Keywords

acute, chronic, definition, end of life, etiology, skin failure, term, wound care

 

Authors

  1. Dalgleish, Lizanne PhD, RN
  2. Campbell, Jill PhD, RN
  3. Finlayson, Kathleen PhD, RN
  4. Barakat-Johnson, Michelle PhD, RN
  5. Beath, Amy BSN, RN
  6. Ingleman, Jessica MSN, RN
  7. Parker, Christina PhD, RN
  8. Coyer, Fiona PhD, RN

ABSTRACT

OBJECTIVE: To map the use of the term "skin failure" in the literature over time and enhance understanding of this term as it is used in clinical practice.

 

DATA SOURCES: The databases searched for published literature included PubMed, Embase, the Cumulative Index for Nursing and Allied Health Literature, and Google Scholar. The search for unpublished literature encompassed two databases, Open Gray and ProQuest Dissertation and Theses.

 

STUDY SELECTION: Search terms included "skin failure," "acute skin failure," "chronic skin failure," and "end stage skin." All qualitative and quantitative research designs, editorial, opinion pieces, and case studies were included, as well as relevant gray literature.

 

DATA EXTRACTION: Data collected included author, title, year of publication, journal name, whether the term "skin failure" was mentioned in the publication and/or in conjunction with other skin injury, study design, study setting, study population, sample size, main focus of the publication, what causes skin failure, skin failure definition, primary study aim, and primary outcome.

 

DATA SYNTHESIS: Two main themes of skin failure were identified through this scoping review: the etiology of skin failure and the interchangeable use of definitions.

 

CONCLUSIONS: Use of the term "skin failure" has increased significantly over the past 30 years. However, there remains a significant lack of empirical evidence related to skin failure across all healthcare settings. The lack of quality research has resulted in multiple lines of thinking on the cause of skin failure, as well as divergent definitions of the concept. These results illustrate substantial gaps in the current literature and an urgent need to develop a globally agreed-upon definition of skin failure, as well as a better understanding of skin failure etiology.

 

Article Content

INTRODUCTION

Skin failure, as a concept, has been increasingly used in healthcare literature since the 1990s. Despite the increasing prevalence of the term "skin failure," the phenomenon appears to be poorly understood, and definitions of skin failure, its causes, and objective measures to determine its severity vary widely.1,2 In addition to the confusion over the broad concept of skin failure, the subcategorization of skin failure into acute, chronic, and end-stage has further contributed to misperceptions surrounding this concept.

 

In dermatology, "skin failure" is a term that has been used since 1990 to describe severe skin conditions such as erythroderma, burns, pemphigus, Stevens-Johnson syndrome, and toxic epidermal necrolysis.3-58 These conditions occur suddenly and result in the derangement of normal skin function, including loss of temperature control, percutaneous fluid, proteins and electrolytes, and mechanical barrier function. In this context of extreme dermatologic conditions, the term "skin failure" is applied and extended from the definition of organ failure: "dysfunction to such a degree that normal homeostasis cannot be maintained without external clinical intervention."59

 

In contrast to the dermatology literature, Langemo and Brown60 were the first to propose a different use of the term "skin failure." They proposed that skin failure develops as a result of hypoperfusion concurrent with severe dysfunction or failure of other organ systems, rather than skin function failure.60 They stratified skin failure into three classifications by the patient's past, current, and future medical condition. These classifications, which continue to be used today, are (1) acute skin failure, in which "skin and underlying tissue die due to hypoperfusion concurrent with a critical illness;" (2) chronic skin failure, which proposes that "skin and underlying tissue die due to hypoperfusion concurrent with an ongoing, chronic disease state;" and (3) end-stage skin failure, where "skin and underlying tissue die due to hypoperfusion concurrent with the end of life."

 

Langemo and Brown60 also argue that skin failure, regardless of classification, cannot occur in a healthy person, and a key distinction between skin failure and pressure injury (PI) development is based on the health status of the individual. However, no further information regarding objective criteria to determine categorization or the potential transition between categories (eg, moving from acute skin failure to chronic skin failure or from chronic to end-stage skin failure) has been published.1

 

Differing intradisciplinary and interdisciplinary descriptions of skin failure and its subcategories have been used without clear definition or parameters, resulting in conceptual and linguistic confusion.61 Some clinicians use the term "skin failure" as an overarching expression to describe disruption to the physiologic function of the skin,62 whereas others use it as a rationale for the development of singular skin injuries such as unavoidable PIs.63

 

The use of the term in multiple ways has resulted in many clinicians and providers becoming justifiably confused. This scoping review aimed to map the use of the term "skin failure" in the literature over time and enhance understanding of this term as it is used in clinical practice.

 

Objective

The objective of this scoping review was to understand the context and scope of the use of the term "skin failure" in the literature and identify areas of confusion.

 

METHODS

Study Design

This review used a scoping framework in which the authors systematically examined published literature on the topic of skin failure. A scoping review is a type of literature synthesis that aims to map the literature on a topic without producing a summary answer to a research question.64 The review was developed using the methodology set out by the Joanna Briggs Institute and reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Extension for Scoping Reviews.64,65 The scoping review methodology is appropriate to determine the depth and breadth of the term "skin failure" in the literature and give clear indication of the volume of literature and studies available, as well as an overview of the subject focus. A scoping review is useful in this circumstance because the evidence related to skin failure is still unclear.66

 

Search Strategy

A comprehensive search strategy to find both published and unpublished (gray) literature was undertaken by the first author in conjunction with a librarian.64 The databases searched for published literature were PubMed, Embase, CINAHL (Cumulative Index for Nursing and Allied Health Literature), and Google Scholar. The search for unpublished literature included two databases, Open Gray and ProQuest Dissertation and Theses. Initial searches of PubMed and CINAHL were conducted to refine index terms and keywords, followed by a second search with keywords and index terms across all databases.

 

Combinations of the following keywords and Boolean operators were used during the search: search (S) 1, "skin failure"; S2, "acute skin failure"; S3, "chronic skin failure"; S4, "end stage skin"; S5, "S1 OR S2 OR S3 OR S4"; S6, NOT "paediatric"; S7, NOT "child"; S8, "NOT children"; S9, "NOT animal."

 

Inclusion and Exclusion Criteria

All qualitative and quantitative research designs, editorials, opinion pieces, and case studies were included. Also included was all literature produced outside of traditional publishing and distribution channels, and which is often not well represented in indexing databases (such as consensus documents and theses), referred to as gray literature. Each record sourced was included if there was reference made to skin failure in an adult human healthcare context.

 

Records were excluded if they were pediatric- or animal-centric. Records were also excluded if they were written in a language other than English. The search was not restricted to any specific date range.

 

Screening and Eligibility

One reviewer screened titles and abstracts to identify relevant articles for full-text retrieval. Full texts were then screened for eligibility against the inclusion criteria by eight reviewers using a verification form developed by the first author for this purpose (Table 1).

  
Table 1 - Click to enlarge in new windowTable 1.

Data Extraction

A flowchart was generated to indicate the articles included in the review at each stage, as per the PRISMA guidelines (Figure 1). A data-charting form was developed to record and extract study characteristics and variables relevant to the review objective. The data extracted were author, title, year of publication, journal name, whether the term "skin failure" was mentioned in the publication, first author's specialty, study/document design, study setting, study population, sample size, the main focus of the publication, whether skin failure was referred to in conjunction with another skin injury, the cause of skin failure, a direct quote of the skin failure definition used in the publication, primary study aim, and primary outcome. To improve data extraction consistency, these items were defined with a data dictionary and validation criteria (Supplemental Table 1, http://links.lww.com/NSW/A73).

  
Figure 1 - Click to enlarge in new windowFigure 1.

The data extraction tool was then tested by two reviewers before use to determine if all relevant information was charted. This resulted in a second adaption-adding the question "What is the cause of skin failure?" The research questions were then imported into a spreadsheet where data extraction was conducted by eight reviewers. Authors were randomly assigned a letter from A through H. Records were then allocated to each reviewer in sequential blocks of 25 records, although in practice one author completed 10 records, and two authors completed 40 records. Each reviewer undertook data extraction independently, and any inconsistences in the data extraction were resolved through discussion with the first author.

 

Data Synthesis

Following data extraction, key information from each publication was tabulated to assist in determining the first author's healthcare specialty, study/document design, study setting, sample size, publication focus, cause of skin failure, and skin failure definition (Supplemental Table 2, http://links.lww.com/NSW/A74). Articles were organized by skin failure definition and publication focus to understand the scope and context in which the term was used.

 

Common themes in the literature and evidence gaps were identified. Data synthesis and analysis were discussed by the authors to ensure consensus and that all relevant themes within the review objectives were identified. Results were tabulated to provide an overview of all included articles.

 

Ethical Considerations

This review did not involve original research, and therefore, ethical approval was not required. However, a potential conflict of interest relating to four of the reviewers (authored two of the included publications) was noted.1,2 In this instance, the relevant authors were not involved in data extraction for these two publications.

 

RESULTS

The literature search returned a total of 663 publications across all six databases. Included in the final review, following screening and eligibility, were 180 records (Figure 1).1-58,60-63,67-187 The use of the term "skin failure" has increased over time, reaching 12 publications in 2009 and steadily increasing to a peak of 19 records in 2019 (Figure 2).

  
Figure 2 - Click to enlarge in new windowFigure 2.

The included articles were written by a range of healthcare specialists (Supplemental Table 1). The term "skin failure" was used most in records where the first author was in the medical field (60%, n = 108), followed by nurses (30%, n = 54) and allied health or other practitioners (3%, n = 6). For 12 of the 180 records (7%), the healthcare specialty of the first author could not be determined.

 

An array of document and design types were used (Table 2). The majority of the records were opinion papers (33%; n = 59), followed by literature reviews (13%; n = 24), case reports (9%; n = 16), educational/book chapters (7%; n = 12), and case series (6%; n = 11).

  
Table 2 - Click to enlarge in new windowTable 2.

Study settings varied. The majority of studies were not designed to have a setting; for example, an opinion piece requires no setting (61%; n = 109). Of the remaining 71 articles, the most common study settings were critical care (44%; n = 31, including intensive care, emergency, and perioperative settings), followed by acute care (27%; n = 19), palliative care (10%; n = 7), aged care (8%; n = 6), community (3%; n = 2), all hospital settings (1%; n = 1), and outpatient (1%; n = 1).

 

Narrative Themes

Two main themes were identified: (1) the etiology of skin failure and (2) the interchangeable use of skin failure definitions.

 

Skin Failure Etiology

Multiple causes of skin failure were considered in 121 of the 180 records examined (Figure 3). Dermatologic conditions were the most common cause discussed (33%; n = 60) followed by hypoperfusion and hemodynamic instability (21%; n = 39), skin changes at life's end (8%; n = 14), other (3%; n = 6), and skin integrity (1%; n = 2). Fifty-nine records (32%) did not describe a cause.

  
Figure 3 - Click to enlarge in new windowFigure 3.

Interchangeable Use of Definitions

Since 1990, 27 different definitions have been used to describe skin failure (Table 3). Definitions based on the skin as an organ that can no longer maintain its functions were the most common (56%; n = 15), followed by definitions founded on hypoperfusion and hemodynamic instability (33%; n = 9) or tissue tolerance (11%; n = 3).

  
Table 3 - Click to enlarge in new windowTable 3.

Doctors most frequently used skin failure definitions related to functional ability or tissue tolerance. Nurses most frequently used the definitions related to hypoperfusion and hemodynamic instability and its connection to skin changes at end of life.

 

DISCUSSION

This is the first scoping review to investigate the context and extent of use of the term "skin failure" within the literature. Several different skin failure contexts and themes were identified, with different meanings used by different clinician groups, some interchangeably. The use of the term has grown substantially over the last 30 years. This review identified 180 articles, but there was no apparent consistent definition of the term. Despite the number of articles included in this review, only six presented level 1 evidence,1,20,60,80,131,146 with the majority being opinion or editorial pieces.

 

The concept of skin failure and the interest in the term from a research and clinical perspective are clear, given the gradual increase in its use. From 1990 to 2008, no more than five publications using the term "skin failure" were published per year. In these early years, publications were predominately focused on describing a singular clinical condition, often in dermatology, such as Stevens-Johnson syndrome or burn injuries. Skin failure was described within the articles as an event that could occur if the conditions were not treated suitably or early enough. However, as this term increased in popularity, the subject focus and theories surrounding the development of skin failure shifted to skin breakdown as a result of cutaneous microcirculation and hypoperfusion to the skin. This steady increase in literature and shift in skin failure etiology within publications also appeared to mirror the implementation of financial penalties and increased litigation related to PI development globally.188,189

 

The two specialties with the highest number of first-authored articles are the medical field, followed by nursing. The first authors on 90% of all published articles on skin failure were from these specialties combined. However, empirical evidence remains scant, with the majority of articles being opinion pieces (Table 3). In fact, more than 50% of the articles addressing skin failure were level 7 evidence (expert opinion).190 As a result, the evidence available has a high risk of bias and a low level of evidence quality.

 

Again, the two predominant themes identified in this review were (1) the etiology of skin failure and (2) the interchangeable terms and definitions for skin failure. The etiology of a disease or pathophysiologic change is essential to further research and clinical care. More than 30% of the 180 articles included in this scoping review did not state how skin failure may develop. The majority of these articles only referred to skin failure once or twice within the article and often in the context of a trajectory of poorly treated illness leading to skin failure. These articles neither provided definition for the term "skin failure" nor offered any explanation regarding pathophysiology of the phenomenon.

 

Causes of skin failure identified in the literature included (1) dermatologic conditions, (2) hypoperfusion and multiorgan failure, and (3) skin changes at life's end. Dermatologic conditions such as Stevens-Johnson syndrome, toxic epidermal necrolysis, pemphigus, and burns were some of the causes reported to result in skin failure. These conditions exist on a spectrum of severity and result from an autoimmune disorder or, in the case of burn injuries, trauma. An autoimmune disease causes a person's immune system to attack the body's own tissues and organs.191 For example, pemphigus, an autoimmune blistering disease, impacts the skin when antibodies erroneously attack proteins that are essential for the layers of skin to adhere together.187 Treating the symptoms of these conditions and providing supportive care of the integumentary system are essential. If the treatment of these conditions does not reduce the integumentary insult and prevent complications, the skin, like all other organs, will deteriorate and fail.22,27,28,46,47,50

 

Hypoperfusion and multiorgan failure were other commonly discussed causes of skin failure within the literature. The articles that described hypoperfusion and organ failure as causes of skin failure frequently discussed the role pathophysiologic changes play in the development of skin breakdown in areas where a PI is likely to develop.60,63,141 It is important to note that PIs and skin failure may occur simultaneously, because failing skin may be more susceptible to the forces of pressure and shear. Further, it can be difficult to distinguish PIs from skin failure. However, PIs can occur in otherwise healthy individuals because of unrelieved pressure resulting in tissue ischemia and necrosis.60 In contrast, skin failure is the result of generalized organ failure. Circulatory dysfunction results in the skin's inability to receive the vital oxygen and nutrition needed to sustain all organ functioning.192 This circulatory effect impacts all organs, hence the justification that multiorgan failure is also observed in patients with skin failure.

 

Most articles that describe the cause of skin failure as a result of hypoperfusion often use the subcategories first described by Langemo and Brown60 (acute, chronic, and end stage). The major difference among these categories is the health status of the individual.60 However, the importance of the health status of an individual when diagnosing skin failure and whether the defining feature of the phenomenon in this context is hypoperfusion remains unclear.1,108

 

The final major cause of skin failure described within the literature is skin changes at life's end. Articles described the well-accepted development of organ failure in the dying process with the assumption that just like the heart and kidneys, the skin can also fail toward the end of life.76 The terms "skin failure" and "terminal PI" were used interchangeably when describing the dying process. Most experts agreed that a PI (in the presence of pressure and shear) and skin failure can occur simultaneously. However, they have differing etiologies and are distinct clinical phenomena. Although little information is available as to how skin changes at life's end result from skin failure, the authors hypothesize that cutaneous dysfunction results in reduced local tissue perfusion as a response to systemic illness and localized changes to inflammatory processes.

 

Within the literature, there are also interchangeable uses of the skin failure term and definition. Multiple consensus documents have agreed that the phenomenon of skin failure does exist. However, the lack of consensus regarding skin failure has resulted in 27 separate definitions. Within the multiple definitions, there were three clear themes: (1) the failure of skin, as an organ, to function as required; (2) hypoperfusion and hemodynamic instability; and (3) tissue tolerance.

 

The most common type of skin failure definition focused on the skin's loss of structure and/or function. These definitions, predominately in the medical and dermatologic literature, describe skin failure as an event that results in homeostatic loss within the integumentary system.28,30 This results in the skin's inability to function as required and can include a loss of barrier function; impaired thermal regulation; and metabolic, endocrine, and hemodynamic changes. In the dermatologic literature, skin failure is said to occur when conditions such as Stevens-Johnson syndrome or toxic epidermal necrolysis are diagnosed at the severe end of the spectrum of skin disease.

 

The second most common definition of skin failure is described predominately within the nursing literature. Skin failure within this context focuses on two systemic aspects of the cardiovascular system: hemodynamic instability and hypoperfusion, or the circulatory system's ability to transport oxygen and carbon dioxide to and from integumentary cells. As a result of decreased perfusion, underlying subcutaneous tissue death occurs. These definitions also suggest skin failure is linked with other organ failure because of a compromised circulatory system.

 

The final definition discussed within the literature is much less widely used. The focus of these definitions is tissue tolerance. Tissue tolerance is suggested as a state in which the cells of the integumentary system are compromised as a result of multiple factors such as hypoxia, pressure, shear, and impaired oxygen and nutrition delivery.120,126 These definitions suggest that local mechanical stress (pressure and shear) plays a role in skin failure development and hypothesize that the stress on the integumentary system and lack of reserve, as a result of the physiologic changes that occur to the body with illness, cause the integumentary tissue to break down.85 However, the addition of mechanical stress into the tissue tolerance skin failure definitions blurs the line between the two distinct clinical phenomena of PI development and skin failure.

 

As a result of these many definitions and subcategories used to describe one phenomenon, clinicians are understandably confused as to whether the definition of skin failure should be based on physiologic markers of hypoperfusion that can make the skin susceptible to breakdown, or if it is a clinical diagnosis where there are visual characteristics of skin failure present (eg, blistering, ulceration, loss of temperature control, mottling, and gangrene), regardless of location on the body.109

 

This scoping review has identified a significant interest in skin failure from both clinicians and researchers. To better diagnose and care for patients with skin failure, it is important that research within this field focuses on the development of objective measurements, diagnostic criteria, and a universal definition to diagnose skin failure.

 

Limitations and Strengths

This scoping review does have limitations. Dual independent reviews of search results are generally recommended for systematic reviews.193 However, in this review, all articles were independently reviewed, in both the title abstract stage and full-text screening stage. As a result, it is possible some records meeting the inclusion criteria were inadvertently missed, despite the extensive and thorough search process used. Another limitation was the restriction to English studies only.

 

Several strengths of this review are also evident. This review highlights the importance of skin failure as an emergent topic of interest and is the first of its kind to undertake this. The breadth of this scoping review allows for a unique look at what has been discussed previously. Further, scoping reviews aid in building a stronger foundation and more convincing argument for future studies. Finally, the inclusion of nonresearch literature and broad overview (iterative nature) has allowed researchers to describe how skin failure is a topic of current "conversation."

 

CONCLUSIONS

This scoping review identified clear themes related to skin failure and its contextual use and scope within the literature. Use of the term has increased significantly over the past 30 years. However, most articles retrieved were opinion based. This illustrates a significant lack of empirical evidence related to skin failure across all healthcare settings. The lack of quality research has also resulted in multiple theories on the cause of skin failure and lack of a commonly agreed-upon definition. These results illustrate the substantial gaps in current literature, a strong need for the development of a universal definition, and a better understanding of how skin failure develops. Acknowledging these issues provides opportunities to maximize research quality in skin failure-focused research, thereby increasing the understanding of this phenomenon, ultimately improving patient care and outcomes.

 

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