Managing pressure injuries in skin of colour
Injuries often identified at higher stages in these populations due to late detection (1,600 words, 8 minutes)
Pressure injuries can be more difficult to stage in darker skin, and managing wounds in this population is often complicated by hypertrophic or keloid scarring, noted Dr. Gary Sibbald in a talk at the 7th annual Skin Spectrum Summit on Nov. 6.
Dr. Sibbald is co-founder and course director of the International Interprofessional Wound Care Course (IIWCC). He is also the director of the Masters of Science in Community Health (Prevention and Wound Care) at the Dalla Lana School of Public Health at the University of Toronto.
Dr. Sibbald cited a literature review published in the Journal of Clinical Nursing (Sept. 2018; 27(17-18), Special Issue: Cultural Issues: 3266-3275) that examined the risk for pressure injuries and associations with skin tones. The authors of that paper found that darker skin tones specifically, rather than ethnicity, predicted who was more likely to develop higher stages of pressure injuries. That fact may be partly due to challenges with early detection.
“Stage one pressure injuries are almost invisible with Black skin. [A physician needs] proper lighting and to look for subtle differences in the colour of the skin. But you may not be able to find them,” said Dr. Sibbald.
He said that physicians should objectively describe the colour variations or even wet the skin to enhance visual assessment.
Stage three and four and unstageable ulcers are comparably easy to identify in both Black and lighter skin types, said Dr. Sibbald.
However, deep tissue injury is challenging to detect in skin of colour because there are many potential causes for colour change in the skin, he said. He reminded physicians that deep tissue injuries, even closed ones, may take 48 hours to develop on the skin surface, and the skin may or may not break down.
A lack of medical education regarding pressure ulcers in darker skin may complicate identifying and staging them. Dr. Sibbald cited a paper (Journal of Clinical Nursing, Nov 2020;29(21-22):4358-4367) that looked at pressure injury lectures during 2017 and 2018 from five Higher Education Institutes in England delivering approved nursing undergraduate programs.
The authors of that paper found that teaching and learning activities about pressure injury were overwhelmingly directed toward people with Caucasian skin tones. The teaching sessions only contained brief and superficial information on people with darker skin tones.
Another issue with managing wounds in darker skin is the elevated risk of keloids and hypertrophic scars, said Dr. Sibbald. These types of scarring may cause intense pain or pruritis, he said.
Dr. Sibbald also noted that it is possible to identify hidradenitis suppurativa lesions or infections as keloid scarring incorrectly. So it is essential to rule out those possibilities, he said.
Tips for preventing and managing keloids include:
Lower keloid risk by closing wounds with minimal tension
First-line treatments include intralesional steroids and occlusive silicone-containing dressings.
Second-line therapies include cryosurgery and radiation.
Third-line therapies include lasers, topical retinoic acid, and surgical excision.
Bottom Line: Stage one pressure injuries and deep tissue injuries can be hard to detect in patients of colour. More medical education is required regarding pressure injuries and skin of colour. When considering keloids, hidradenitis suppurativa and infection need to be ruled out.
From the literature on wounds in skin of colour
Pressure injuries and skin tone diversity in undergraduate nurse education: Qualitative perspectives from a mixed-methods study
The authors of this study explored the perceptions of nursing school students and educators in the U.K. about classroom content on pressure injuries in different skin tones. They also wanted to see how that content impacted student nurses' understanding of pressure injury in people with dark skin tones.
They found that most classroom education was largely framed through a White lens. Teaching and learning activities reinforced White skin as the default skin type.
The authors write that nurses involved in the design and delivery of education for nursing students need to ensure these learning experiences are meaningful and will help students understand biases that may exist in medical and educational systems.
Peritraumatic vitamin D levels predict chronic pain severity and contribute to racial differences in pain outcomes following major thermal burn injury
Black Americans have worse chronic pain outcomes than White Americans and are more frequently deficient in vitamin D. The authors of this study wondered if vitamin D levels at the time of injury might predict chronic pain severity and help to explain these racial differences in pain outcomes.
The authors found that in a group of 77 burn survivors, Black patients were more likely to be deficient in vitamin D at the time of their injuries. Vitamin D levels were also inversely associated with chronic post-burn pain outcomes across all burn injury survivors, whether they were Vitamin D deficient or not. These low vitamin levels accounted for about one-third of the racial differences in post-burn pain outcomes.
They write that more research is needed to determine how vitamin D levels influence post-burn pain. Research is also required to find out if supplementing this vitamin might improve pain outcomes and reduce racial differences.
When acral malignant melanoma [imitates] diabetic foot
When the 85-year-old Indian man in this case report went to a clinic with an ulcer over his left heel that was not healing, he received standard treatment, including offloading, debridement and antibiotic therapy. At first, the wound responded to this treatment and shrank.
However, improvement in the wound stalled, and two small black spots in the wound bed made the physicians suspect melanoma.
An incisional biopsy confirmed an acral lentiginous melanoma coexisting with a diabetic foot ulcer. The tumour was removed, and the wound was closed and healed completely. Cancer later recurred, and the patient passed away in palliative care.
The authors write that the case shows the importance of early biopsy and treatment is with diabetic foot ulcers, especially when there is an atypical presentation or when standard treatment is not effective.
Diabetic foot ulcer disease in the African continent: 'From clinical care to implementation' - Review of diabetic foot in last 60 years - 1960 to 2020
This review notes that the most significant potential increases in diabetes will occur in Africa. Along with an increase in diabetes rates will come an increase in the complications of diabetes, including diabetic foot ulcers.
They conducted a literature search (1960 to 2020) on all foot complications of diabetes in Africa. The review showed that rates of complications of diabetic foot varied quite widely by country.
Rates of diabetic peripheral neuropathy ranged from 4% to 90%, peripheral artery disease rates from 0% to 77%, foot ulcers from 4% to 61% and amputation rates from 3% to 61%. Mortality rates were as high as 55% in patients who presented late with infection and gangrene.
The authors write that educational and prevention programs could combat the growing rates of these complications in Africa. They also say that governments across Africa need to recognize the public health implications of diabetic foot disease.
VIDEO: Staging pressure injury in darkly pigmented skin webinar
At the intersection of skin and society
APTN, the Aboriginal Peoples Television Network, and CBC/Radio-Canada have announced they are collaborating to create more Indigenous content for all Canadians.
A press release explains that this agreement should enhance both networks’ creation of First Nations, Inuit and Métis programming. Both organizations also hope to increase access to and awareness of the new content.
The two broadcasters say they will work more closely on Indigenous productions, news and information programming by:
They are increasing the opportunities, training and resources for Indigenous creators to produce content.
They are collaborating on news and information programming. This will include sharing content and technical resources. Both will retain editorial control over their programming and their journalistic standards and practices.
They are expanding the audiences for Indigenous programming.
To be considered an Indigenous production under the agreement, production companies and copyright should be majority-owned by Indigenous persons.
“We are delighted to begin this new collaborative partnership with CBC/Radio-Canada, which will help further the voices of Indigenous Peoples through authentic news coverage and unique Indigenous-produced content,” said APTN CEO Monika Ille in the release.” Indigenous journalists, creators and producers will also feel its benefits, since this partnership expands their reach and invites more Canadians to enjoy their work.”
“CBC/Radio-Canada has an important role to play in reconciliation,” said CBC/Radio-Canada President and CEO Catherine Tait. “We are proud to partner with APTN to deepen our commitment to First Nations, Inuit and Métis journalists and creators. This initiative dovetails with the work we have undertaken to strengthen our relationships with Indigenous-led broadcasters, production companies and creators through a new Indigenous strategy that will build on the public broadcaster’s services, such as CBC Indigenous and CBC North, and Espaces autochtones and ICI Grand Nord.”
In addition to programming, both broadcasters say they will collaborate on their common objectives of employing and advancing Indigenous people and supporting independent Indigenous producers.
This week
March 7-13 is National Feet Week in the U.K.
Mar. 8 is International Women’s Day
Something to think about in the week ahead…
Next week
Furthering our discussion of diabetic ulcers, next week, we cover a talk by Dr. Veronica McKinney about the challenge of these ulcers in Indigenous Canadian populations. Dr. McKinney is an assistant professor of medicine at the University of Saskatchewan and director of Northern Medical Services.
Coming soon
Registration is ongoing for the 2022 Summit on Atopic Dermatitis, held virtually on Apr. 23, 2022.
Presentations for this one-day virtual medical educational event will discuss the most current treatments for all disease severities. The conference will also emphasize AD diagnosis in skin of colour.
Registration for the Summit on Atopic Dermatitis is open and available at this link.