researchers have attempted to close this health disparity through education. A study by Rosen and colleagues,2 using a quality improvement intervention to decrease pressure ulcers, found that education, real-time feedback, and staff financial incentives were effective in reducing the overall incidence rates of pressure ulcers in both black and white nursing home residents. Thus, this tripartite approach may work in other healthcare settings.

Several studies have also attempted to decrease the disparity in skin assessments between patients with light and darkly pigmented skin through the wise use of technology. Spectroscopy, thermography, and high-resolution ultrasound have been used to identify erythema in darkly pigmented skin with varying degrees of success.3 One challenge with some of the identified instruments is their portability (or lack of) in the clinical setting. The present study by Bates-Jensen and colleagues4 is most promising. The use of a simple instrument to detect epidermal barrier function in the skin is novel. More impressive is the correlation between epidermal barrier function and pressure ulcer development 1 week later in residents with darkly pigmented skin. Although this study's sample size was small, results suggest that judicious use of technology enables clinicians to more accurately predict stage I pressure ulcers in patents with darkly pigmented skin than visual inspection. More research using this technology is warranted.

Overall, the identification of stage I pressure ulcers remains challenging. It is evident that visual inspection may not be enough to identify early stage pressure ulcers in patients with darkly pigmented skin. The wise use of technology coupled with visual and tactile cues may provide the best offense to identifying these ulcers earlier, thus closing the gap in assessing skin of patients with darkly pigmented skin.

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