Skin and Wound Care

Skin Tears

  • Skin tears are “a traumatic wound caused by mechanical forces, including removal of adhesives. Severity may vary by depth (not extending through subcutaneous layer).” (LeBlanc et al, 2018)
  • Skin tears are traumatic wounds that may result from a variety of mechanical forces such as shearing or frictional forces, including blunt trauma, falls, poor handling, equipment injury or removal of adherent dressings.1
  • In already fragile or vulnerable skin (e.g., in aged or very young skin), less force is required to cause a traumatic injury, meaning that incidence of skin tears is often increased.1
  • Skin tears can occur anywhere on the body, but are particularly common on the extremities.2

Intrinsic factors

Aging: normal aging process causes changes to the skin that impact fragility of the skin and make it more vulnerable to damage. 

  • Changes to the skin associated with aging:
    • thinning of the epidermis and flattening of the epidermal junction
    • loss of  collagen, elastin and glycosaminoglycans 
    • atrophy and contraction of the dermis
    • decreased activity of the sweat glands and sebaceous glands, causing skin to dry out
    • thinning of blood vessels wall and reduction of blood supply to extremities

Extrinsic Factors

Patients who require assistance with ADLs are at an increased risk for skin tears due to handling and force or trauma.1

  • General health:
    • Altered sensory, auditory and visual status
    • Cognitive impairment: aggressive behavior, dementia 
    • Chronic/critical disease
    • Polypharmacy: can lead to pharmacological interactions, cognitive decline, unsteady gait and skin reactions3
    • Nutritional concerns: malnutrition and dehydration can affect skin integrity2
  • Mobility2:
    • History of falls
    • Decreased level of mobility: ability to reposition independently, having spasticity
    • Use of mobility devise or aids: unsteady gait, transfers, blunt trauma from bumping into objects
  • Mechanical trauma: use of adhesives on fragile skn

Prevention: Key is to Protect Skin from Trauma

  • Inspect skin daily
  • Avoid use of adhesives on skin; use silicones when appropriate or paper tape
  • Hydrate skin with moisturizers twice daily, especially after bathing
  • Use warm, not hot, water for bathing
  • Use soap-free, no-rinse skin cleansers and/or pH-neutral skin cleansers
  • Protect skin from trauma by encouraging patient to wear long sleeves and pants to cover extremities
  • Avoid sharp fingernails or jewelry in patient contact (for client and healthcare provider)
  • Avoid friction and shearing forces during repositioning and transfers (consider use of glider sheets and other assistive devices)
  • Use padding for equipment and furniture (e.g., foam pads on corners, wheelchairs, bed rails)
  • Ensure a safe environment: adequate lighting, remove obstacles
  • Falls risk assessment and interventions
  • Optimize nutrition and hydration
  • Optimize health status
  • Consider possible effects of medications and polypharmacy on patient's skin

Classification1

Skin Tears should be classified using the ISTAP (2013) classification system.

  • Type 1 Skin Tear: No skin loss
    • Linear of flap tear where the skin flap can be repositioned to cover the wound bed
  • Type 2 Skin Tear: Partial Flap Loss
    • The skin flap cannot be repositioned to cover the whole wound bed
  • Type 3 Skin Tear: Total Flap Loss
    • Total skin flap loss that exposes the entire wound bed

Skin Tears: Types 1, 2 and 3

Figure used with permission from ISTAP: Retrieved December 17, 2019 from http://www.skintears.org/wp-content/uploads/2019/03/ISTAP-CLASSIFICATION.pdf

Management of Skin Tears

The aim is to preserve the skin flap, maintain the surrounding tissue, re-approximate the wound edges, and reduce the risk of infection and further trauma.3

  • Control bleeding:
    • Apply pressure and elevate the limb if appropriate
    • Dressing with hemostatic properties may be used to control bleeding (alginates)
  • Cleanse and debride:
    • Cleanse with normal saline and remove any debris (including hematoma)
    • Debride skin flap if not viable
  • Re-approximate skin flap if viable:
    • Gently ease the flap back into place using a gloved fingertip, dampened cotton tipped applicator or forceps
    • The flap will act as a biological dressing
    • Never use staples, sutures or skin closure strips to approximate edges 
    • Skin glue can be used to re-approximate skin flap edge
  • Manage infection/inflammation:
    • Wound inflammation from trauma needs to be distinguished from wound infection
    • Wound infection can result in pain and delayed healing; determine wound infection based on wound assessment signs and symptoms - appropriate infection control measures should be taken
    • Check tetanus immunization status 
  • Consider moisture balance/exudate control:
    • Skin tears tend to be dry, but for some exudate becomes a concern
    • Moisture balance is essential to promote healing and protect peri-wound skin form maceration
    • Consider exudate type and amount to decide on appropriate dressing
  • Monitor wound edge/closure:
    • Skin tears are acute wounds that should typically follow an acute healing trajectory of 14-21 days
    • Ensure factors that could affect healing have been addressed (e.g., nutrition, diabetes, vascular supply, edema)
    • Compression therapy should be considered if the wound is on the lower leg
Product Categories Indications Skin Tear Type Considerations NSHA Products
Non-Adherent Mesh Dressings (e.g., lipido-colloid mesh, impregnated gauze mesh, silicone mesh, petrolatum)
  • Dry or exudative wound
1, 2, 3
  • Maintains moisture balance for multiple levels of wound exudate
  • Atraumatic removal
  • May need secondary cover dressing
  • Mepitel®
  • Adaptic™
Foam dressing
  • Moderate exudate
  • Longer wear time (2-7 days depending on exudate levels)
2, 3
  • Caution with adhesive border foams, use non-adhesive versions when possible to avoid peri-wound trauma
  • Mepilex®
Hydrogels
  • Donates moisture for dry wounds
2, 3
  • Caution: may result in peri-wound maceration if wound is exudative
  • For autolytic debridement I wounds with low exudate
  • Secondary cover dressing required
  • IntraSite◊ gel
2-octyle cyanoacrylate topical bandage (skin glue)
  • To approximate wound edges
1
  • Use in a similar fashion as sutures within first 24 hours post-injury
  • Relatively expensive
  • Medical directive/protocol may be required
 
Calcium Alginates
  • Moderate to heavy exudate
1, 2, 3
  • May dry out wound bed if inadequate exudate
  • Secondary cover dressing required
  • Nu-Derm™
Hydrofiber
  • Moderate to heavy exudate
2, 3
  • No hemostatic properties
  • May dry out wound bed if inadequate exudate
  • Secondary cover dressing required
  • Aquacel®
Acrylic Dressing
  • Mild to moderate exudate without any evidence of bleeding 
  • May remain in place for an extended period of time
1, 2, 3
  • Care on removal
  • Should only be used as directed and left on for extended wear time
  • 3M™ Tegaderm™ Absorbent Clear Acrylic

Reused and revised with permission from ISTAP: Retrieved December 17, 2019 from http://www.skintears.org/education/tools/product-selection-guide/

Special Considerations for Infected Skin Tears

Product Categories Indications Skin Tear Type Considerations NSHA Products
Methylene Blue and Gentian Violet Dressings
  • Effective broad spectrum antimicrobial action including antibiotic resistant organisms

1, 2, 3

  • Non-traumatic to wound bed
  • Use when local or deep tissue infection is suspected or confirmed
  • Secondary dressing required
  • Hydrofera Blue®
Ionic Silver Dressings
  • Effective broad spectrum antimicrobial action including antibiotic resistant organisms

1, 2, 3

  • Should not be used indefinitely
  • Contraindicated in patients with silver allergy
  • Use when local or deep infection is suspected or confirmed
  • Use non-adherent products whenever possible to minimize risk of further trauma
  • Silvercel™
  • Aquacel® Ag
  • Silvasorb®
  • Acticoat 
  • Biatain® Ag

Reused and revised with permission from ISTAP: Retrieved December 17, 2019 from http://www.skintears.org/education/tools/product-selection-guide/

Resources

References

1. LeBlanc K. et al. Best practice recommendations for the prevention and management of skin tears in aged skin. Wounds International 2018. Available to download from www.woundsinternational.com

2. Wounds Canada.

3. Idensohn P., Beeckman D., Conceição V.L., de Gouveia Santos H.H., Campos D.L., LeBlanc K., Gloeckner M., Woo K., Holloway S. Ten top tips: skin tears. Wounds International 2019. 10(2). pp 6-10.

4. Idensohn P., Beeckman D., Campbell M., Gloeckner M., LeBlanc K., Langemo D., Holloway S. Skin tears: a case-based and practical overview of prevention, assessment and management. J Community Nurs. 2019a. 2019 Apr 1;33(2):32-41.