Regular skin inspection, to identify skin abnormalities, is key practice in preventing the development of pressure ulcers and it is recognised that skin changes are a key signal in predicting the presence of early or deeper pressure damage (Fletcher, 2019).
The UK is an ethically diverse society, and the national census shows a decrease in the percentage of the population identifying as being from a white ethnic group, from 94% in 1991 to 81.7% in 2021 (ONS 2022). This means that Health Care Practitioners (HCP), in all care settings, will encounter more patients with a wider variety of skin tones. Gunowa, (2020) literature review indicted that people with dark skin tones are more likely to develop higher categories of pressure ulcers. Despite this, it continues to be a challenge for HCPs to detect early stage pressure ulcers in people with darker skin and failure to detect this early damage can have an adverse effect on the patients, including physical, psychological, pain, reduced quality of life, and increased morbidity and mortality (Hondi, 2023).
A holistic assessment considers the whole of the patient and should consider their health, physical, psychological, and psycho-social factors, as well as their skin tone. Different skin tones respond differently to tissue injury, pressure, healing, and treatment provided, and therefore it is vital that any assessment and care planning is tailored to the individual and their needs from the beginning (Dhoonmoom et al, 2023). It has been found that using a skin tone tool (Adapted from Ho and Robinson, 2015), which is validated and shows a range of skin tones, is the simplest way of assessing skin tone across care settings.
Why is it more difficult detecting pressure damage in darker skin tones?
The knowledge of HCPs directly impacts on the reduction and harm caused by pressure damage, however, there is a lack of educational material which promotes the skin tone variations and recognises that not all patients are the same. The continued use of terminologies such as erythema, redness and non-blanching skin, as the only clinical indicators of early signs of pressure damage create a level of disparity in risk assessment for patients with darker skin tones (Gunowa, 2020).
Erythema refers to a change in colour of an area of skin, caused by increased blood flow and has been used, traditionally, to detect early stage pressure ulcers. It is important to understand that erythema does not always appear as ‘redness’ in many darker skin tones, for example black, brown and olive skin tones (Dhoonmoom et al, 2023).
What should we be doing?
It is important to establish what is normal for the patient’s skin tone; ruling out normal age-related pigmentation or hyperpigmentation by using the skin tone tool to assess and record the baseline skin tone. Asking patients how their skin feels or whether they have noticed any changes such as itching, pain or altered sensations, will help to focus your assessment to areas of concerns.
Do not look for ‘redness’, instead use all of your senses, particularly touch, which is important in assessing darker skin tones. Skin can feel different than the surrounding skin, tighter, more swollen (oedema), indurated (hardened or lumpy). Temperature of the skin is also a useful marker. Skin may be warmer (inflammation) or cooler (tissue hypoxia) than the surrounding skin or in comparison to the other leg, heel. When developing a care plan it is important to remember that you need to take the approach that ‘one size does not fit all’.
Visualising the skin in good light will help to notice any deepening or loss of pigmentation, white or grey discolouration can also indicate tissue damage. As healing can change the pigmentation, the pigmentation of previously damaged skin, noticing and discussing any areas of scar tissue or colour changes will help to establish a baseline of ‘normal’ skin changes for each individual which can then be documented for other HCPs to access.
Clinical photographs can be useful and a good visual aid for other HCPs who are caring for the same patients and can help to track any skin changes. It is important to use a good source of natural light if possible. If not use a pen light or the light on a mobile phone as fluorescent light casts a blue tone on darkly pigmented skin giving a distorted colour.
Some HCPs find the topic of skin tone a ‘difficult’ or ‘awkward’ thing to talk with their patients about and worry they may cause offence. This is not only dangerous and unprofessional, it may put patients at risk of harm. Clear and appropriate language can reduce miscommunication and the use of appropriate communication tools (i.e. Google Translate) can help patients to understand their risk of developing pressure ulcers and promote partnership in care. Remember that not all black people have dark skin tones and it is more appropriate to use terms like ‘brown’ or ‘black’ to describe skin tones rather than ‘darker’ which implies that white skin is the baseline or the norm. Avoid comparing skin tones to food (coca or coffee), instead use the skin tone tool (Hondi, 2023. Dhoonmoon et al, 2023. Gunowa, 2020. Wounds UK, 2021).
What is the future?
It is the responsibility of every HCP to educate themselves and make their clinical practice inclusive and informed of skin tone variations, especially in areas where there may not be a diverse patient population, to prevent health inequality and prevent patient harm (Wound UK, 2021).
Dhoonmoon, L et al. (2023). International Consensus Document: Wound care and skin tone signs, symptoms and terminology for all skin tones. Wounds International. Available at www.woundsinternational.com (Accessed 19.06.23)
Fletcher, J. (2019). Pressure ulcer education 3: skin assessment and care. Nursing Times[online]. https://cdn.ps.emap.com/wp-content/uploads/sites/3/2019/11/191120-Pressure-ulcer-education-3-skin-assessment-and-care.pdf (Accessed 19.06.23).
Gunowa, N.O, et al. (2020). Embedding skin tone diversity into undergraduate nurse education: Through the lens of pressure injury. Journal of Clinical Nursing. https://onlinelibrary.wiley.com/doi/10.1111/jocn.15474 (Accessed 19.06.23).
Ho, B.K. Robinson, J.K. (2015). Color bar tool for skin type self-identification: a cross-sectional study. J Am Acad Dermatology 73(2): 312-313.
Hondi, M. (2023). Assessing pressure ulcers in patients with darker skin tones. Primary Health Care. https://journals.rcni.com/primary-health-care/evidence-and-practice/assessing-pressure-ulcers-in-patients-with-darker-skin-tones-phc.2023.e1795/full#R31 (Accessed 19.06.23).
Office for National Statistics (2022) Ethnic Group, England and Wales: Census 2021. http://www.ons.gov.uk/peoplepopulationandcommunity/culturalidentity/ethnicity/bulletins/ethnicgroupenglandandwales/census2021 (Last accessed: 17 April 2023.)
Wounds UK, (2021). Best Practice Statement: Addressing skin tone bias in wound care; assessing signs and symptoms in people with dark skin tones. Wounds UK. (available at) https://wounds-uk.com/best-practice-statements/addressing-skin-tone-bias-wound-care-assessing-signs-and-symptoms-people-dark-skin-tones/ (accessed 19.06.23).