In the medical world, we are often taught that the first sign of a pressure injury is “non-blancable erythema”–a fancy way of saying a red spot that doesn’t turn white when you press on it. But there is a significant flaw in that standard: it primarily describes how a wound looks on light skin.
As an in-home Nurse Practitioner, I see patients of all backgrounds. If we only look for “redness,” we are going to miss early warning signs in patients with darker skin tones. When a wound is missed in its early stages, it has a much higher chance of progressing into a serious, deep seating injury.
To provide the best care, we have to look beyond color.
The Challenge of Pigmentation and Pressure Injuries
In darker-pigmented skin, the “redness” phase may not appear at all. Instead, the skin may take on different hues, looking purple, bluish, or even slightly grayish. Because the changes can be subtle, the injury is often much more advanced by the time it is “visible” to the naked eye.
This is why “skin of color” assessments require a more holistic approach. We aren’t just looking with our eyes; we are “looking” with our hands, and listening to the patient’s experience.
“Big Three” Signs to Indentify Pressure Injuries
If you are caring for a loved one with a deeper skin tone, I recommend focusing on these three indicators rather than searching for a red spot:
- Temperature Changes: Before the skin breaks or changes color significantly, it will often feel different to the touch. Early on, an injured area might feel significantly warmer than the surrounding skin due to inflammation. As the injury progresses and blood flow is restricted, it might feel noticeably cooler.
- Texture and Consistency: These are often the most reliable “early warning” signs. When you palpate (gently feel) the bony areas, like heels, sacrum, or hips, pay attention to the “give” of the tissue.
- Does it feel “boggy” or mushy, like an overripe fruit?
- Does it feel unusually firm or hard compacted to the surrounding skin?
- Is there a “shiny” or taut appearance of the skin in that specific spot?
- The Patient’s Report of Pain: Never underestimate the patient’s “localized” pain. If a patient or loved one says a specific spot on their heel or tailbone feels “sore,” “burning,” or “throbbing,” treat it as a pressure injury until proven otherwise–even if the skin looks perfectly normal.
Why Inclusive Assessment Matters
Health disparities in wound care are a real concern. Statistics show that patients with darker skin tones are often diagnosed with pressure injuries at more advanced stages. This isn’t because their skin is “harder to care for,” but because the traditional tools for assessment weren’t designed with them in mind.
By shifting our focus from color to consistency, temperature, and sensation, we can catch these injuries in Stage 1, where they are still reversible.
Advice for Caregivers
If you are monitoring a loved on at home:
- Check in good lighting: Natural light or “cool” LED light is better than warm, yellow, indoor lighting for seeing subtle color shifts
- Trust your touch: Your hands will often find a wound before your eyes will.
- Advocate: If a healthcare provider dismisses a spot because “it isn’t red,” don’t be afraid to point out changes in temperature, firmness, or the change from their normal skin tone!
- Color changes still happen! They just might look different than someone else’s.
Early detection is the best medicine. Whether skin is porcelain, olive, or deep ebony, the goal remains the same: keep the pressure off and the tissue healthy.
I’m currently accepting new patients in Marion and the surrounding donut counties. Contact Circle City Foot and Medical Care today at 317-269-7351 or visit circlecityfootandmedicalcare.com to schedule an appointment for your in-home foot care.
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