Erythema, or “redness”, is still used as a principal indicator for skin damage seen in moisture and pressure damage, and infection. Whilst erythema is more visible in less pigmented skin, where colour contrast is greater, this is not consistently seen across all skin tones, particularly in skin with higher pigmentation1,2. In skin with higher levels of pigmentation, including black, brown, and olive tones, redness may be harder to see, or appear as 1,2: Hyperpigmentation, or darkening of the skin Purple or bluish tones Grey or ashy changes Very slight differences compared to the surrounding skin These changes are commonly observed with pressure ulcers, moisture associated skin damage (MASD), dermatitis, radiotherapy induced skin reactions, burns and infected wounds. Holistic assessment of skin Undertaking a holistic assessment is an important part of wound care, and ensuring care is optimised for each individual’s needs3,4. This can include assessing a patient’s skin with an awareness of how skin tone can affect the appearance of damage, taking into consideration the person’s overall health and medical history and looking at non visual cues of skin damage. Non-visual cues Tactile assessment and sensation are as important as visual inspection when assessing the skin or a wound. How the skin feels to touch, and how a patient describes their symptoms, can provide early and valuable information that may not be easily visible3,4. These cues can help identify problems sooner and support more thorough and inclusive assessment across all skin tones. Assessing how the skin feels Increased warmth Pain or tenderness Itching, stinging, or burning Changes in texture Swelling Fragility or thinning of the skin Dryness, scaling, or skin breakdown These changes are often early indicators that the skin barrier may be compromised, or that a wound is deteriorating2,3,4. Identifying infection Early identification of infection is essential to prevent complications and delayed healing. Erythema can be an indicator of infection but may not always be visible. Infection should therefore be assessed using a combination of visual, tactile, and sensory signs, rather than colour alone. Signs of infection may include: Increased warmth compared to surrounding skin New or worsening pain or tenderness Swelling or skin breakdown, including weeping or delayed healing New or worsening odour Pus or foul-smelling discharge General signs of infection, such as fever or feeling unwell Awareness of these signs can help spot infection earlier, enabling faster assessment, timely treatment, and improved patient outcomes3,4. Inclusive care: A lack of visible redness or obvious colour change does not inherently mean the skin is healthy. Skin inspection should always be carried out with an awareness of skin tone, and as part of a holistic assessment. This includes looking at the skin, considering the person’s overall health and medical history, and thoroughly assessing any wounds present. If something feels different, uncomfortable, or abnormal, it should be checked, even if there are no obvious visual changes. For more information on this topic, make sure to check out the resources below: Flen health webinar: Radiotherapy induced skin reactions and early signs of damage in different skin tones: https://www.youtube.com/watch?v=C-qZOziN4eQ Article: https://www.flenhealth.co.uk/news/radiotherapy-skin-reactions-what-they-are-and-how-to-spot-them-in-different-skin-tones Best Practice Statement: Addressing skin tone bias in wound care: assessing signs and symptoms in people with dark skin tones: https://wounds-uk.com/wp-content/uploads/2023/02/191ac9b79f47de2896cf1a30f39037f5.pdf References British Association of Dermatologists (2021). Describing erythema in skin of colour. Available at: https://www.bad.org.uk/healthcareprofessionals/inclusivityandrepresentation/erythema-in-skin-of-colour Wounds UK (2023). Skin tone bias in wound care. Available at: https://wounds-uk.com/wp-content/uploads/2023/02/191ac9b79f47de2896cf1a30f39037f5.pdf Wounds UK (2023). Best practice statement: Addressing skin tone bias in wound care: assessing signs and symptoms in people with dark skin tones. London: Wounds UK. Available from: https://wounds-uk.com/best-practice-statements/addressing-skin-tone-bias-wound-care-assessing-signs-and-symptoms-people-dark-skin-tones/ Wounds International (2021). Wound care and skin tone: Signs, symptoms and terminology for all skin tones. London: Wounds International. Available from: https://woundsinternational.com/made-easy/wound-care-and-skin-tone/
