Skin is considered the body’s largest organ, and any damage can often lead to scarring. Although the pathology and physiology of what leads to scarring are not entirely understood, some details are concrete, including the series of processes that occur after the skin is damaged. These processes will be discussed in detail below, as well as the different types of scars. The appearance of these scars, as a result of these processes, may also present differently on various skin tones and types.

What are Scars?

A scar develops as part of the remodeling stage in the wound healing process and can commonly happen after surgery, skin trauma, or an infection.1 In more clinical terms, a scar results from a fibroblast replacement of regular skin tissue that didn’t heal via regeneration.1 Instead, the body forms scar tissue to repair the wound through unidirectional collagen clumps instead of uniform collegian layers.1 Some scars may fade completely, and others may leave a mark.2 The type of wound and the length of time between occurrence and healing will often determine the scar’s depth, scope, and appearance.1 Specific factors that could contribute to a scar forming include “infections, retention of foreign bodies, and prolonged healing beyond 2-3 weeks.”1

How Do Scars Form?

This process is complex. Immediately after a wound occurs, the body attempts to repair itself through a variety of wound healing stages3,4:

The first step is called hemostasis. The body attempts to clot the wound by sending platelets to the source of the injury. This process happens immediately after the wound occurs.
The second step is inflammation. White blood cells attempt to fight off bacteria through phagocytosis. This phase often causes the skin to appear red, discolored, and even swollen.3 This phase should last anywhere from 1 to 4 days.
The third step is proliferation. The skin creates new cells, causing the formed scab to shrink. After this process, the scab will be replaced with new skin cells. This phase can take anywhere from 4-21 days.
Maturation, also known as remodeling, is the last step in wound healing, where new skin, including scarring, is visible. The skin can be in this phase post-injury for up to 2 years.

Other factors can affect scar formation, such as wound tension, infection, hypoxia, pregnancy, puberty, age, and cellular and genetic factors.5

Different Types of Scars and Presentation in Skin Colors

A few types of scars have different presentations depending on skin tone and scar type. Keloid scars can appear dark or red and are thick and round. Unlike other types of scarring, it will appear and extend outside of the place where there was a wound.6 After a wound has healed, these scars result when the body produces too much collagen. As a result, they can often be painful. Keloids will develop anywhere and are challenging to treat.7-9 Hypertrophic scars appear raised and red.9 They may appear similar to keloid scar tissue, but hypertrophic scars are contained within the wound area, unlike a keloid scar.9 Like keloid scars, hypertrophic scars are more present in skin of color.9 Both keloid and hypertrophic scars tend to develop in places on the body where the tension of the skin is very tight. The presentation of these scars may look different on various skin tones, particularly in patients with skin of color.7 Although people of any skin color can get keloid or hypertrophic scarring, it is more prevalent in those with skin that is more pigmented. According to research that Tchero reported in their 2020 study “Management of Scars in Skin of Color,” 6-16% of African-Americans, Asians, and Hispanics developed keloids.7 Researchers have found that the greater the presence of melanin in the body, the more likely one is to experience the development of keloids.8 When skin is injured, in addition to other cellular processes, the body produces cells called melanocytes, which, put simply, means that there is an increase of melanin in the area.8 Additionally, as a wound goes through the stages of healing, these melanocytes may be destroyed in the process. As the skin heals, these cells return in varying degrees, which is why some scars may appear lighter or darker than the surrounding skin.10

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Treatment

Both forms of scarring, keloid and hypertrophic, may create discomfort and diminish patient’s self-perceptions.11 A study looked at how African Americans and white patients’ perception of their scars impacted how they viewed their “appearance, psychosocial health, and career,” for instance.11 The study found that African Americans were more likely than white patients to have a lower self-perception. These findings point to the larger need for clinicians to consider a patient’s individual needs when creating a treatment plan.11 Several treatments for scar minimization exist, including the following12:

Steroid injections
Silicone sheets
Cryotherapy
Excision and laser surgery

One in particular, nonablative fractional laser resurfacing, has been found to be effective in treating scarring in patients with skin of color.12 Nonablative fractional lasers target water instead of melanin in the skin and, as a result, are safer for use on darker skin. However, more information and research about its use are still taking place. Although fractional lasers are safer than traditional lasers for those with darker skin, side effects are still present, including edema, hyperpigmentation, and transient erythema.12

Conclusion

There are various treatments for scars; however, there isn’t a way to remove them completely. Some treatments have the potential to worsen a scar.11 Understanding how scars present is essential for managing them in patients of varying skin tones. Giving patients a proper treatment plan can maximize the opportunity for a positive outcome.

References

Al-Shaqsi S, Al-Bulushi T. Cutaneous Scar Prevention and Management: Overview of current therapies. Sultan Qaboos Univ Med J. 2016;16(1):e3-e8. doi:10.18295/squmj.2016.16.01.002
American Society for Dermatological Surgery. Scars. Accessed March 29, 2023. https://www.asds.net/skin-experts/skin-conditions/scars
Hultman S. Everyday Cuts and Scrapes: How to Prevent Scarring. Johns Hopkins Medicine. Accessed March 29, 2023. https://www.hopkinsmedicine.org/health/wellness-and-prevention/everyday…
Nova Scotia Health. Skin and Wound Care. Updated March 21, 2023. Accessed March 29, 2023. https://library.nshealth.ca/WoundCare/HealingBasics
Aydoğmuş S, Kelekçi KH, Şengül M, et al. Factors affecting the development of scar formation in abdominal surgery performed for gynecologic and obstetric conditions. Turkderm-Turk Arch Dermatol Venereology. 2017;51:12-7. doi: 10.4274/turkderm.58751
Stanford Medicine. Keloid Scars. Accessed March 29, 2023. https://stanfordhealthcare.org/medical-treatments/s/scar-revision-surge…
Tchero H. Management of Scars in Skin of Color. In: Téot L, Mustoe TA, Middelkoop E, Gauglitz, GG (eds). Textbook on Scar Management. Springer, Cham. 2020. https://doi.org/10.1007/978-3-030-44766-3_43
Ludmann P. Keloid Scars: Causes. American Academy of Dermatology Association. Updated August 8, 2022. Accessed March 29, 2023. https://www.aad.org/public/diseases/a-z/keloids-causes
Xue M, Jackson CJ. Extracellular Matrix Reorganization During Wound Healing and Its Impact on Abnormal Scarring. Adv Wound Care. 2015;4(3):119-136. doi:10.1089/wound.2013.0485
McGrory C. Reducing the impact of hypertrophic scarring. Wounds UK. 2013;9(3):18-22. https://www.wounds-uk.com/resources/details/reducing-impact-hypertrophi…
Garg SP, Hassan AM, Patel A, et al. Scar Perception: A Comparison of African American and White Self-identified Patients. Plast Reconst Surg. 2022;10(5):p e4345. DOI: 10.1097/GOX.0000000000004345
Kaushik SB, Alexis AF. Nonablative Fractional Laser Resurfacing in Skin of Color: Evidence-based Review. J Clin Aesthet Dermatol. 2017;10(6):51-67.

Introduction

Venous Leg Ulcers (VLUs) are among the most widespread chronic lower extremity wounds, with approximately 70% of chronic leg ulcers reported as VLUs.1 Across the population in the western hemisphere, it’s estimated that 2% have VLUs, while those in the aging population have a greater prevalence at 5%.2 In the United States, 6 million people struggle with these wounds, a number dwarfed by those in other countries. For instance, in Africa, approximately 25-135 million individuals have VLUs. Several populations face greater occurrence and severity of VLUs, including those aged 65 and over, those with pigmented skin, and the female demographic. Across these populations, different factors put each population at risk. For instance, in hard-to-heal VLUs, researchers have found race to be a novel risk factor, even in circumstances where non-white patients had equal access to care as white patients—suggesting that “other factors” may be the cause of this discrepancy in healing.3

In contrast, for those of the aging population, the greatest risk factors for VLU development and chronicity concern the fragility of skin and the presence of concomitant health conditions, like diabetes.4 For these reasons, wound care professionals must familiarize themselves with the intricacies of care necessary to treat patients with VLUs across diverse populations to reach best outcomes for these vulnerable patients.

How to Treat VLUs Across At-Risk Populations

Overall, best practices for the diagnosis and treatment of VLUs may include the following4,5:

Clinical examination, color flow duplex, and doppler sonography (ultrasound)
Compression therapy
Physical therapy
Manual lymphatic drainage
Endovascular procedures (ie, Venous Ablation)
Phlebotonics

Many of the above assessment and treatment options will require the help of a multidisciplinary team, including vascular specialists, physical therapists, nurses, and wound care professionals.4 Despite compression therapy being a gold standard, clinicians may hesitate to use it in some contexts due to the risk of mixed etiology pathologies. Using proper methods to evaluate for arterial insufficiency can alleviate these concerns. With the help of a vascular specialist, methods such as transcutaneous oxygen pressure (TcPO2), ankle-brachial pressure index (ABPI), and toe pressure can be used to assess for both micro- and macrocirculation, respectively.4 Some experts recommend using compression therapy with another conservative therapy for best outcomes once mixed etiology is ruled out.

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In contrast, according to a recent consensus document, compression therapy may still be recommended despite the presence of minor arterial insufficiency as long as the pressure applied does not “exceed the local arterial perfusion pressure.” 4 However, clinicians should remain cautious when applying compression therapy in patients with arterial inflow, as it may prove dangerous and painful.4 Elastic (long stretch) and inelastic (short stretch) bandages provide varying forms of compression dependent on if the patient is at rest. Elastic bandages provide more pressure at rest, while inelastic bandages compress more during patient activity. Because of its high adherence rates and a better ability to reduce venous reflux, inelastic bandages tend to be more effective. It is important to note that although compression therapy provides best outcomes for patients with VLUs, it does not treat the root cause. Endovascular procedures and certain phlebotonics have been found to reduce wound reoccurrence, edema, and inflammation.4

Female Population

Risk Factors

As many wound care professionals are familiar, VLUs are a result of chronic venous insufficiency (CVI). This condition has a myriad of risk factors, both modifiable and non-modifiable, such as genetics, prolonged standing, age, and trauma, to name a few. Of note, the non-modifiable risk factor of female (assigned at birth) gender and modifiable risk factor of past pregnancy increase likelihood of CVI development.4 Other risk factors include several conditions female patients have an increased risk of developing, including the following:

Deep vein thrombosis (DVT)
Post-thrombotic syndrome (PTS)
Varicose veins

These risk factors help to explain why female patients are at higher risk for VLUs. Pelvic congestion syndrome (PCS) is theorized to also contribute to this discrepancy. PCS can occur during menstruation or pregnancy and is impaired circulation of pelvic veins indicated by pelvic pain.5

Best Practices

Since female patients have a higher risk of edema, it is important to differentiate between the etiology of edema for proper treatment of the underlying cause. Wound care professionals can differentiate between these 2 etiologies by observing whether the foot or ankle/leg has swelling. Typically in lymphedema, the second digit of the foot may exhibit swelling, while edema from CVI typically only appears in the leg or ankle.6 If a patient has persistent edema, the lymphatic system may be damaged, leading to lymphedema, further complicating differential diagnosis. A vascular specialist may use Doppler ultrasonography and color flow duplex ultrasonography to confirm edema caused by CVI.4 Compression therapy may be recommended for pregnant patients to mitigate venous insufficiency symptoms in the lower extremities.7

Patients With Skin of Color

Risk Factors

The literature cites essential differences in the presentation of injuries and assessing erythema among varying skin tones.8 However, there is less available data on venous and vascular wounds in this population. Much in the same way that African American patients have been found to present with more significant PIs, these patients also present with more severe chronic venous disease (CVD).9 Experts theorize that lower rates of endovascular abdominal aortic aneurysm (AAA) repair, revascularization, and overall aggressive treatment of venous disease contribute to the higher rates of severe CVD in this population.9 Also of note, there are increased amputation rates in relation to peripheral arterial disease (PAD) among this population, even when revascularization rates were higher.9

Best Practices

Clinicians working with patients with skin of color must ensure they assess for CVI early to intervene procedurally at earlier rates.9 To improve visual assessment of the patient, ensure the area of assessment has appropriate lighting. To determine any discoloration present, compare the area of concern to a portion of the patient’s skin that does not exhibit an injury. Besides visual assessment, wound care professionals should use doppler sonography if a patient reports edema, heaviness of the extremities, or nighttime leg cramps.10

Aging Population

Risk Factors

The aging population refers to individuals who are aged 65 and over.6 The prevalence of VLUs in this population is estimated at 1.7% annually, with peak prevalence between 60-80 years of age.6 This patient population struggles with compounding chronic diseases and, consequently, multiple medications.6 They may also experience difficulty or inability to ambulate, social isolation, reduced skin barrier function, and a lower production rate of keratinocytes.11-13

Best Practices

Those in the aging population may have conditions that make them unfit for compression therapy outside of arterial disease. These include but are not limited to the following14:

Musculoskeletal conditions
Uncompensated organ failure
Neuropathy
Ischemic pain at rest

If a patient from the aging population has any condition that makes them unfit for compression or surgical intervention, clinicians may consider sclerotherapy. For this treatment to create localized thrombosis, the clinician injects a chemical solution into an insufficiently functioning vein, triggering an inflammatory response in the vessel wall’s endothelium.15 A 2016 study analyzed the results of this treatment and found that patients in the dataset had lower rates of varicose veins and better quality of life.16

A Note on Adherence

Despite the evidence surrounding the standard of care for VLU treatment, it is often discontinued across care settings. For patients of diverse populations, this discontinued care can needlessly overcomplicate already complex wounds. However, literature continues to show this occurrence. A 2023 study of one UK hospital identified 3 obstacles: clinician education regarding compression therapy, patient adherence, and the presence of equipment and specialized staff.17 In terms of adherence to compression therapy, evidence suggests clinicians understand patients’ specific lifestyles and apply that knowledge to choose a type of compression for the patient. The provision of aids to ensure patients can perform self-care activities like showering was also essential, especially for patients of the aging population. Last, some patients may not be able to tolerate compression due to the pain, and those patients need support and advice from staff.17,18

Conclusion

It is important to note that the economic burden of these VLU wounds in the United States ranges from $15,000 to $34,000 per individual, not including other factors, such as missed workdays.1 Experts report a staggering $14.9 billion is spent annually by taxpayers in the United States on VLUs.2 These statistics, of course, do not include the psychological burden that also affects these patients, such as isolation, depression, lack of sleep, and dependency, to name a few.1 As VLUs continue to burden patients and the health care system, continuous research of solutions and education of best practices is vital. Through best practices and the multidisciplinary team, wound care professionals can help patients across populations who suffer from these wounds.

References

Kolluri R, Lugli M, Villalba L, et al. An estimate of the economic burden of venous leg ulcers associated with deep venous disease. Vascular Med. 2022;27(1):63-72. https://journals.sagepub.com/doi/pdf/10.1177/1358863X211028298
Raffetto J, Ligi D, Maniscalco R, et al. Why Venous Leg Ulcers Have Difficulty Healing: Overview on Pathophysiology, Clinical Consequences, and Treatment. J Clin Med. 2021; 10(1):29. https://doi.org/10.3390/jcm10010029
Melikian R, O’Donnel TF, Suarez L, et al. Risk factors associated with the venous leg ulcer that fails to heal after 1 year of treatment. Vasc Surg Venus Lymphat Disord. 2019;7(1):98-105. https://doi.org/10.1016/j.jvsv.2018.07.014
Bernatchez SF, Eysaman-Walker J, Weir D. Venous Leg Ulcers: A Review of Published Assessment and Treatment Algorithms. Adv Wound Care. 2021;11(1):28-41. http://doi.org/10.1089/wound.2020.1381
Placke JM, Jockenhofer F, Benson S, et al. Venous ulcerations occur more frequently in women on the left lower leg. Can pelvic congestion syndrome be an often undetected cause? Int Wound J. 2020;17(1):230-231. doi: 10.1111/iwj.13260
Lymphedema. The Vein Center of Arizona. Accessed March 9, 2023. https://www.veincenterofarizona.com/chronic-venous-insufficiency/lymphe….
Heller J, Canner J, Lum WY, Tsuchiya K. Compression Stockings During Pregnancy: Superfluous? A Pilot Study. J Vasc Surg. 2016;4(1):148. doi:https://doi.org/10.1016/j.jvsv.2015.10.038
Gunowa N, Hutchinson M, Brooke J, et al. Pressure injuries in people with darker skin tones: A literature review. J Clin Nurs. 2018;27(17-18):3266-3275. doi:10.1111/jocn.14062
Dua A, Desai S, Heller JA. The Impact of Race on Advanced Chronic Venous Insufficiency. Ann Vasc Surg. 2016;34:152-156.
Chronic Venous Insufficiency (CVI). Cleveland Clinic. Updated July 17, 2022. Accessed March 22, 2023. https://my.clevelandclinic.org/health/diseases/16872-chronic-venous-ins….
Pugliese DJ. Infection in Venous Leg Ulcers: Considerations for Optimal Management in the Elderly. Drugs Aging. 2016;33:87-96. https://link.springer.com/article/10.1007/s40266-016-0343-8
Aguiar ACSA, Sadigursky D, Martins LA, et al. Social Repercussions experienced by elderly with venous ulcer. Rev Gaucha Enferm. 2016;37(6):e55302. https://doi.org/10.1590/1983-1447.2016.03.55302
Banvolgyi A, Grog A, Gado K, et al. Chronic wounds in the elderly: Decubitus, leg ulcers, and ulcers of rare aetiology. DHS. July 5, 2022;4(4):81-85. https://doi.org/10.1556/2066.2022.00054
Guideline: Application of Compression Therapy to Manage Venous & Mixed Venous/ Arterial Insufficiency. British Columbia Provincial Nursing Skin and Wound Committee. Published 2016. Updated 2019. Accessed 2023. https://www.clwk.ca/get-resource/compression-therapy-for-venous-insuffi….
Santler B, Goerge T. Chronic venous insufficiency — review of pathophysiology, diagnosis, and treatment. J German Soc Derm. 2017;15(5):538-556. https://doi.org/10.1111/ddg.13242
Isobe J, Onyeachom U, Taylor R, Dimitropoulos S. Sclerotherapy Use for Chronic Venous Insufficiency Across the United States: A Report From the Venous Patient Outcome Registry. J Vasc Surg. 2016;4(1):144-145. doi:https://doi.org/10.1016/j.jvsv.2015.10.030
Lian Y, Birt L, Wright D. Hospital clinicians’ perspectives of using compression on venous leg ulcers: a systematic qualitative review. Br J Nurs. 2023;32(4). https://doi.org/10.12968/bjon.2023.32.4.S30
Perry C, Atkinson RA, Griffths J, et al. Barriers and facilitators to use of compression therapy by people with venous leg ulcers: A qualitative exploration. J Adv Nurs. 2023. https://doi.org/10.1111/jan.15608

Introduction

Recent literature has established that there is much for the medical community to learn about highly pigmented skin, specifically in the realm of wound healing and even more so in diabetic foot ulcers (DFUs). Most distressing is the higher prevalence of amputation and mortality among patients with skin of color and DFUs as opposed to their Caucasian cohorts. In fact, a 2022 study found that patients identifying as Black were approximately 4% more likely to experience above-ankle amputation or death.1

Identifying Physiological Characteristics of Skin of Color

To begin, clinicians can look to available general dermatological information and the science of skin pigmentation. Highly pigmented skin has different properties with respect to structure and function and, therefore, may exhibit differences in wound healing. Various skin-related conditions, including DFUs, may appear significantly different between varying skin tones.2

Melanin is a key determinant of skin pigmentation.2 Melanocytes produce melanin in the basal epidermal layer of the skin. Melanosomes then transport the melanin into keratinocytes. Several factors then influence skin pigmentation, such as the size and distribution of melanosomes, timing of melanin degradation, and type of melanin.2

Clinical Challenges Related to DFUs in Highly Pigmented Skin

Erythema, often presenting as redness, is one key factor evaluated in DFUs that can be challenging to detect in pigmented skin. The redness visible against lighter skin tones that often alerts clinicians to inflammation or infection is usually not present in skin of color or may be somewhat masked.2 Associated inflammatory changes may also appear differently, as more brown, grey, purple, or black. The appearance of pressure injury or shear forces can also be difficult to discern in skin with darker pigmentation, contributing to delays in recognition of preulcerative states by both patients and clinicians.3

Unique changes in skin texture or contour may pose challenges to diagnosis. Clinicians will also note that skin of color may be thicker (by micrometers) and appear drier than skin with lighter pigmentation.4,5 These states are due to additional corneocyte layers and a higher risk for transepidermal water loss and xerosis, respectively, which are essential to keep in mind when assessing risk for skin breakdown like DFU and during treatment.

Overall, changes in coloration and texture, as described above, can make it more difficult to identify related conditions such as ischemia, lymphangitis, and infection in DFUs,6 so it behooves health care professionals to be familiar with these differences in order to maintain the most accurate clinical index of suspicion.

Post-Inflammatory Response in Skin of Color

The post-inflammatory process is another instance where melanin plays a role in wound healing. Post-inflammatory hyperpigmentation or hypopigmentation may arise due to trauma, inflammation, or other skin damage, such as from a DFU.2 Hyperpigmentation triggers increased melanin production, which is deposited in the surrounding epidermal keratinocytes. Occasionally, this melanin will be found in the deeper dermal layer. Hypopigmentation, although less common than hyperpigmentation, can also occur from similar stimuli, which results in decreased melanin production or a loss of melanocytes.2 Either presentation has the potential to confound continued assessment during treatment. For example, one should be cautious to avoid misdiagnosing hyperpigmentation as eschar or necrosis or vice versa.6

Additional Educational and Logistical Challenges to Consider

Unfortunately, there is a gap in available education and evidence on DFU management in patients with diverse skin types. This gap is evident in the available classification systems that help describe skin types and pigmentation. Dermatologic practice most frequently uses the Fitzpatrick Skin Phototype, but this scale is not typically applied to assessment and documentation of DFUs. Alternate classifications also exist but also suffer the same challenges to DFU applicability.2 Although not specific to DFUs, but at least directed at wound care, the 2019 National Pressure Injury Advisory Panel guidelines discuss using a color chart such as the Munsell skin tone chart to describe and classify observation of various skin tones objectively.4

Key Obstacles Related to Differential Diagnosis

There is a particular complexity noted in the literature regarding DFUs in general and the potential misdiagnosis of skin cancers. Although this is not yet directly tied to skin of color, there is a logical association to consider. Dermal malignancies can clinically mimic DFUs, including melanoma, squamous cell carcinoma, certain lymphomas, and Kaposi’s sarcoma, and may have ulcerative properties.7 Such mimicry is more prevalent in patients over age 65.7

However, as previously stated, there is a scarcity of literature surrounding DFU in highly pigmented skin. There are discussions of a lack of lower extremity-related publications on the diagnosis of melanoma in patients with Fitzpatrick skin types 5 or 6.8 Therefore, given the challenges in visual assessment of DFU-appearing presentations in those with pigmented skin, dermatologic malignancies should be part of an overall differential diagnosis, and biopsy may be a vital tool in these cases.

Important Considerations During and After DFU Healing

When wounds like DFUs heal, scar formation is expected. Collagen and extracellular matrix (ECM) are produced by fibroblasts when scar tissue is formed.9 However, in patients with diabetes, this process is different, and scars have lower collagen synthesis and exhibit a different overall structure, with lower tensile strength, increased collagen density, and reduced contractibility. They rely more on the processes of re-epithelialization and granulation than on contraction, which can make diabetic scars more susceptible to trauma like tension and shear forces.9

These challenges may magnify, though, for patients with skin of color. Increased inflammation in DFUs can lead to a higher risk for hypertrophic or keloidal scarring.9 Keloids are benign but potentially hyperproliferative scars that impact 4.5-16% of the Black and Hispanic populations in the United States.2 When keloids form, it is possible for the scar tissue to continue to worsen over time and to extend beyond the original wound borders. This process is thought to possibly result from reduced levels of collagenase, an enzyme that breaks down collagen. Family history of keloidal scarring is present in 5-10% of those that form them and is thought to be, in part, hereditary.2

Connecting these sets of information, increased collagen density in patients with diabetes and decreased collagen breakdown in patients with skin of color could lead to an amplified risk of such abnormal scarring. Depending on the size, location, and characteristics of these hypertrophic or keloidal scars, they may pose a risk for subsequent skin breakdown and DFU recurrence.

DFU Assessment Pearls for Highly Pigmented Skin

As with all wound assessments, a thorough history is important in this patient population. Specifically, it is vital to elucidate any history of pressure, friction, or other macro- or microtrauma to the foot in patients presenting with a DFU, and even more so in patients with skin of color since visual signs of such injuries will not always be clear.4

To enhance the accuracy of visual inspection, one may choose natural or enhanced lighting when possible. It is essential to know that fluorescent lighting may cast blue tones on darker skin.4 It is also wise, when possible, to use skin in a comparable alternate location as a comparison to assess for contrast in appearance. For DFUs, this may be the contralateral foot or limb in a comparable location (dorsal versus plantar foot), but remember that this may not always be possible in cases of amputation.6

Palpation also becomes an important tool, specifically to assess for signs of temperature changes or fluctuance of tissues that may alert the clinician to infection or other important states.

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Technology may also serve as an adjunctive tool when visual assessment alone is problematic. Options like infrared thermography or subepidermal moisture readings may hold value for clinicians.4 One recent presentation looked at bacterial load via fluorescence imaging.10 They found a 12-times increase in detection sensitivity across all skin tones compared to standard assessment for at-risk and clinically infected wounds, which increased further when the clinician analyzing the information was an expert in the technique.10

What Will The Future Bring?

The hope is that there will be continued generation of research and high-quality literature on diabetic foot ulcers in highly pigmented skin, including honing expertise in assessment, diagnosis, and optimizing treatment. Additionally, clinicians may continue to learn more about the role of technology in achieving these goals. There are early discussions of what part machine learning may be able to play, including in classifying infection, ischemia, malignant transformation, and other metrics.11

Appropriate and comprehensive assessment and care for wounds in patients with skin of color is vital, as one study found that Black patients were nearly twice as likely to undergo a lower limb amputation within a year of DFU diagnosis compared with Caucasian/Non-Hispanic patients.12 Another study identified significantly higher risks of major amputation for African-American, Hispanic, and Native-American patients with diabetic foot infections.13 Overall, however, enhanced awareness of the need for careful and thoughtful assessment methodology, along with a desire to learn how to best care for all unique patient populations, will likely serve wound care clinicians well.

References

Brennan MB, Powell WR, Kaiksow F, et al. Association of Race, Ethnicity, and Rurality With Major Leg Amputation or Death Among Medicare Beneficiaries Hospitalized With Diabetic Foot Ulcers. JAMA Netw Open. 2022;5(4):e228399. doi:10.1001/jamanetworkopen.2022.8399
Hutchison E, Yoseph R, Wainman H. Skin of colour: essentials for the non-dermatologist. Clin Med J. 2023;23(1):2-8.
Harms S, Bliss DZ, Garrard J, Cunanan K, Savik K, Gurvich O, Mueller C, Wyman JF, Eberly L., Virnig B. Prevalence of pressure ulcers by race and ethnicity for older adults admitted to nursing homes. J Gerontol Nurs. 2014, 40, 20–26.
Black J, Simende A. Ten top tips: assessing darkly pigmented skin. Wounds Int. 2020;11(3):8-11.
Evoria AS, Adams MJ, Johnson SA, Zhang Z. Corneocytes: Relationship between structural and biomechanics properties. Skin Pharmacy Physiol. 2021;34:146-161. https://doi.org/10.1159/000513054
Dhoonmoon L, Fletcher J, Atkin L, et al. Addressing skin tone bias in wound care: assessing signs and symptoms in people with dark skin tones. Wounds UK. 2021; Available at: https://www.wounds-uk.com/resources/details/addressing-skin-tone-bias-w…. Accessed March 14, 2023.
Lyundup AV, Balyasin MV, Maksimova NV, et al. Misdiagnosis of diabetic foot ulcer in patients with undiagnosed skin malignancies. Int Wound J. 2022;19(4):871-877.
Jicman PA, Smart H, Ayello EA, Sibbald RG. Early malignant melanoma detection, especially in persons with pigmented skin. Adv Skin Wound Care. 2023;36(2):69-77.
Dasari N, Jiang A, Skochdopole A, et al. Updates in diabetic wound healing, inflammation, and scarring. Semin Plast Surg. 2021;35(3):153-158.
Johnson J, Johnson Jr A, Andersen C, Kelso MR, Oropallo A, Serena TE. Closing the gap on racial disparities in diagnosis of chronic wound infections: the concerning trend involving skin pigmentation and a role for fluorescence imaging. Presented at the Symposium on Advanced Wound Care Fall. October 2022. Las Vegas, NV.
Ahsan M, Naz S, Ahmad R, Ehsan H, Sikandar A. A deep learning approach for diabetic foot ulcer classification and recognition. MDPI. 2023;14(1):36.
Miller TA, Campbell JH, Bloom N, Wurdeman SR. Racial Disparities in Health Care With Timing to Amputation Following Diabetic Foot Ulcer. Diabetes Care. 2022;45(10):2336-2341. https://doi.org/10.2337/dc21-2693
Tan TW, Shih CD, Concha-Moore KC, Diri MM, Hu B, Marrero D, Zhou W, Armstrong DG. Disparities in outcomes of patients admitted with diabetic foot infections. PLOS ONE. 2019;14(4):e0215532. https://doi.org/10.1371/journal.pone.0215532

Introduction: A Case Study

A 55-year-old African American male was admitted to our inpatient rehabilitation facility (IRF) with a right trochanter stage 4 pressure injury, sacral stage 3, and left below the knee amputation (L BKA) with comorbid diabetes mellitus (DM) and end-stage renal disease (ESRD). A 2-person skin assessment was completed on admission by 2 RNs, one of whom had worked in a wound clinic for several years. While changing his negative pressure wound therapy device on his right hip 1 week later, I decided to check his right heel.

He had evidence of callus and ashy skin, but I thought I could see an injury curved around the callus area, as seen in image 1. Upon further inspection, I discovered a stage 2 blister approximately 4×5 cm. The skin had the texture of dry, crumpling, thin cardboard. He had no sense of pain in the area. As an amputee, he did not have another heel to compare temperature, texture, or color.

Pigmented Skin and Pressure Injuries

The National Pressure Injury Advisory Panel published new guidelines in 2020 on the assessment of skin of color to improve the capture of pressure injuries (PI)—especially stage 1 and unstageable pressure injuries.1 Of course, pain can be an indicator for sensate patients. Medium to darkly pigmented skin can be easily obscured in visual skin assessments due to the presence of callus, dry or ashy skin, and dim lights.2

In addition, dark skin does not blanch when pressure is applied over bony prominences. Improving our skills can capture these “hidden” tissue injuries. A well-lit room, the use of moisture for dry skin, and palpating for tenderness can help reveal these injuries. Rolling the patient to their side exposes the heel to light and for ease of palpation. While palpating, does the skin feel cooler or hotter than other areas; is it boggy or hardened? Darkly pigmented skin may not blanch or redden, but it will turn a purple, bluish, or eggplant color as the pressure injury develops. Remember that PIs cannot be staged from a photo, as nearly all indicators aren’t available in a photo.1-2

Don’t forget to also note any verbal reports from the patient, their family, or a previous facility’s medical record. One family informed me of a bruise on a patient’s nose under his glasses, which was present during his stay at a previous hospital. He did not want to lose them and wore them continuously for a few weeks, which may have led to the bruising.

What the Case Study Revealed

After I discovered the stage 2 blister on the patient’s right heel, the client and hospital staff became more diligent with offloading, using a podus boot in therapy and a soft boot in bed. Despite these efforts, the blister did rupture (Image 2) and the blistered skin macerated (Image 3). Per NPIAP guidelines, the blister was debrided to reveal a pink, viable, moist wound bed. No fat was visible as observable in Image 4. Our facility’s protocol indicated a collagen product would be the next course of action, in addition to continued offloading. By the time of the patient’s discharge from our facility, a dull pink layer of epithelium had partially covered the heel (Image 5).

Lessons Learned

With the above case study in mind, I would recommend most to re-educate all nursing staff to assess skin of color properly. I would also recommend the use of soft offloading boots in bed for all patients with amputations to prevent the development of any PIs on their remaining foot. Always turn on and maximize lighting when performing assessments. Always turn the patient, when possible, to assess the heel in good light. Moisten when appropriate and palpate all at-risk areas, especially for skin of color on bony prominences, to achieve an assessment worthy of your patient. For more information on the differences between assessing skin of light and dark pigmentation, please see the following resource provided by the NPIAP: 6-NPIAP-Staging-Card.pdf (advancingexcellence.org)

References

Haesler E. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance; 2019.
Bennett AM. 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(6):34-35.

Suggested Reading

Black JM, Brindle CT, Honaker JS. Differential diagnosis of suspected deep tissue injury. Int Wound J. 2016;13(4):531-539.

About the Author

Janet Wolfson is a wound care and lymphedema educator with former ILWTI, and Lymphedema and Wound Care Coordinator at Health South of Ocala with over 30 years of field experience.