Sixty men with spinal cord injury who had developed pressure ulcers in the past but whose skin was intact when they joined the study were followed for 2 years, or until a pressure ulcer developed. Forty of the men were contacted every 4-6 weeks to answer questions about their skin care practices and to provide a 24 hour urine sample. The others were only contacted at the beginning and the end of the study to answer a questionnaire and to provide a urine sample. Changes in skin collagen metabolism were monitored by measuring urinary excretion of a metabolite, glucosyl-galactosyl hydroxylysine (glu-gal Hyl), corrected for creati nine excretion. Sustained increases in levels of glu-gal Hyl excretion were detected at least 2 months and as much as 5 months in advance of overt clinical signs of ulcer development. Increased excretion of glu-gal Hyl was significantly associated (p < 0.05) with the development of a pressure ulcer. An increase in the urinary excretion of glu-gal Hyl is an indication of increased degradation of skin collagen. Body mass index (weight/height 2 ) of 33% of subjects with pressure ulcers, and 12% of those without, was at least one standard deviation below the mean of all subjects. Thirty-six percent of those who smoked developed ulcers, while only 26% of the nonsmokers did. The majority of the subjects who developed ulcers had injury levels above T6. Present age and time since injury were similar among those subjects who developed ulcers and those who did not. Subjects who developed ulcers were more likely to be unemployed, not attending school, and to have had a greater number of ulcers previously. There was no statistically significant difference between subjects who developed a pressure ulcer and those who did not with regard to beliefs about risk or severity of pressure ulcers and about the relative importance of various pressure ulcer prevention strategies. The data indicate that biochemical indicators, such as urinary excretion of glu-gal Hyl, and specific behavioral factors can be used to identify subjects at risk for developing pressure ulcers in time to institute vigorous preventative procedures to avoid skin breakdown.

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