A
cute skin failure has been described by dermatologists as a life-threatening condition with loss of massive amounts of skin. Many of the diseases that could classified as “acute skin failure” in the past now have different names, such as Stevens-Johnson syndrome, erythroderma, extensive burns, generalised pustular psoriasis or exfoliative dermatitis. These diseases have known causes. Today, acute skin failure is used as a diagnosis when there is a local loss of skin in patients who are critically ill or at end of life, especially on the sacrum.
So, can it be both widespread and localised? Widespread loss of skin creates a life-limiting emergency from hypothermia, which leads to an inability to maintain normal temperature control and an inability to prevent transcutaneous loss of fluids and proteins, resulting in electrolytic imbalances and susceptibility to systemic infections. In contrast, a limited skin loss on the sacrum and buttocks in the critically ill patient with sepsis is a loss of skin that is not fatal, in and of itself.
Because historically the diseases that comprise acute skin failure involve large portions of skin, is there a percentage of skin loss that can be classified as “skin failure”? Is 1% of the body surface area enough for a skin change to be called “skin failure”? I know of no other body organ that is diagnosed as “failing” with 1% of its function lost.
I presented the concept of skin failure at a recent conference for wound care providers. I asked them if they could label pressure injury on the sacrum and buttocks as “unavoidable”, would they use the term “skin failure”? Their answer was no.
Has skin failure become the workaround for hospital-acquired pressure injury? In the US, hospitals are not paid for the treatment of hospital-acquired pressure injury. Pressure injuries are also reportable in many US states. Therefore, there is a huge push to reduce the reporting of pressure injuries.
The ICD code used for “acute skin failure” is L98.9, defined as a “disorder of the skin and subcutaneous tissue”, which is unspecified in the record. It is also a non-billable ICD code. The use of the L89.9 code to disguise pressure injury is wrong. Pressure injury has its own ICD code.
The National Pressure Injury Advisory Panel (NPIAP) hosted a multidisciplinary think tank to address acute skin failure. They defined the problem as “non-pressure related skin failure” to remove pressure injury from the problem. The group identified many gaps in the term and agreed that there is too much missing data for the term “acute skin failure” to become a medical diagnosis (Black et al, 2025). The conclusions were:
Non-pressure-related skin failure in the critically ill is defined as skin injury that occurs despite standard preventive interventions and for which no other aetiology has been identified.
A distinct aetiology for non-pressure-related skin failure in the critically ill has not been elucidated to set it apart from pressure injury.
Histopathology for non-pressure-related skin failure in the critically ill has not been described.
A distinct pathophysiology for non-pressure-related skin failure in the critically ill is not clear. Based on limited evidence, hypoperfusion has been proposed to contribute to the pathophysiology of non-pressure-related skin failure.
Research is needed to establish a reproducible description of the characteristic morphology and natural history of non-pressure-related skin failure.
Until the term “skin failure” has more study, as identified by the think tank, the term has no scientific basis to be used to describe pressure injury in the critically ill.
A list of research questions was created and is posted on the NPIAP website: https://npiap.com/page/Non-Pressure-RelatedSkinFailure
