Dr. Levine is a nationally recognized expert in wound care and pressure ulceration. and has published and spoken widely on this topic. He is a Board Member of the National Pressure Ulcer Advisory Panel (NPUAP). Dr. Levine's Pocket Guide to Pressure Ulcers co-authored by Elizabeth Ayello RN and published by the New Jersey Hospital Association is in its 4th printing and has sold over 30,000 copies.

This post is based on my article that recently appeared in the Journal of the American Medical Directors Association.

Skin failure is an emerging concept that ties together current trends in clinical practice and deserves wider acceptance. Wound care providers have long recognized that skin failure exists, but adoption of the name has been limited due to confusion as to its clinical manifestations. Terms such as Kennedy Terminal Ulcer (KTU) and skin changes at life’s end (SCALE) have been advocated to describe the phenomenon of skin breakdown in patients who are dying, however this does not fit wounds that have similar characteristics in patients who do not die. In my opinion the term ‘skin failure’ assembles these clinical observations into an easily understandable and more accurate term.

Jeff Levine, Jeffrey Levine MD geriatrician physician artist photographer

There is growing recognition that pressure ulcers can occur when risk is recognized and prevention measures are implemented. We now have improvements in life-support technologies in intensive care, hospital, and rehabilitation settings applied to an increasingly high-risk population that effectively prolongs life, negating terminology that implies imminent mortality. I propose clarification of nomenclature through recognition of skin failure as a clinical syndrome that shares similar mechanisms with other organs. This will encourage a broader conceptual framework that some pressure ulcers, whether or not associated with mortality, are unavoidable consequences of skin failure.

 Skin Failure: A Working Definition

“Skin failure is the state in which tissue tolerance is so compromised that cells can no longer survive in zones of physiological impairment that include hypoxia, local mechanical stress, impaired delivery of nutrients, and buildup of toxic metabolic byproducts.”

When defining skin failure, a logical place to start is the normal function of skin. If skin no longer performs its role maintaining vasomotor tone, body temperature and water balance, and ceases protecting the body from infection and mechanical trauma, it is failing. In this model the KTU and SCALE are manifestations of skin failure because the organ can no longer provide these functions. Skin failure can account for the high rate of breakdown in the setting of multi-organ system failure, and unavoidable pressure injury when preventive interventions have been implemented. By folding these observations into the spectrum of skin failure, quality deficit implications are removed and the terminology becomes more accurate and uniform.

Skin failure fits neatly into the phenomenon of unavoidable pressure ulceration. Evidence shows that unavoidable wounds occurs frequently in the setting of hypoxia and multi-organ system disease. It is natural to conclude that once skin can no longer survive intact in the setting of severe physiologic and mechanical stress (i.e. nonmodifiable intrinsic and extrinsic risk factors) that it has undergone failure. If a pressure ulcer is an unavoidable result of multi-organ system dysfunction, sepsis, SIRS, or end-of-life conditions, it is incorrect to attribute this outcome to inadequate care when providers have implemented appropriate preventive interventions. Doing so mars the reputations of facilities and practitioners and gives rise to patient and family dissatisfaction.

Recognition of skin failure will lay the foundation for common nomenclature and open new directions for research. From a clinical perspective this terminology builds upon the KTU and SCALE for more accurate classification of an identified disease state that will facilitate data collection for research and improve quality measurement. In an era of data driven, outcomes oriented, value based care, it is time to collaborate with our colleagues and create a unified approach to skin failure – a phenomenon that occurs in the course of acute and chronic illness as well the end of life when the body is shutting down.

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Complete citation for this article is:  Levine JM.  Skin Failure: An Emerging Concept.  Journal of the American Medical Directors Association.  2016; 17: 666-669.

Download a PDF of the article here.

Related posts:
Historical Roots of the “Avoidable-Unavoidable” Pressure Ulcer Controversy
Determining the Avoidability of Pressure Ulcers
New Research Sheds Light on Hospital Acquired Pressure Ulcers
CMS recognizes the Kennedy Terminal Ulcer in Long-term Care Hospitals
NPUAP Introduces New Clinical Practice Guideline for Pressure Ulcers
Jean Martin Charcot’s Lecture on Pressure Ulcers:  An Important Historical Document

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PLEASE NOTE:  The content of this site is the sole responsibility of Jeffrey M. Levine MD and does not represent the views of any affiliated medical centers or organizations. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.



  • Rick Hall RN,CWON
    10/01/2016, 5:01 pm  Reply

    I was a Hospice Nurse for 6 years and did wound care on the terminally ill. Almost immediately I came across a KTU. I have been working on this since 2002. I have a blog on Please check it out. I do not believe these are Pressure Ulcers. I believe it is a form of lividity prior to death. If that theory can be proved a lot of grief from CMS, state surveyors and now the courts will be put to rest. I have the fastest recorded KTU in 1 1/2 hours. I am also a SCALE panel member.

  • Deborah Glover MBE
    09/28/2016, 3:47 am  Reply

    Deborah Glover MBE Dr Levine, An interesting piece. Agree this concept has been bandied around for a few years now, but only in relation to E-0-L care. I think it also manifests as skin tears, bruising and other ‘oddities’ seen on ‘elderly’ skin. If this is accepted, this will make us rethink how PUs (VLUs and other wounds) are managed – which means anoth 50 years of trying to get it right.

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Dr. Jeffrey M. Levine has authored numerous articles on topics related to healthcare of the elderly. These include medical history, prevention and treatment of chronic wounds such as pressure ulcers, elder neglect and abuse, and physical restraints. He has also edited a book on legal and regulatory aspects of nursing homes.