Tuesday August 20, 2019
Dear Editor,
We want to thank Christine Berke for taking the time to respond to our article, "Definition and Characteristics of Chronic Tissue Injury: A Unique Form of Skin Damage" from the May/June 2019 issue of the Journal of Wound, Ostomy and Continence Nursing.
Ms Berke requested clarification of the citation referencing her article "Pathology and Clinical Presentation of Friction Injuries."1 Our statement specified there was no coloration as a characteristic of friction skin injury. In her article, Berke thoroughly notes that friction injuries are surface damage due to mechanical forces that result in deformation and structure damage to the skin resulting in lichenification, ridging, skin deformation in the direction of the chronic friction forces, and shallow ulcerations. We acknowledge that coloration was included as a friction skin injury observation in the body of Berke's article. Berke noted that friction skin injury coloration of the patients she studied were characterized as blanchable erythema or violaceous skin discoloration and therefore specific coloration was not a consistent feature of friction skin injury. Coloration was not indicated when comparing friction skin injury to pressure ulcers,1(p50) or in the summary of her article. The summary states, "The resulting lesions were usually lichenified with skin ridging or skin surface deformation."1(p61) Therefore, we surmised the characteristics of friction skin injury specifically related to the mechanical damage leading us to conclude that, although coloration was noted in patient findings, the coloration was irrelevant to the specific definition of friction skin injury. We anticipate more discussion and consensus to help clarify the characteristics of friction skin injury.
In addition, Berke's Letter to the Editor noted that her ongoing clinical practice has supported 4 key features of friction skin injury, noting that lichenification and violaceous discoloration are always present. We respectfully disagree with this finding, as we have seen numerous friction skin injury patients in our clinical homecare practice with the lichenification and either no coloration or mild erythema. See Case Study 5 of our article, where the friction skin injury patient has mild erythema and not violaceous discoloration.2(p190)
Additionally, Berke mentioned in her letter, "as they stated in their article, the discoloration persists but does not worsen and only resolves when the offending trauma stops, although it can take some time for resolution." To clarify, we stated the chronic tissue injuries are characterized by purple-maroon discoloration, thinned epidermal tissue, with or without open skin injury that persists over time (ie, there is no resolution of the discoloration in a set time frame or when the offending trauma stops).
We applaud the work of all individuals involved in the genesis of definitive terminology for skin lesions (eg, moisture-associated skin damage [MASD], friction skin injury). We appreciate the opportunity to open the discussion regarding chronic tissue injury and look forward to further clarification of the various soft tissue injuries. While many of these characteristics of tissue injury will occur together, delineating the specific characteristics of each will further the ability to study and research these topics.
Sincerely,
Mary F. Mahoney, MSN, RN, CWOCN, CFCN
Barbara J. Rozenboom, BSN, RN, CWON
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