Stage 1 ulcer definition revised for pigmentation

NPUAP now seeking endorsements

The board of the directors of the National Pressure Ulcer Advisory Panel (NPUAP) has approved a revised definition of Stage I pressure ulcers to account for patients with darkly pigmented skin whose sores create changes that are often unobservable, such as skin blanching.

The previous definition of a Stage I pressure ulcer was: "Nonblanchable erythema of intact skin; the heralding lesion of skin ulceration."

The new definition is as follows:

"A Stage I pressure ulcer is an observable pressure-related alteration of intact skin whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues."

"The NPUAP felt that it was important to revisit the old definition of a Stage I pressure ulcer to make it inclusive for all clients seen by clinicians, regardless of skin pigmentation," says Elizabeth A. Ayello, PhD, RN, CS, CETN, clinical assistant professor in the Division of Nursing at New York University in New York City and chairperson of the NPUAP Task Force on Stage I Definition. "The definition was broadened to look at many parameters that we see in all clients."

The process of redefinition began more than a year ago at the fifth annual NPUAP meeting, which charged the task force with the job of critically reviewing the current definition. The task force reviewed available literature on the topic and solicited input from leaders in the field. According to Ayello, the committee received about 100 written responses to its draft of the new guidelines.

Ayello explains that the task force is now planning the dissemination of the new definition and is soliciting endorsements from other medical organizations.

How often are diagnoses incorrect?

During the redefinition process, the task force noted a dearth of related literature to guide it, and inadequate definitions of darkly pigmented skin. According to an article written by members of the task force, "A serious limitation of the group was the lack of scientifically based literature on Stage I pressure ulcers in people with darkly pigmented skin."1

A number of publications, they added, raised concerns about the ability of practitioners to accurately describe early pressure ulcers or pressure injury in people with darkly pigmented skin. However, no studies were found to indicate how often the current definition of Stage I pressure ulcers led to incorrect diagnoses in that population. This lack of information, they wrote, "underscored the need to test the predictive validity of any definition of Stage I pressure ulcers in people with darkly pigmented skin."1

The task force also challenged the assumption that all skin should normally blanch, and that nonblanchable erythema is a universal phenomenon in Stage I pressure ulcers. One source summed up the dilemma: "Darkly pigmented skin does not blanch when pressure is applied over a bony prominence, irrespective of the patient's race or ethnicity."2

Separating race from pigmentation

The author went on to say that, for the purposes of diagnosing Stage I ulcers, the clinician determines if a patient has darkly pigmented skin by using two fingers to depress the skin over a bony prominence until blood flow is occluded, then releases pressure. If no shift in blood flow is seen, the patient's skin is considered darkly pigmented and will not show the characteristic redness of nonblanchable erythema.

This method of determining if a patient's skin could be considered darkly pigmented was accepted by the NPUAP task force "because it allows the separation of race and ethnicity from pigmentation."1

The task force also recommended that, when assessing dark skin, clinicians avoid fluorescent lamps, which cast blue tones on dark skin and can distort assessment efforts. Natural or halogen lighting is preferable.

According to the NPUAP task force, signs that a patient with darkly pigmented skin may be developing a Stage I pressure sore include:

· Patient complains of or indicates currently or recently relieved pain, itching, or discomfort in an area that's predisposed to pressure ulcer development.

· Patient has a history of healed pressure ulcers. In people with dark skin, the skin becomes lighter before returning to its original color (this is opposite for patients with light skin).

· Patient rates as a risk on a validated pressure ulcer assessment tool.

· Patient has a localized area of skin that's purplish, bluish, or violet.

· Detection of localized heat (indicating inflammation) compared with surrounding skin.

· Patient shows signs of edema and the skin appears taut and shiny.


1. Henderson CT, Ayello EA, Sussman C, et al. Draft definition of Stage I pressure ulcers: inclusion of persons with darkly pigmented skin. Adv Wound Care 1997; 10:16-19.

2. Bennett MA. Report of the task force on the implications for darkly pigmented intact skin in the prediction and prevention of pressure ulcers. Adv Wound Care 1995; 8:34-35.