What happens when the skin fails?

Multiple Organ Dysfunction Syndrome (MODS) in the Acute Care Patient

MODS is the physiologic abnormality involving two or more organ systems simultaneously.

Multiple Organ Dysfunction Syndrome is the physiologic abnormality involving two or more organ systems simultaneously. It’s a process, rather than a single event, and is categorized as a dysfunction because of its potential for reversal. In acutely ill patients, the altered organ function hinders the body’s ability to maintain homeostasis. MODS typically involves the following organ functions: respiratory, cardiovascular, renal, hepatic, neurologic, and/or hematologic, while often including the immune and endocrine systems as well. So why not the skin? It is, after all, the largest organ in the human body. 

The integumentary system includes the epidermis, dermis, hypodermis, associated glands, hair, and nails. It functions as a physical barrier between the external and internal environments, protecting against pathogens, promoting immunity, and initiating wound healing. The skin is indispensable. But the debate still wages among healthcare workers on the concept of total skin failure. In the early 90s, clinician John La Puma connected the dots between organ and skin failure. His view was if organs such as the heart or kidneys were failing, it stood to reason that the skin could fail as well.

Skin failure is categorized as acute, chronic, and end-of-life. In the acutely ill patient, changes in the skin are directly linked to the illness at hand. Hypoperfusion causes the skin and underlying tissue to die synchronous with multiple organ failure. Further opinion identifies that when tissue tolerance is so severely compromised, cells cannot survive in the midst of impairments such as hypoxia or mechanical stresses. This included pressure injuries occurring concurrently with skin failure on the same patient.

While there are no clear-cut criteria for diagnosing acute skin failure (ASF), there is agreement that ASF is not a pressure injury. As such, it can’t always be prevented or treated with conventional methods. The fact remains that the skin is the largest organ in the body, and — while often excluded from MODS — it is as susceptible to failure as any other organ system. Unfortunately, until the pathophysiology of MODS-like occurrences is fully understood, pressure injury formation cannot be completely avoided.

Asim, M., Amin, F., & El-Menyar, A. (2020). Multiple organ dysfunction syndrome: Contemporary insights on the clinicopathological spectrum. Qatar medical journal, 2020(1), 22. https://doi.org/10.5339/qmj.2020.22

Kim, J. H., Shin, H. K., Jung, G. Y., & Lee, D. L. (2019). A case of acute skin failure misdiagnosed as a pressure ulcer, leading to a legal dispute. Archives of plastic surgery, 46(1), 75–78. https://doi.org/10.5999/aps.2018.00087

Kim JY, Dao H. Physiology, Integument. (2022). [Updated 2021 May 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing: https://www.ncbi.nlm.nih.gov/books/NBK554386/

Ayello EA, Levine JM, Langemo D, Kennedy-Evans KL, Brennan MR, Sibbald GR. (2019) Reexamining the literature on terminal ulcers, SCALE, skin failure, and unavoidable pressure Injuries. Adv. Skin and Wound Care. Wolters Kluwer Health, Inc.