Use of Munsell color charts to measure skin tone objectively in nursing home residents at risk for pressure ulcer development

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To assess the feasibility of classifying skin tone using Munsell color chart values and to compare Munsell-based skin tone categories to ethnicity/race to predict pressure ulcer risk.


Pressure ulcer classification uses level of visible tissue damage, including skin discoloration over bony prominences. Prevention begins with early detection of damage. Skin discoloration in those with dark skin tones can be difficult to observe, hindering early detection.


Observational cohort of 417 nursing home residents from 19 nursing homes collected between 2009–2014, with weekly skin assessments for up to 16 weeks.


Assessment included forearm and buttocks skin tone based on Munsell values (Dark, Medium, Light) at three time points, ethnicity/race medical record documentation, and weekly skin assessment on trunk and heels.


Inter-rater reliability was high for forearm and buttock values and skin tone. Mean Munsell buttocks values differed significantly by ethnicity/race. Across ethnicity/race, Munsell value ranges overlapped, with the greatest range among African Americans. Trunk pressure ulcer incidence varied by skin tone, regardless of ethnicity/race. In multinomial regression, skin tone was more predictive of skin damage than ethnicity/race for trunk locations but ethnicity/race was more predictive for heels.


Given the overlap of Munsell values across ethnicity/race, color charts provide more objective measurement of skin tone than demographic categories. An objective measure of skin tone can improve pressure ulcer risk assessment among patients for whom current clinical guidelines are less effective.

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