Understanding skin tone bias in wound care

The accuracy of assessment and diagnosis in all skin tones can have an impact on a patient's healing outcome. At the same time, there is a general deficiency of evidence regarding the impact of skin tone on wound care outcomes. However, studies suggest that individuals with dark skin tones are more frequently diagnosed with advanced-stage pressure ulcers (PUs), likely due to challenges in accurate assessment and delayed early identification of these conditions.¹ It is well documented that individuals with dark skin tones experience poorer health outcomes compared to those with light skin tones. Current assessment tools and educational practices within healthcare systems are inadequately designed to address the needs of patients with dark skin tones, particularly in wound care.^2,3,4 Most health care professionals receive training that primarily includes information and illustrative images focused on white skin.^1,4 The lack of emphasis on skin tone diversity in clinical practice and education perpetuates health disparities, leading to suboptimal care and increasing the risk to patients' well-being.¹ Skin changes are not observed quickly enough and can lead to avoidable skin and tissue breakdown and damage.¹

Questions to consider as part of skin assessment

Skin assessment is often based on erythema alone, a condition characterised by inflamed or injured blood capillaries, commonly referred to as ‘redness’. However, this symptom may present differently across various skin tones.¹ Therefore, the term redness itself can be misleading, as the colour change can range from pink to red, to purple and in some cases, may present as subtle darkening of the existing skin tone. Although erythema may be more difficult to detect in individuals with dark skin, there are methods for recognising it. Variations in skin colouration are often the primary indicator and can vary across different anatomical locations. They can be more easily identified by comparing affected with unaffected areas, e.g. left arm and right arm. The colour of erythema can vary depending on a patient’s skin tone and on the disease at hand.¹

Aside from skin tone, we also need to look at other aspects of the skin, including touch and temperature. The following questions adapted from Wounds UK (2021) Best Practice Statement¹ should be considered as part of a skin assessment:

Are there any other skin tone changes, not just ‘redness’ – like, darkening, lightening, grey blue or purple tones?
As skin tone may vary across different anatomical locations on the body, it is important to compare, for example, the right and left heel.
What is the periwound like in comparison to surrounding skin?
Does the skin feel warm / cool? Is there a change in temperature?
Does the skin feel spongy or firm to the touch?
Does the skin look or feel shiny and/or tight?
Are there signs of swelling or inflammation?
Are there any changes in the texture of the skin and/or underlying tissue?
How is the overall condition / integrity of the skin?
Is the patient experiencing pain, itchiness or a change in sensation?
Did you listen to the patient’s perspective on their own skin? Ask questions such as: “Are any parts of your skin sore?” or “Have you noticed any changes to your skin?”

Since skin tone and ethnicity are not connected, Healthcare Professional's should use a neutral and professional language and focus on skin tone rather than race.¹ Skin assessment should be holistic including the patient’s skin, their overall health and medical condition and history, and their wound, ensuring that care is tailored to the individual and their needs. It should focus on prevention strategies and the importance of skin integrity.¹

Therefore, addressing skin tone bias is fundamental for an accurate diagnosis and skin and wound assessment.¹

Erythema (redness) in people with different skin tones

Erythema with no visible redness

(photograph courtesy of Simone McConnie⁶)

An infected surgical site incision

(photograph courtesy of Ethel Andrews⁶)

Using the Skin Tone Tool

Recognising and addressing skin tone bias in wound care is essential to achieve equitable care for all. Regardless of skin tone, all patients should receive an equitable level of assessment to help achieve the best possible outcomes.¹ Thorough skin inspection, that includes baseline skin tone assessment, is crucial for early detection of changes and prevention of tissue damage.¹ The Skin Tone Tool⁵ is a validated classification tool that matches a patient’s skin tone using a range of tones. It provides an objective way to assess and monitor skin tone, avoiding biases and ensuring accurate care.¹

More effective than subjective self-description to describe skin tone
Easy to use in various care settings
May be a useful tool in wound care assessment
Suitable for all patients, including those who may have language barriers

Assessing skin tears in dark skin tones

Skin tears occur frequently and are at risk of not healing if managed inappropriately: How to assess skin tears in dark skin tones.

Learn more

Common wound types and their presentation across skin tones

Best practice is important across all skin wound types, from pressure ulcers to skin tears, which can present differently depending on a patient’s skin tone. For further details on how wounds can appear differently depending on skin tone, refer to the Wounds UK Best Practice Statement.¹

View the Wounds UK Best Practice Statement

Pressure ulcer (PU) presentation in different skin tones

PU – Dark skin tone

Category 1 PU in dark skin: the erythema is clear on the lighter sole of the foot but harder to detect on the dark skin at the side of the heel (photograph courtesy of Jacqui Fletcher)

PU – Light skin tone

Category 1 PU in light skin: the erythema is clearly demarcated across the whole wound (photograph courtesy of Jacqui Fletcher)

What you can do to reduce skin tone bias in practice

The power to address skin tone bias is in your hands, and resources are available to enhance your knowledge and improve the care you provide to all your patients. Wounds UK and Wounds International have developed a Best Practice Statement¹, an international consensus document⁶ and three Made Easy guides, focusing on wound care⁷, skin tears⁸ and pressure ulcers⁹ to help spread awareness and knowledge. Essity is dedicated to advancing and enhancing the knowledge and practice of accurate skin assessment. We supported the development of the Best Practice Statement and the Made Easy skin tear and skin tone documents through educational grants. These efforts highlight our commitment to improving patient care and addressing skin tone bias.