EPUAP (EUROPEAN PRESSURE ULCER ADVISORY PANEL) PRESSURE ULCER CLASSIFICATION 2019 – Part 2
There is often confusion between a pressure ulcer and a moisture lesion due to the presence of moisture, which may be as a result of incontinence of urine and/or faeces (EPAUP, 2019)
- Moisture lesions are often reported as category 2 pressure damage
- Important to identify the cause of any skin damage, as the treatment and management of pressure damage and moisture associated skin damage may differ (Yates 2012)
| PRESSURE ULCERS/ INJURY | MOISTURE LESIONS | |
|---|---|---|
| Causes | Pressure and/ or shear must be present | Desiccation and loose skin may indicate additional shearing injury |
| Location | A wound NOT over a bony prominence is unlikely to be a pressure ulcer/ injury | Moisture lesion may occur over a bony prominence. Pressure and shear should be excluded as causes, if moisture is present |
| Shape | Circular wounds with a regular shape that are limited to a single spot are likely to be a pressure ulcer/ injury | Diffused, different superficial spots are more likely to indicate moisture lesions |
| Depth | Partial thickness up to full thickness skin loss | Superficial to partial thickness skin loss. Depth may increase if they become infected |
| Necrosis | Necrosis can be present | No necrosis |
| Edges | Distinct edges | Diffused or irregular edges |
| Colour | Non blanchable, red skin is likely to be a pressure ulcer/ injury. However, within a wound red tissue indicates granulation whereas black necrotic tissue is likely to be a pressure ulcer/ injury | Redness that is not uniformly distributed is likely to be a moisture lesion whereas pink or white skin surrounding a wound is likely to be maceration due to moisture |
Adapted from Yates 2012