Skin and Tissue Assessment
Published online: 07 May 2026
Suggested citation
National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Skin and Tissue Assessment. In: Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline: Fourth Edition. Emily Haesler (Ed.). 2026. [cited: download date]. Available from: https://internationalguideline.com.
Introduction
The purpose of assessing the skin and tissues is to identify any signs and symptoms of skin and tissue alteration, and to determine the cause of the alteration. In the context of pressure injuries (PIs), the condition of the skin and its underlying soft tissue can indicate early signs of pressure damage.
Various skin alterations, including, but not limited to, skin dryness (1, 2), overhydration of the skin surface or inflammation, might be associated with PI development. However, these signs can also indicate other skin disorders (e.g., incontinence associated dermatitis, Intertriginous dermatitis, medical adhesive related skin injury, etc.) so differentiation is important. Excess moisture on the skin surface (e.g., due to increased perspiration or incontinence) increases vulnerability of the skin to damage including skin maceration, pressure and shear forces (3). In addition, individual factors such as advanced age, medications (e.g., steroids), or chronic diseases (e.g., diabetes mellitus) also impact the susceptibility and tolerance of the skin to conditions that increase PI risk (3).
Regular and comprehensive skin and tissue assessment is a key component of PI risk assessment that informs the development and implementation of a PI prevention plan.
Visual and Tactile Skin and Tissue
Assessment
A usual/minimum standard of care for skin and tissue assessment of pressure points involves visual (i.e., inspection) and tactile assessment (i.e., palpation) of the skin for breaks in skin integrity and/or color changes in relation to surrounding skin. Persistent erythema may be seen in light skin tones. In medium to dark skin tones, the relative change in skin color from the individual’s usual skin tone (especially further darkening of the affected area) can be indicative of early tissue damage.
The usual/minimum standard of care also involves palpation for differences in skin temperature (warmer or cooler) and tissue consistency between pressure points and surrounding tissue. There is a growing body of evidence that identifies skin temperature as a potential risk factor for PIs in adults (4). This is under-explored in neonate and child populations.
STA1: Good Practice Statement
It is good practice to include feedback from the individual and carer, and to use a range of assessment techniques to comprehensively assess the skin and soft tissues. Assessment techniques should be appropriate to the individual’s skin characteristics and tone, risk profile, clinical condition and care setting and age group and may include:
Comprehensive visual skin assessment with a focus on bony prominences and under medical devices,
Finger/transparent disc press for blanching or non-blanching erythema,
Inspection, touch and palpation for changes in skin and tissue temperature (warmer from inflammation or cooler from ischemia), texture and consistency (harder or softer than normal tissue), and presence of scar tissue,
Assessment for localized pain at bony prominences/pressure points and under medical devices, and
Assessment for changes in skin color in comparison to surrounding skin.
More information
Clinical question: What usual bedside techniques should be used when assessing the skin and tissues?
Implementation considerations
Document the findings of all skin and tissue assessments and communicate the results with the interdisciplinary team, and the individual and their carer as appropriate.
Ask the individual about changes to their skin using direct questions (15).
Ensure there is adequate lighting when undertaking an assessment of the skin and tissues. Where possible, use halogen or natural ambient light, and consider using a torch/penlight/flashlight/smartphone light (5, 7, 28).
Cleanse the area of skin being assessed and remove topical skin products, including lifting preventive dressings (7).
Perform bilateral or symmetrical anatomical comparisons (e.g., compare pressure points on either side of the body) to detect skin changes indicative of early PIs more effectively (5, 7, 15, 19).
Ask the individual to identify areas of localized pain at every skin assessment (15). Localized pain at pressure points is a potential symptom of PIs (5, 10, 11, 12, 15). Be aware that some individuals cannot perceive or communicate pain due to comorbidities.
Encourage individuals and their carers to perform skin and tissue inspection. Provide education and engage the individual in the assessment process.
Visual skin assessment
Assess the full skin surface, including underneath medical devices and skin folds. Gently lift and separate skin folds for full assessment of underlying skin and tissue, including under pendulant breasts and between the buttock cheeks.
Consider using a skin tone chart designed for assessing pigmentation to establish baseline skin tone as compared to the assessment area. Assess the baseline skin tone at the individual’s inside upper arm (7, 14, 15) or another area with low exposure to ultraviolet light (7). Continue to use the same skin tone assessment tool for repeat assessments comparing baseline skin tone to changes in skin tone.
Observe the visual appearance of skin for subtle color changes such as deeper or lighter skin tone in the assessment area as compared to the adjacent skin or skin on the opposite side of the body (5, 19).
Perform the finger pressure method to evaluate erythema by pressing a finger on erythema on intact skin for three seconds. Look for blanching of color under finger with return of erythema after finger removal (13, 29). Alternatively, a transparent disk can be used to apply pressure equally over an area of erythema while observing for blanching underneath the disk (13, 29).
Perform the finger or transparent disk pressure method at several measurement points to assess erythema over larger areas.
Tactile skin and tissue assessment
Palpate bony prominences/pressure points to identify skin warmth or coolness in relation to surrounding skin. A comparison can be made by palpating anatomical locations that have not been recently pressure loaded (5). As areas of skin and tissue become inflamed and edematous, the skin may feel warmer in contrast to intact, undamaged skin and tissue (5). As underlying tissue become ischemic, the skin may feel cooler in contrast to intact, undamaged skin and tissue (6).
Be aware that other factors, including but not limited to, comorbidities (e.g., infection, vascular conditions, skin changes at the end of life etc.), the support surface type or the ambient environment can influence skin temperature (4, 30). This indicator should be considered within the context of the full skin and tissue assessment.
Palpate to identify tissue of softer or harder consistency, palpable edema and texture changes (31).
Additional implementation considerations for special populations
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Be aware that many skin conditions, including but not limited to maceration, inflammation, intertrigo, fungal rashes, present differently in medium to dark skin tones (5, 19). Most descriptors of these conditions are focused on light skin tones. Therefore, differential diagnosis is more complex.
Do not rely on visual changes in skin color (e.g., presence of erythema or blanching) alone because skin color changes are not easily identifiable in medium to dark skin tones (32). Augment a visual skin assessment with palpation to assess skin and tissue consistency and temperature and assessment of the individual’s pain. Consider using advanced technology to augment the assessment when available.
Use tangential light and slightly moisten the skin to aid in the detection of early pressure injury in dark skin tones (5).
Do not rely on characteristics such as ethnicity or race because these are not objective or determinants of skin tone (7, 14).
Involve individual and caregiver in assessing normal skin and signs of change that may indicate early pressure injury (33).
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Include the occiput in a head-to-toe skin assessment for neonates and young children because their comparatively larger head circumference places them at higher risk for occipital PIs than older children and adults (34).
Minimize heat loss during the head-to-toe skin assessment to limit the risk of temperature instability/cold stress (35).
Move the hair to visually inspect the scalp.
Be aware of the expected presentation of the skin and tissues based on the neonate/infant/child’s age, particularly for preterm and full-term neonates (36). Do not use the finger press method or transparent disc in premature infants of less than 30-week gestation. It can be difficult to identify blanchable versus non-blanchable erythema in this population (36).
When assessing the skin of a premature infant, cover the individual’s eyes when using a light. The premature infants’ eyes are still developing, and the light can damage the developing retinas (37).
Assess under medical devices. Device related PIs are more common in children and neonates. In premature infants of less than 30-week gestation, typically the skin color changes are noted as the medical device is removed.
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Assess the full surface area of the skin. Support the weight of the pannus and other skin folds to ensure the full skin surface is assessed.
Assess the skin for signs of moisture associated skin damage (MASD) and other abnormalities, paying particular attention to skin folds (26, 27).
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Assess malnourished individuals with less subcutaneous fat over at-risk sites; bony sites are more prominent and suspectable to pressure injuries.
Position off bony prominences as much as possible with positioning strategies that specifically offload the most prominent areas. Consider prophylactic dressings.
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Highlight the importance of good lighting to optimize a skin and tissue assessment (e.g., natural lighting, torch/flashlight or smartphone light).
Teach the individual and their informal caregivers to perform regular visual and tactile skin assessments, including assessing pressure points during routine activities (e.g., washing, dressing and repositioning).
Encourage use of hand-held mirrors/smartphone camera to inspect hard-to-see areas such as heels, sacrum, buttocks and under the abdominal pannus or other skin folds.
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Be aware that individuals with neurological conditions may not be able to perceive early signs of pressure damage such as localized pain.
Supporting information
Early identification of changes in skin and tissue color, skin temperature and tissue consistency enables implementation of an appropriate PI prevention and treatment plan (5). Localized warmth (5, 6, 7, 8), edema (5, 7), and change in tissue consistency in relation to surrounding tissue (e.g., induration/hardness) (5, 7) are warning signs for PI development. Areas of scar tissue from previous pressure injuries, operative repair of pressure injuries or trauma lack full tensile strength and may be particularly vulnerable to pressure (9). Additionally, several studies also offer some indication that pain over the site is a precursor to tissue breakdown (10, 11, 12).
Assessing erythema
Assessment for erythema and differentiation between blanchable and non-blanchable erythema by pressing on the skin and making a visual assessment for changes associated with pressure damage is best practice (13). Blanchable erythema is indicative of normal reactive hyperemia (i.e., the capillaries retain normal structure and function) that will dissipate over time. Non-blanchable erythema may indicate inflammatory changes in the capillaries (e.g., endothelial dysfunction, margination of white blood cells, loss of intra-capillary fluids to the interstitial space). At a minimum non-blanchable erythema indicates poor capillary refill and impaired capillary function to an area of tissue, although this may not be visible in medium and dark skin tones.
Skin and tissue assessment in individuals with medium and dark skin tones
Assessment for erythema as discussed above is more challenging in medium to dark skin tones in which erythema may not be visible. In particular, visual assessment alone may not be sufficient. Early signs of pressure damage can present differently in medium to dark skin tones than in light skin tones (14, 15). For example, early tissue damage may present as hyperpigmentation, subtle darkening or hue changes (e.g., blue/purplish tone) (16) on the skin or may not be visible at all. Because traditional training has under-prepared clinicians to identify early pressure-related skin and tissue changes, pressure damage is often identified at more advanced stages in individuals with medium to dark skin tones (17, 18). Therefore, it is important to assess for other indicators of skin and tissue damage, including localized heat, focal edema, and change in tissue consistency in relation to surrounding tissue (e.g., induration/hardness) (15, 19). When assessing medium to dark skin tones, comparison of the skin and tissue to adjacent areas assists in identifying if changes are present.
One approach is to use a skin tone chart to identify the individual’s baseline skin tone and cue clinicians that there is a need to use special assessment techniques to identify changes that might indicate tissue damage. Numerous tools are available to measure skin tone. Each has its strengths and weaknesses (see resources for more information about skin tone tools).
Skin and tissue assessment in individuals with increased body fat and/or skin folds
Increased body weight and skin folds (e.g., due to overweight, obesity or following significant weight loss) can make it difficult to view bony prominences and the skin. The weight of the pannus (the abdominal fat and the skin fold apron) can cause PIs to develop in areas such as the sacrum, heels, hip, pubis, thighs and torso. Pressure injuries may also develop in areas of high adipose tissue concentration, due to the additional tissue weight that exerts pressure, and contributes to vascular occlusion and tissue deformation. Therefore, PIs may develop in unique locations, such as underneath folds of skin and in locations where tubes and other devices have been compressed between skin folds. Skin problems associated with obesity include: maceration, inflammation, intertriginous dermatitis and tissue/skin necrosis, especially in large and deep skin folds, which can be exacerbated by a fragile vascular and lymphatic system, increased diaphoresis (26) and increased risk for fungal or bacterial infection (27). Therefore, inspection of the full skin surface when undertaking a comprehensive skin and soft tissue assessment is essential.
Resources
Skin tone tools
Detailed descriptions of various tools can be found in literature reviews and clinical studies (20, 21, 22); however, there are few reliability and validity studies. The three most commonly used skin tone tools in non-dermatological general clinical settings are:
Fitzpatrick Skin Type Scale,
Monk Skin Tone Scale (20), and
Robinson-Ho Skin Tones Tool (23, 24, 25, 26).
The Fitzpatrick Scale is a six-category color scale originally designed to evaluate sensitivity to UV light and takes ethnicity into consideration. The Monk Scale is a 10-category scale that has been used to train AI facial recognition programs. The Robinson-Ho Skin Tones Tool is a six-category scale, with each category including multiple tones (from two to five tones in each category) that is designed to assess skin cancer risk and requirement for sun protection (26).
Weir et al. (2025) (22) asked two independent clinicians to assess 64 subjects representing a wide range of skin tones. Interrater reliability was 0.75 (linear Cohen kappa) for the Monk Scale and 0.66 for the Fitzpatrick Scale. Interrater reliability was more stable across anatomical sites for the Monk Scale than the Fitzpatrick Scale. To determine which skin tone measures are most inclusive Heldreth et. al. 2024 (27) recruited 2,214 subjects representing a wide range of skin tones. Subjects were randomly assigned to one of three skin tone scales and asked to rate how well their skin tone was represented in the scale. The Fitzpatrick Skin Type Scale was identified as significantly less representative of skin tone (especially in those with dark skin tones) than the Monk Scale (p<0.01). When the Monk Scale was compared to a 40-category scale (i.e., Fenty Scale) there were no significant differences, indicating that there was no real advantage in using a more complex 40-category scale. Using a modified version of the Robinson-Ho Skin Tones Tool the overall agreement between study unit clinical nurses and research team nurses was 0.49 (SE 0.05) (p>0.001) with a 95% confidence interval (CI) of 0.38 to 0.60 (23).
Skin tone tools may be limited by (7, 20, 21, 28):
the wide variability in melanocyte concentration (and therefore skin tone) across the body,
the often-observed variability between certain anatomical areas (e.g., skin folds, joints, groin creases, etc.), and
the surrounding skin, and
the conditions under which they are used (e.g., lighting).
Some of these limitations can be addressed by developing protocols that require (25):
natural (not fluorescent) lighting for conducting the skin tone assessment,
use of a consistent body site for determining baseline skin tone; this should be an anatomical site that is not usually exposed to UV light (e.g., underside of upper arm), and
consideration factors that can influence skin tone (e.g., sunburn).
STA2: Good Practice Statement
It is good practice to assess the vascular/perfusion status of the lower limbs, feet and heels when performing a skin and tissue assessment.
Clarifiers:
Poor perfusion from peripheral arterial disease (or other causes) increases the risk of pressure injury; these areas require special attention during skin and tissue assessment.
Bedside assessment of perfusion status may include skin temperature, presence/absence of peripheral pulses, capillary refill time , changes in skin color or sensation and skin appearance. Thin, shiny skin and loss of leg hair are considered signs of peripheral arterial disease.
More information
Clinical question: What usual bedside techniques should be used when assessing skin and tissues?
Implementation considerations
Consider the individual’s clinical condition, medical history and risk factors for feet and heel and foot PIs, including vascular disease, diabetes mellitus, and having a previous heel PI. Also consider decreased sensation and/or mobility in the lower limbs from peripheral neuropathy, spinal cord injury or other neurological conditions
Inspect the skin of the feet and heels regularly, even if a prophylactic dressing is in situ.
Comprehensively assess the skin and tissues of the lower limbs/ feet/heels, with a goal of evaluating vascular supply to the heel.
Bedside skin and tissue assessment
Bedside assessments may include (but are not limited to):
Skin temperature,
Presence or absence of peripheral pulses of the arteries that perfuse the heel, particularly the posterior tibial artery that supplies the heel,
Capillary refill time (45, 46, 47),
Skin color (e.g., pale, hemosiderin staining, etc.),
Quality and appearance of skin and its structures (e.g., shiny, presence or absence of hair), and
Sensation to touch or the individual’s report of diminished sensation.
Additional assessments
Perform or refer the individual for additional assessments of vascular and neurological status (e.g., ankle brachial pressure index, toe brachial pressure index, monofilament testing) when indicated.
Refer to clinical guidelines focused on assessing the lower limb (48, 49) and/or diabetic foot (50) when selecting appropriate additional assessments.
Consider using infrared thermography with imaging if available as it may identify areas of poor perfusion (51).
Advanced assessment
Refer individuals with a suspected or known compromised vascular status to a vascular specialist or podiatrist as indicated for advanced assessment (e.g., Doppler wave forms, plethysmography, pulse volume recording, segmental pressures, transcutaneous oxygen evaluation, angiography) (52).
Additional implementation considerations for special populations
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Educate individuals and caregivers to inspect heels and feet regularly, including when offloading devices or prophylactic dressings are in place.
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Do not apply pulse/oxygen probes to the lower limbs of infants or children aged less than eight years when there is a concern regarding decreased vascular perfusion.
Supporting information
The heel is considered an anatomical area that is particularly vulnerable to pressure damage due to factors such as the heel anatomy, comorbid conditions (e.g., peripheral arterial disease) and the aging process (41, 42, 43). Vascular status is particularly significant to the prevention and treatment of heel PIs (41, 44), and should be included when conducting a comprehensive assessment of the skin and tissue at the heels. Consideration should be given to the clinical assessment, as well as the individual’s past clinical history, previous heel pressure injuries, and current physical and medical status (see guideline chapter Preventing Heel Pressure Injuries). Suggested clinical guidelines on peripheral arterial disease that include more on screening and diagnosis are provided in the resources.
Resources
Peripheral arterial disease guidelines
Many vascular and diabetes-focused organizations have developed guidelines for screening, assessment and management of peripheral arterial disease, including but not limited to the following:
Combined associations of the United States of America (a collaboration of 11 associations focused on medical practice in the USA) (54)
European Society for Vascular Surgery (ESVS) (57)
Frequency of skin and tissue assessment
STA5: Good Practice Statement
It is good practice to conduct a comprehensive, head-to-toe skin and tissue assessment for all individuals:
● As soon as possible after admission/transfer to the healthcare service,
● As a part of every pressure injury risk assessment,
● Periodically as indicated by the individual’s clinical status and evolving pressure injury risk,
● Whenever the individual’s clinical condition worsens,
● When there is a transition of care (including completion of a surgical or radiological procedure) and
● Prior to discharge from the care setting.
More information
Clinical question: When should a skin and tissue assessment be conducted?
Supporting Information
The timing and frequency of comprehensive skin assessments may vary between settings and with the individual’s clinical condition and risk status. Suggested frequencies and timing are provided to support prompt enhancements in prevention strategies with early skin changes and early recognition and treatment of new pressure injuries.
STA6: Good Practice Statement
It is good practice to inspect the skin over bony prominences/pressure points that are visible during repositioning.
More information
Implementation considerations
Frequency of comprehensive, head-to-toe skin and tissue assessments
Prioritize the performance of a baseline skin inspection following admission to a healthcare service.
At the organizational level, ensure that a complete skin assessment is considered a part of the PI risk assessment process.
Conduct a comprehensive, head-to-toe assessment by focusing on:
Skin overlying bony prominences, including the sacrum, heels, hip, pubis, thighs and torso.
Skin and soft tissues underneath medical devices (see Device Related Pressure Injuries),
Skin and soft tissues underneath prophylactic dressings (see Preventive Skin Care), and
Skin folds.
Document the findings of all skin assessments, including clinical photography.
Increase the frequency of skin assessments in response to deterioration in the individual’s overall condition, when consistent with their management plan and goals of care.
Supplemental inspection of skin during repositioning
Perform a visual check of the skin for signs of early damage during repositioning. This can be limited to the bony prominences/pressure points that are visible during repositioning. Palpate areas where skin abnormalities are observed.
Avoid positioning the individual on anatomical areas with erythema, new skin color change that is lighter or darker than the surrounding skin, or tissue alterations when possible.
Develop local procedures for roles and responsibilities associated with performing, reporting and documenting skin and tissue assessments and their findings. Consider the scope of practice for different health professionals and implement processes to ensure abnormal/concerning clinical findings are escalated for further investigation and/or review of the individual’s PI prevention plan.
Follow-up with a more comprehensive skin assessment by qualified licensed personnel when skin changes are noted during repositioning.
Implementation considerations for special populations
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Conduct a comprehensive skin and tissue assessment as early as possible on entry to community care and following transition from other care settings.
Encourage the individual and their carer to observe pressure points at each repositioning or mobility activity and during routine hygiene activities.
Consider recommending telehealth consultations if available. Include review of photo documentation and video consultation for improved early detection of PIs to reduce hospital admissions (58).
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Assess the occiput whenever the individual is repositioned (37).
Supporting Information
In addition to comprehensive skin assessment, a brief/targeted inspection of the skin and tissue at pressure points should be undertaken during repositioning to identify any alterations in condition, determine that the skin and tissue have fully recovered from previous loading, and to evaluate the effectiveness of the repositioning regimen. If identified, the presence of persistent erythema and/or tissue changes can indicate a need to increase frequency of repositioning. Erythema may not be visible in medium to dark skin tones. This is not intended as a comprehensive skin assessment but brief inspection of the pressure points that are visible during repositioning. Abnormalities would indicate a need for more comprehensive assessment.
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