Tissue Destruction Classification Systems
Assessing the level of tissue destruction in wounds can be confusing and generate several
questions. Classification systems have been developed to assist with this task; however, some
are specific to etiology of the wound. The purpose of this document is to help clarify how to
assess the level of tissue destruction by providing information on the classification systems.
All Wounds
All wounds, regardless of etiology, can be assessed as either partial or full thickness.
Classification of Wound by Thickness of Tissue Destruction
Partial thickness
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Extends through the epidermis (first layer of skin), but not through dermis
(second layer)
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Full thickness
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Extends through epidermis and dermis; may involve subcutaneous tissue,
muscles, joint capsule, bone
Chapter 6: The General Evaluation in Wound healing: evidence-based management, [edited by] Joseph M.
McCulloch, Luther C. Kloth. 4th ed., F.A. Davis Company, Philadelphia, PA 2010.
Pressure Ulcers
Pressure ulcers are classified according to the most commonly accepted international classification system, which was
designed uniquely for pressure ulcers and should not be used for wounds of other etiologies.
International NPUAP-EPUAP Pressure Ulcer Classification System
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly
pigmented skin may not have visible blanching; its color may differ from the surrounding area. Further
description:
The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be
difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of
risk)
Category/Stage I: Nonblanchable
Erythema
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without
slough. May also present as an intact or open/ruptured serum-filled blister.
Further description:
Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to
describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
Category/Stage II
Category/Stage III
Category/Stage IV
*Bruising indicates suspected deep tissue injury
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.
Slough may be present but does not obscure the depth of tissue loss. May include undermining and
tunneling.
Further description:
The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear,
occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast,
areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not
visible or directly palpable.
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on
some parts of the wound bed. Often include undermining and tunneling.
Further description:
The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear,
occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV
ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule)
making osteomyelitis possible.
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or
brown) and/or eschar (tan, brown or black) in the wound bed.
Further description:
Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and
therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance)
eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.
Unstageable
Suspected Deep Tissue Injury
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of
underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful,
firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Further description:
Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a
thin blister over a dark wound bed. The wound may further evolve and become covered by thin
eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers:
clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009. www.npuap.org.
Venous Ulcers
The CEAP Classification of venous ulcer disease is a consensus statement, of which the C, or clinical
signs component is most frequently used. The C is based upon examination, whereas the other
components (E, A, P) require noninvasive vascular testing.
CEAP Classification
Class
C- Clinical signs
6 Grades, supplemented by (S) for
symptomatic or (A) for asymptomatic presentation
Symptoms: pain, aching, tightness, skin
irritation, heaviness, muscle cramps or other
complaints due to venous dysfunction
Example: C3A
E- Etiologic factors
A- Anatomic distribution
P- Pathophysiologic dysfunction
Descriptors
C0: No visible or palpable signs of venous disease
C1: Telangiectasies or reticular veins
C2: Varicose veins; distinguished from reticular
veins by having 3mm or more diameter
C3: Edema
C4: Changes in skin & subcutaneous tissue
C4a: Pigmentation or eczema
C4b: Lipodermatosclerosis or atrophie blanche
C5: Healed venous ulcer
C6: Active venous ulcer
Ec: Congenital
Ep: Primary
Es: Secondary (postthrombotic)
En: No venous cause identified
As: Superficial veins
Ap: Perforator veins
Ad: Deep veins
An: No venous location identified
Pr: Reflux
Po: Obstruction
Pr,o: reflux & obstruction
Pn: No venous pathophysiology identifiable
Eklöf B, Rutherford RB, Bergan JJ et al. Revision of the CEAP classification for chronic venous disorders:
consensus statement. J Vasc Surg. 2004;40:1248-52.
Sibbald RG, Williamson D, Contreras-Ruiz J et al. Venous Leg Ulcers. In: Krasner DL, Rodeheaver GT,
Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals , 4th ed.
Malvern, Pa: HMP Communications, 2007:429-442.
The venous clinical severity score (VCSS) augments the CEAP classification by assessing a patient’s
health related quality of life as a result of the symptoms of chronic venous insufficiency (CVI). Scoring
is based on ten clinical attributes that are ranked from zero to three as demonstrated by the following
table.
Venous Clinical Severity Score (VCSS)
MODERATE = 2
ABSENT = 0
MILD = 1
SEVERE = 3
ATTRIBUTE
PAIN
None
VARICOSE VEINS
None
VENOUS EDEMA
None
Evening ankle
swelling
SKIN
PIGMENTATION
None
Diffuse, but limited in
area and old (brown)
INFLAMMATION
None
INDURATION
None
Mild cellulitis, limited
to marginal area
around ulcer
Focal,
circummalleolar
NUMBER OF
ACTIVE ULCERS
ACTIVE ULCER
DURATION
ACTIVE ULCER
DIAMETER
COMPRESSION
THERAPY
0
1
Diffuse over most of
gaiter distribution
(lower third) or
recent pigmentation
(purple)
Moderate cellulitis,
involves most of
gaiter (lower third)
Medial or lateral, less
than lower third of
leg
2
None
<3 months
>3 months, <1 year
Not healed >1 year
None
<2 cm
2-6 cm
>6 cm
Not used or patient
not compliant
Intermittent use of
stockings
Wears elastic stocking Full compliance,
most days
stockings + elevation
Occasional, not
restricting activity or
requiring pain
medication
Few scattered
Daily moderate
activity limitation;
occasional pain
medication
Multiple; great
saphenous veins,
confined to calf and
thigh
Afternoon swelling,
above ankle
Dail, severe limiting
activities or requiring
regular use of pain
medications
Extensive: thigh and
calf or great and small
saphenous
distribution
Morning swelling
above ankle and
requiring activity
change, elevation
Wider distribution
(above lower third)
plus recent
pigmentation
Severe cellulitis
(lower third and
above) or significant
Entire lower third of
leg or more
>2
Collins KA. Classification of lower extremity chronic venous disorders. In: UpToDate, Basow DS (ed),
UpToDate, Waltham, MA, 2010.
Ricci MA et al. Evaluating chronic venous disease with a new venous severity scoring system. J Vasc Surg.
2003;38:909-915. Available via American Venous Forum at:
https://openaccess.leidenuniv.nl/bitstream/1887/1578/1/303_071.pdf . Accessed 2/26/11.
Diabetic Foot Ulcers
There are two commonly accepted classification systems for diabetic foot ulcers that were developed to
guide future surgical treatment and protocols. The Wagner scale, which was developed first,
incorporates depth, presence of cellulitis /abscess formation/osteomyelitis and aspects of arterial
circulation by assessing gangrene levels.
Wagner Scale for Diabetic Foot Ulcers
Grade
Description
Grade 0
Pre-ulcerous lesion, healed ulcer, bony deformity
Grade 1
Superficial ulcer without subcutaneous tissues involvement
Grade 2
Grade 3
Deep ulcer, penetration through the subcutaneous tissue; may have exposed bone,
tendon or ligament or joint capsule
Deep ulcer with cellulitis, abscess formation, or osteomyelitis
Grade 4
Localized gangrene of digit
Grade 5
Extensive gangrene involving whole foot
Wagner FW. The Dysvascular Foot: A system for diagnosis and treatment. Foot & Ankle 1981;2(2):64-122.
The University of Texas system stages diabetic foot wounds based on depth of the ulcer and whether
the wound is infected, ischemic, or both.
0
University of Texas Classification System of Diabetic Foot Ulcers
II
III
I
A
Pre-or post-ulcerative lesion
Superficial wound, not involving
tendon, capsule, or bone
Wound penetrating to tendon or
capsule
B
Pre-or post-ulcerative lesion
Pre- or post-ulcerative lesion,
completely epithelialized with
infection
Superficial wound, not involving
tendon, capsule, or bone with infect
C
Pre- or post-ulcerative lesion, Superficial wound, not involving
completely epithelialized
tendon, capsule, or bone with
with ischemia
ischemia
Wound penetrating to tendon or
capsule with ischemia
D
Pre- or post-ulcerative lesion, Superficial wound, not involving
completely epithelialized
tendon, capsule, or bone with
with infection and ischemia
infection and ischemia
Wound penetrating to tendon or
capsule with infection and ischemia
Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. Diabetes care
1998;21(5):855-858.