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The phenomenon of skin failure as distinct from pressure ulcers has been documented in the adult literature. However, in the pediatric population, skin injury continues to be grouped indiscriminately as various types of pressure ulcers.To identify and describe the phenomenon of skin failure in critically ill children.Retrospective chart review of 19 patients who had serious skin injuries develop. Organ dysfunction scores, medications, pressure ulcer prevention techniques used, and laboratory values in the 7 days leading up to the development of a skin lesion were evaluated.At the start of the evaluation period, all patients (N = 19) had pressure ulcer prevention measures in place before the development of a serious skin injury. All of the skin lesions were full-thickness injuries on the day they were identified (as opposed to the more gradual progression from simple to complex skin injuries typically seen in pressure ulcers). As predicted, 18 of 19 patients had multiple organ dysfunction syndrome (MODS) in the week leading up to the skin injury. All patients with MODS had at least 2 dysfunctional systems, and 12 patients had 4 or more dysfunctional systems. Of the 19 patients, 8 (42%) progressed to death, compared with 1.8% in our general pediatric intensive care unit population.Although the traditional paradigm is that pressure ulcers are preventable, a subset of pressure ulcers in critically ill children may actually represent acute skin failure as a consequence of MODS.