J WOCN ■ September/October 2005 Copyright © 2005 by the Wound, Ostomy and Continence Nurses Society
SECTION EDITOR:Dorothy Doughty, MN, RN, FNP, CWOCN, FAAN
Statement of the European Pressure
Ulcer Advisory Panel—Pressure
Differentiation Between Pressure Ulcers and Moisture Lesions
Tom Defloor ? Lisette Schoonhoven ? Jacqui Fletcher ? Katia Furtado ?
Hilde Heyman ? Maarten Lubbers ? Ann Witherow ? Sue Bale ?
Andrea Bellingeri ? George Cherry • Michael Clark ? Denis Colin ?
Theo Dassen • Carol Dealey ? Laszlo Gulacsi ? Jeen Haalboom ?
Ruud Halfens ? Helvi Hietanen ? Christina Lindholm ? Zena Moore ?
Marco Romanelli ? Jose Verdú Soriano
Commentary by Dorothy Doughty
? Tom Defloor, Belgium; Lisette Schoonhoven, the Netherlands;
Jacqui Fletcher, United Kingdom; Katia Furtado, Portugal; Hilde
Heyman, Belgium; Maarten Lubbers, the Netherlands; Ann
Witherow, Northern Ireland; Sue Bale, United Kingdom; Andrea
Bellingeri, Italy; George Cherry, United Kingdom; Michael Clark,
United Kingdom; Denis Colin, France; Theo Dassen, Germany; Carol
Dealey, United Kingdom; Laszlo Gulacsi, Hungary; Jeen Haalboom,
the Netherlands; Ruud Halfens, the Netherlands; Helvi Hietanen,
Finland; Christina Lindholm, Sweden; Zena Moore, Northern
Ireland; Marco Romanelli, Italy; Jose Verdú Soriano, Spain, Trustees
of the European Pressure Ulcer Advisory Panel.
Correspondence: Tom Defloor, Nursing Science Ghent University,
U.Z. Blok A 2°v, De Pintelaan 185, B-9000 Gent, Belgium (e-mail:
and/or a combination of these.
The identification of pressure damage is an essential
and integral part of clinical practice and pressure ulcer
research. Pressure ulcer classification is a method of de-
termining the severity of a pressure ulcer and is also used
to distinguish pressure ulcers from other skin lesions. A
classification system describes a series of numbered
grades or stages, each determining a different degree of
The European Pressure Ulcer Advisory Panel (EPUAP)
defined 4 different pressure ulcer grades (Table 1).1
Nonblanchable erythema is a sign that pressure and
shear are causing tissue damage and that preventive mea-
sures should be taken without delay to prevent the devel-
opment of pressure ulcer lesions (Grade 2, 3, or 4).
The diagnosis of the existence of a pressure ulcer is
more difficult than one commonly assumes. There is often
confusion between a pressure ulcer and a lesion that is
caused by the presence of moisture, for example, because
of incontinence of urine and/or feces. Differentiation be-
tween the two is clinically important, because prevention
and treatment strategies differ largely and the conse-
quences of the outcome for the patient are imminently
pressure ulcer is an area of localized damage to the
skin and underlying tissue caused by pressure or shear
This statement on pressure ulcer classification is lim-
ited to the differentiation between pressure ulcers and
moisture lesions. Obviously, there are numerous other le-
sions that might be misclassified as a pressure ulcer (eg, leg
ulcer and diabetic foot). Experience has shown that be-
cause of their location, moisture lesions are the ones most
often misclassified as pressure ulcers.2-3
Wound-related characteristics (causes, location, shape,
depth, edges, and color), along with patient-related char-
acteristics, are helpful to differentiate between a pressure
ulcer and a moisture lesion (Table 2 and Figure 1).
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J WOCN ■ Volume 32/Number 5
Defloor et al 303
European Pressure Ulcer Advisory Panel Classification1
GradeShort Description Definition
of intact skin
Nonblanchable erythema of intact skin. Discoloration of the skin, warmth, edema,
induration, or hardness may also be used as indicators, particularly on individuals
with darker skin.
Partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and
presents clinically as an abrasion or blister.
Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may
extend down to, but not through, underlying fascia.
Extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures
with or without full-thickness skin loss.
Pressure UlcerMoisture Lesion Remarks
Pressure and/or shear must be present.
A wound not over a bony prominence is
unlikely to be a pressure ulcer.
If the lesion is limited to one spot, it is
likely to be a pressure ulcer.
Circular wounds or wounds with a
regular shape are most likely
pressure ulcers; however, the
possibility of friction injury has to be
Moisture must be present (eg, shining
wet skin caused by urinary
incontinence or diarrhea).
A moisture lesion may occur over a
bony prominence. However, pressure
and shear should be excluded as
causes and moisture should be
A combination of moisture and friction
may cause moisture lesions in skin
A lesion that is limited to the anal cleft
only and has a linear shape is not a
pressure ulcer and is likely to be a
Perianal redness/skin irritation is most
likely to be a moisture lesion
resulting from feces.
Diffuse different superficial spots are
more likely to be moisture lesions.
In a kissing ulcer (copy lesion) at least
one of the wounds is most likely
caused by moisture (urine, feces,
transpiration, or wound exudate).
If moisture and pressure/shear are
simultaneously present, the lesion
could be a pressure ulcer as well as a
moisture lesion (combined lesion).
It is possible to develop a pressure ulcer
where soft tissue is compressed
(eg, by a nutrition tube, nasal oxygen
tube, or urinary catheter).
Wounds in skin folds of bariatric
patients may be caused by a
combination of friction, moisture,
Bones may be more prominent where
there is significant tissue loss
Irregular wound shapes are often
present in a combined lesion
(pressure ulcer and moisture lesion).
Friction on the heels may also cause a
circular lesion with full-thickness skin
loss. The distinction between a
friction lesion and a pressure ulcer
should be made based on history
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Defloor et al
J WOCN ■ September/October 2005
Wound-Related Characteristics (Continued)
Pressure Ulcer Moisture LesionRemarks
Partial-thickness skin loss is present
when only the top layer of the skin is
damaged (Grade 2).
In full-thickness skin loss, all skin layers
are damaged (Grade 3 or 4).
If there is a full-thickness skin loss and
the muscular layer is intact, the
lesion is a Grade 3 pressure ulcer. If
the muscular layer is not intact, the
lesion should be diagnosed as a
Grade 4 pressure ulcer.
A black necrotic scab on a bony
prominence is a pressure ulcer Grade
3 or 4.
If there is no or limited muscular mass
underlying the necrosis, the lesion is
a pressure ulcer Grade 4.
Necrosis can also be considered present
at the heel when the skin is intact
and a black/blue shimmer is visible
under the skin (the lesion will most
likely evolve into a necrotic eschar)
If the edges are distinct, the lesion is
most likely a pressure ulcer.
Wounds with raised and thickened
edges are old wounds.
If redness is nonblanchable, this is most
likely a pressure ulcer Grade 1.
For people with darkly pigmented skin,
persistent redness may manifest as
blue or purple.
Red in wound bed:
If there is red tissue in the wound bed,
the wound is either a Grade 2, a
Grade 3 or a Grade 4 pressure ulcer
with granulation tissue in wound
Yellow in wound bed:
Softened necrosis is yellow and not
superficial; it is either a Grade 3 or a
Grade 4 pressure ulcer.
Slough is a creamy, thin and superficial
layer; it is a Grade 3 or a Grade 4
Black in wound bed:
Black necrotic tissue in the wound bed
indicates a pressure ulcer Grade 3
Moisture lesions are superficial (partial-
thickness skin loss).
In case where the moisture lesion gets
infected, the depth and extent of the
lesion can be enlarged/deepened
There is no necrosis in a moisture
Moisture lesions often have diffuse or
If the redness is not uniformly
distributed, the lesion is likely to be a
moisture lesion (exclude pressure
and shear as causes).
Pink or white surrounding skin:
Maceration resulting from moisture.
An abrasion is caused by friction.
If friction is exerted on a moisture
lesion, this will result in superficial
skin loss in which skin fragments are
torn and jagged.
Necrosis starts without a sharp edge
but evolves into sharp edges.
Necrosis softens up and changes
color (eg, blue, brown, yellow, or
grey) but is never superficial.
Distinction should be made between a
black necrotic scab and a dried blood
Jagged edges are seen in moisture
lesions that have been exposed to
If the skin (or lesion) is red and dry or
red with a white sheen, it could be a
fungal infection or intertrigo.
This is often observed in the anal cleft.
Green in wound bed: Infection.
Be aware that zinc oxide ointments
may result in whitened skin.
While eosin is not recommended, it is
still used in some areas. It will turn
the skin red/brown and obstruct the
observation of the skin.
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FIGURE 1. Patient-related characteristics.
Try to find out the causes of the lesion:
Check the (wound) history in the patient record.
– If the lesion commenced as a large and deep lesion, it is unlikely that it is a moisture lesion.
– If the lesion developed after a long period of pressure and/or shear (eg, surgery, emergency department, radiology), even if the
pressure and/or shear are not currently present, it is likely the lesion is a pressure ulcer.
Which measures are taken/what care is provided?
– Superficial linear lesions are often caused by removing sticking plaster and are neither pressure ulcers nor moisture lesions.
– If the pressure ulcer does not improve despite pressure relieving measures and suitable dressings for more than 7 to 10 days, and
moisture is present, consider the possibility that the lesion is a moisture lesion.
– If the moisture lesion does not improve despite the use of skin barrier products and incontinence/moisture management for more
than 2 days, and pressure and/or shear is present, consider the possibility that the lesion is a pressure ulcer. Exclude the possibility
of contact sensitivity (eg, latex allergy). A dermatological consultation is recommended when in doubt about the diagnosis of
What is the skin condition at the different pressure points?
– If a pressure ulcer is present at another pressure point, it is likely this new lesion is also a pressure ulcer.
Check whether the movements, transfers, and position (changes) of the patient may have caused the lesion.
– If the affected area is a pressure point, a pressure ulcer is likely.
– If the affected area is not a pressure point, it is unlikely that the lesion is a pressure ulcer.
– If friction is exerted on a moisture lesion, this will result in superficial skin loss in which skin fragments are torn and jagged.
– Continuous friction causes abrasions.
– If shear deforms the superficial and deeper tissue layers, a pressure ulcer may be the result.
– If a lesion occurs on the heel, check if the lesion was caused by:
a) pressure and/or shear very likely a pressure ulcer
b) movement/transfer/shoes very likely a friction lesion/abrasion not pressure ulcer
If a patient is incontinent, consider whether the lesion is a moisture lesion or not.
– If skin barrier products are used in patients who are incontinent, then the chance that a new lesion is a moisture lesion is limited.
– If diapers or incontinence pads are often saturated, consider possibility of a moisture lesion.
Exclude other possible causes.
– Sometimes it can be difficult to differentiate between a moisture lesion and an infection, also characterized by irregular edges and
satellite lesions (‘islands in front of the coastline’). In these cases, the clinical picture (fever, leukocytosis) should differentiate from
– Other dermatological conditions should be considered when in doubt about the diagnosis of pressure ulcer or moisture lesion.
A dermatological consultation is then recommended.
Texture of the skin
Dead tissue feels dry/leathery and not pliable.
Temperature of the skin
Compare the temperature of the skin at the pressure point with the temperature of the surrounding skin. This may also be an
indicator for detecting Grade 1 pressure ulcer in patients with a darkly pigmented skin.
• If the temperature is higher than that of the surrounding skin, hyperemia is present and the lesion is recent.
• If the temperature is lower than that of the surrounding skin, the blood flow is limited and the lesion is not recent.
Pain is described in 37% to 87% of the patients with pressure ulcers.4Therefore, pain is not a discriminating characteristic for
Pain is caused:
a) by irritation of the sensory nerve endings in and around the ulcer;
b) when the wound is debrided;
c) when aids are applied too tightly (eg, tubes, drains);
d) when dressings rub against the surface of the wound;
e) when dressings that stick to the wound surface are removed.
Patients with pressure ulcers experience both acute and chronic pain and describe the sensation as burning, stinging, sharp, stabbing,
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■ References Download full-text
1. European Pressure Ulcer Advisory Panel. Guidelines on treat-
ment of pressure ulcers. EPUAP Rev. 1999;1:31-33.
2. Defloor T, De Bacquer DD, Grypdonck MH. The effect of a
pressure reducing mattress on turning intervals in geriatric
patients at risk of developing pressure ulcers. Int J Nurs Stud.
3. Defloor T, Schoonhoven L. Interrater and Intrarater Reliability
of the EPUAP Pressure Ulcer Classification System. Paper pre-
sented at the 2004 Second World Union of Wound Healing
Societies’ Meeting, July 8-13, 2004; Paris, France (pp. 56).
4. De Laat HEW, Scholte op Reimer WJM, van Achterberg T.
Pressure ulcers: diagnostics and interventions aimed at
wound-related complaints: a review of the literature. J Clin
■ Commentary by Dorothy Doughty
Dr DeFloor and the EPUAP have produced a thought-
provoking statement on differentiation of pressure ulcers
and moisture lesions, which coincides with similar issues
raised during the recent consensus conference held by
the National Pressure Ulcer Advisory Panel (NPUAP). The
EPUAP and NPUAP staging systems for pressure ulcers are
essentially equivalent; both use depth of breakdown as
the basis for wound “stage,” and both include partial-
thickness (Stage 2) lesions. Both of these systems were
developed when our understanding of the pathology of
pressure ulceration and other mechanical injuries was
limited; it made sense at that time to classify wounds based
on depth of tissue injury. As our knowledge base has grown,
however, we have realized that our staging system is fre-
quently problematic. One “problem” is that both partial-
thickness and full-thickness lesions are labeled as pressure
ulcers, although the current evidence suggests that pressure
ulcers are full-thickness injuries and that partial-thickness
lesions are generally a result of friction and maceration.
These are not just semantic issues; as the EPUAP statement
notes, accurate determination of causative factors is criti-
cal to the effective management of any patient with skin
breakdown, because effective management begins with
correction of the causative factors.
This document reflects the EPUAP’s recognition of and
response to this problem; it effectively highlights the im-
portance of differentiating between pressure ulcers and
moisture-related lesions, and it provides helpful guidance
to the clinician in conducting a thorough assessment and
in accurately interpreting the assessment parameters. As
noted, lesions caused by pressure or shear are typically full-
thickness lesions with regular borders, whereas lesions caused
by moisture or friction are typically partial-thickness lesions
with irregular borders. This document, however, also ac-
knowledges that these distinctions are not always as sim-
ple as they sound, because a lesion can be caused by a
combination of factors.
The NPUAP has also begun to deal with the many
complex issues related to pressure ulcer staging. The re-
cent consensus conference posed numerous questions, in-
cluding: “Are Stage 2 ulcers actually pressure ulcers (are
they caused by pressure)?” and “Should lesions caused by
factors other than pressure and shear be included in the
pressure ulcer staging system?” This conference stimu-
lated lively debate, and the WOCN’s contributions to this
conference will be highlighted in an article in the January
2006 issue the Journal of Wound, Ostomy, and Continence
Defloor et al
J WOCN ■ September/October 2005
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