Guest Editorial: Stage 2 Pressure Ulcers Do Develop Granulation Tissue

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Marie Brown-Etris, RN, CWON

In a recent deposition transcript I reviewed from the defense perspective, plaintiff’s counsel questioned the certified wound specialist as to whether she was familiar with the National Pressure Ulcer Advisory Panel and if she commonly referred to their literature and authoritative texts. She responded, yes. She was asked if she used the NPUAP’s authoritative text in her usual and everyday practice. She responded, yes. She was asked if she taught the nursing staff at her acute care facility from the NPUAP literature and authoritative texts. She responded, yes.

In another legal matter involving a long-term care facility I reviewed from the plaintiff’s perspective, the electronic medical record was well designed and expanded the wound assessment area to prompt the nurse to fully assess the pressure ulcer. The category wound bed offered 8 choices; the option granulation tissue included the definition pink/red to beefy red, full-thickness. 

The presence of granulation tissue has definite implications for pressure ulcer staging. An accepted authority, the NPUAP now states that if granulation tissue is present, the pressure ulcer is definitely Stage 3.  But is it?

Background. I was asked to present a session on the differences between partial-thickness and full-thickness wound healing at the 1994 NPUAP Conference. Given the fact that wound healing by stage (reverse staging) was the acceptable/required manner of documenting healing pressure ulcers back then (with which I disagreed) and was required by our state Department of Health and the Centers for Medicare and Medicaid Services, I included this inaccuracy of pressure ulcer healing by stage in my presentation. The CMS ultimately acknowledged the fact that pressure ulcers do not heal by stage.

In my presentation at the 1995 NPUAP conference and subsequent publication “Measuring Healing in Wounds,” I discussed the anatomy and physiology of skin, tissue destruction and the healing process, and the reparative process of full-thickness wound healing versus the regenerative process of partial-thickness wound healing. I elaborated on the deep dermal wound and described it as a hybrid of partial-thickness and full-thickness tissue healing owing to granulation tissue formation and cell contraction. Superficial (and avascular) partial-thickness wounds heal rapidly by tissue regeneration that is commonly referred to as resurfacing or reepithelialization; deep partial-thickness wounds involve the dermis, a highly vascular tissue layer that when injured progresses through the same series of events and steps to repair as full-thickness wounds. These facts are supported by the literature. Two additional differences distinguish deep, dermal partial-thickness from full-thickness wounds: because of the lack of wound depth, granulation tissue formation and cell contraction are more subtle and rapid and reepithelialization occurs simultaneously from the wound margins as well as from the dermal appendages (hair follicles, sebaceous glands, and sweat glands) located across the wound’s surface.   

Changes. In January 2015, the NPUAP formed a task force to revise the staging system and artwork to further clarify and refine the system and to develop new nomenclature relevant to pressure-related soft tissue injury. Outcomes were presented and discussed at the NPUAP Staging Consensus Conference in April 2016 and were later presented at the Wound Ostomy Continence Nurses Society/Canadian Association for Enterostomal Therapy Joint Conference in Montreal in June 2016. The NPUAP definition has been changed to the following:

Stage 2 pressure injury: partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist (important note: granulation tissue is red and moist) and also may present as an intact or ruptured serum-filled blister. Adipose (fat) and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. 

Stage 3 pressure injury: full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) often are present. Slough and/or eschar may be visible.

Stage 4 pressure injury: full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole, undermining, and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, the ulcer is noted to be unstageable.  

Of note: granulation tissue can be present in a Stage 4 pressure injury once healing commences. When a Stage 4 wound heals to the point of no or minimal depth, it can easily be miscategorized as a Stage 3 or Stage 2 pressure injury. This often happens when a patient’s wound is assessed by another health care provider or the care delivery setting is changed, such as with a transfer, because the continuity has been lost.  

Potential implications of this new NPUAP staging definition inaccuracy. The following are the possible implications of a nurse or physician accurately identifying granulation tissue.  

  1. A wound ostomy continence (WOC) nurse educator for a large national wound care company has been mandated to teach according to the NPUAP Guidelines, and if the NPUAP considers granulation tissue to be a determining factor for the identification of Stage 3, so be it.
  2. As of 2009, Stage 3 and Stage 4 acute care nosocomial pressure ulcers are reportable events to the State Department of Public Health by the National Quality Forum. They are also reported to federal agencies via the quality department for quality indicators. If the acute care facility is seeking Magnet status, the American Nurses Credentialing Center also must be notified. Money is withheld from Medicare for these wounds.
  3. In a medical malpractice case, when a nurse or physician documents the presence of granulation tissue, plaintiff’s counsel can claim the pressure ulcer deteriorated to Stage 3. 

As stated so eloquently by Laura Bolton, PhD, a renowned scientist in our wound healing community, “all of the consensus in the world cannot change the biology of healing…dermal healing requires proliferation…forming granulation tissue” in her letter to the editor published in Ostomy Wound Management in June 2016. Wound healing researchers who have spent their entire careers looking through a microscope are now clarifying this NPUAP inaccuracy, and further stating the fact that Stage 2 pressure injuries do, indeed, develop granulation tissue.

Given the abundance of wound research, clinical evidence, and opinion of our scientific partners, I would now formally request that the NPUAP change its position and state in its definition that Stage 2 pressure injuries granulate. 


Ms. Brown-Etris is President, Etris Associates Incorporated, Churchville, PA. Please email her at: This article was not subject to the Ostomy Wound Management peer-review process.