What are the levels of skin breakdown and how many are there?
Answer
There are four levels of skin breakdown. The first level is hyperemia. This can be seen within 30 minutes, usually appears as redness, and if you change the patient’s position and alleviate the pressure, usually the redness will be gone in approximately an hour. Ischemia is where the tissue is starting to not get the blood flow it needs and that is when it can start to cause some skin damage. This occurs after two to six hours of continuous pressure, and may actually take up to 36 hours to be alleviated once the pressure is removed, but it can be reversed. The next level is necrosis. This occurs after 6 hours of continuous pressure. The skin may turn blue or gray and may become indurated or firm. This necrosis may or may not disappear once the pressure is removed, and would actually lead to the ulceration which is level IV. Ulceration may occur within two weeks after necrosis and you may get potential infection. However it is important to keep in mind that it does not take up to two weeks for these pressure ulcers to occur.
Jennifer Gardner-Harbison, PT, DPT, MHA, CWS
Dr. Gardner-Harbison has been a physical therapist since 1997, with the last 20+ years concentrated solely on wound care. She has been a Certified Wound Specialist since 2001. Prior to entering the industry, she served as the Manager of Wound Care and Hyperbaric Oxygen at Inspira Medical Center Woodbury for 10 years. In 2017, she moved to the industry side of wound care. In 2026, she returned to her PT roots and joined Fox Rehab. Dr. Gardner also sat on the APTA Integumentary Specialty Council for 3 years, during which the first certification exam for Wound Management Clinical Specialist was administered. After her term on the Council, she also served as a subject matter expert for the Wound Management Certification exam.
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