February 1, 2026
Letter to the Editor on “Advancing Coding and Education on Skin Failure”
I read with interest the recent article, Advancing Coding and Education on Skin Failure, in the October 2025 issue of Caring for the Ages.1 Although informative, the article contains several statements that are either controversial or potentially erroneous.
Skin failure remains a complex and controversial topic with little professional consensus. This lack of agreement presents a significant challenge for developing ICD-10 codes, as coding systems require widely accepted definitions and criteria. Because ICD coding affects all healthcare providers as well as the patients we serve, it is troubling that this article presents speculative theories as facts.
Several examples illustrate this problem. The article relies heavily on the Langemo-Brown Skin Failure Conceptual Framework (2006)2 a model that, while conceptually appealing, lacks firm clinical criteria for broad application. Accepting it as authoritative requires disregarding nearly two decades of subsequent research that has refined and challenged earlier assumptions.3,4,5 Although the authors call for greater precision in terminology, they simultaneously introduce new, loosely defined terms that invite misinterpretation and misuse at the bedside.6
The article further perpetuates the myth that skin failure and pressure injury are distinct, mutually exclusive entities—a claim that lacks definitive evidence. Tissue deformation is a well-recognized cause of cellular death, and skin failure commonly occurs in pressure-prone areas with lesions indistinguishable from pressure injuries.7 Mechanical stress interacts with physiologic and pathologic processes in ways that make it impossible to separate “pressure injury” from “skin failure.”8,9 A more defensible and logical view is that these conditions exist on a continuum shaped by definable comorbidities, including both intrinsic and extrinsic factors.
Equally problematic is the assertion that skin failure is synonymous with an unavoidable wound. This is not necessarily the case. Recognizing the array of physiologic determinants for the development of such wounds could help clinicians identify novel interventions to reduce the risk of their occurrence.4 Moreover, the avoidable/unavoidable dichotomy is a regulatory construct rather than a clinical one, generally defined by the success or failure of implementing known risk-reducing interventions.
In summary, while the article is informative, Caring for the Ages would have better served its readers by presenting a fuller picture of the controversies and challenges related to the definition and determination of skin failure. This important subject deserves a balanced, evidence-based discussion.
Sincerely,
Jeffrey M. Levine, MD, AGSF
Clinical Professor of Geriatric and Palliative Medicine
Icahn School of Medicine at Mount Sinai
1 Krasner D, McNicholas F, Steinberg K, Bird T. Advancing Coding and Education on Skin Failure. Caring for the Ages, Oct 2025, 24: 6, p. 1.
2 Langemo DK, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care. 2006 May;19(4):206-11. doi: 10.1097/00129334-200605000-00014. PMID: 16641567.
3 Dalgleish L, Campbell J, Finlayson K, et al. Understanding Skin Failure: A Scoping Review. Advances in Skin & Wound Care. 2021 Oct 1;34(10):542-550. doi: 10.1097/01.ASW.0000755844.87283.20. PMID: 34175867.
4 Levine JM, Delmore B, Cox J. Skin Failure: Concept Review and Proposed Model. Advances in Skin & Wound Care 2022: 35(3): 139-148. PMID: 35188481 DOI: 10.1097/01.ASW.0000818572.31307.7b
5 Ayello EA, Levine JM, Langemo D, et al. Reexamining the Literature on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries. Advances in Skin & Wound Care 32(3): 109-121, 2019. PMID: 30801349 DOI: 10.1097/01.ASW.0000553112.55505.5f
6Kottner J, Sigaudo-Roussel D, Cuddigan J. From bed sores to skin failure: Linguistic and conceptual confusion in the field of skin and tissue integrity. Int J Nurs Stud. 2019 Apr;92:58-59.doi: 10.1016/j.ijnurstu.2019.01.007. Epub2019 Jan 22.PMID: 30710690.
7. Gefen A, Brienza DM, Cuddigan J, Haesler E, Kottner J. Our contemporary understanding of the aetiology of pressure ulcers/pressure injuries. International Wound Journal. 2022 Mar;19(3):692-704. doi:10.1111/iwj.13667. Epub 2021 Aug 11. PMID:34382331; PMCID: PMC8874092.
8. Berlowitz DR, Levine JM. The Evolving Case for Skin Failure-Beyond Pressure Injury. JAMA InternMed.2025 Apr 1;185(4):359-360. doi:10.1001/jamainternmed.2024.7461. PMID: 39804609.
9. Mody L, Rittenberg E, Inouye SK. Pressure Injuries and Skin Failure-Pressure Still Matters. JAMA InternMed.2025 Apr1;185(4):360-361. doi: 10.1001/jamainternmed.2024.7464.PMID:39804608.