Skin Tear Prevention and Management

Despite seeming like minor injuries, skin tears can be complex wounds with the potential to significantly affect an individual’s health and cause chronic discomfort (LeBlanc 2014).

Skin tears are often misdiagnosed and underreported, and in many cases are preventable (Wounds International 2018).

What are Skin Tears?

Skin tears are acute, traumatic injuries caused by shearing, friction or blunt force wherein the layers of skin are separated. This may be a separation of the epidermis from the dermis (partial thickness) or separation of both the epidermis and dermis from underlying structures (full thickness) (RWV 2018).

Any part of the body can be affected by skin tears, but 70 to 80% occur on the arms and hands (Wounds International 2018).

Generally, skin tears affect those with fragile skin. They are most common in older adults, accounting for nearly 55% of all wounds (LeBlanc 2014; Western Alliance 2018).

Skin tears are more common in women than men, as decreased oestrogen levels (caused by menopause) adversely affect the wound-healing process. Women’s greater life expectancy is also a factor (Western Alliance 2018; Horng et al. 2017).

Why are Older Adults More Susceptible to Skin Tears?

The physiology of skin undergoes several changes with age, causing it to become more fragile and vulnerable to trauma:

• The epidermis thins;
• The epidermal junction flattens;
• There is a loss of collagen, elastin and glycosaminoglycans;
• Levels of dermal proteins (which contain moisture) decrease;
• The dermis will atrophy and contract;
• There is decreased activity of sweat glands and sebaceous glands; and
• Blood vessel walls thin and blood supply to the extremities decreases.

(Wounds International 2018; Clothier 2014)

These changes, in tandem with reduced skin regeneration abilities and a weakened protective immune system, mean that an older adult’s skin integrity can be damaged by even a small amount of force (Wounds International 2018).

Risk Factors for Skin Tears

Factors that increase the risk of developing skin tears include:

• Age (those over 75 are more at risk);
• Gender (females are more at risk);
• Previous skin tears;
• Dehydrated skin;
• Impaired mobility;
• Reliance on others for personal needs (e.g. bathing);
• Sensory or cognitive impairments;
• Visual impairment;
• Poor nutrition and hydration; and
• Medications that cause skin thinning.

(Clothier 2014)

Preventing Skin Tears

Identifying at-risk patients through a holistic skin assessment on admission is crucial in the prevention of skin tears (Wounds International 2018).

The healthcare worker should assess:

• The patient’s skin;
• The patient’s medical history;
• Intrinsic risk factors for vulnerable skin;
• Whether the skin is in-tact;
• Wound-related risk factors (e.g. eczema, oedema);
• Any skin conditions, rashes, itches, pain or other unusual issues;
• The patient’s knowledge about the condition of their own skin;
• History of skin conditions; and
• Physical factors (temperature, texture).

(Wounds International 2020)

A risk reduction program checklist (p. 13) should be implemented for patients deemed at-risk.

When caring for patients at risk of suffering skin tears, healthcare workers should take the following measures:

• Keeping fingernails short;
• Not wearing jewellery;
• Padding or removing dangerous furniture or devices (e.g. bed rails, wheelchairs);
• Covering the skin of vulnerable patients with appropriate clothing, shin guards or retention bandages/stockinettes;
• Using products that are pH balanced and have preventative emollients to maintain the patient’s skin integrity;
• Reducing the patient’s sun exposure;
• Minimising the frequency of the patient’s bathing, ensuring water is not too hot and gently patting their skin dry with a soft towel (instead of rubbing); and
• Regular moisturising.

(Wounds International 2018, 2020)

Identifying and Assessing Skin Tears

Correct and prompt identification of skin tears is essential in the effective management of the wound. A thorough examination of the skin tear as well as a holistic patient assessment (see above) should be performed upon presentation (Wounds International 2018).

The following should be documented as part of the skin tear assessment:

• Cause of the skin tear;
• Anatomical location and duration;
• Dimensions (length, width, depth);
• Wound bed characteristics;
• Percentage of viable and non-viable tissue;
• Exudate (type and amount);
• Any bleeding or haematoma;
• Integrity of the surrounding skin;
• Any signs of symptoms of an infection; and
• Any pain related to the wound.

(Wounds International 2018)

Australia uses the Skin Tear Audit Research (STAR) classification system to distinguish between different types of skin tear. The STAR system comprises five categories:

Category	Edges	Colour of skin or flap
1A	Edges can be realigned to their normal anatomical position (without excessive stretching).	Not pale, dusky or darkened.
1B	Edges can be realigned to their normal anatomical position (without excessive stretching).	Pale, dusky or darkened.
2A	Edges can not be realigned to their normal anatomical position (without excessive stretching).	Not pale, dusky or darkened.
2B	Edges can not be realigned to their normal anatomical position (without excessive stretching).	Pale, dusky or darkened.
3	The skin flap is completely absent.

(Adapted from VIC DoH 2015)

While the STAR system is common practice in Australia in Japan, the International Skin Tear Advisory Panel (ISTAP)’s system is used in other countries (Wounds International 2018).

Managing Skin Tears

Prompt and appropriate treatment of skin tears improves patient outcomes. The goals of treatment are primarily to:

• Preserve the skin flap;
• Protect the surrounding tissue;
• Re-approximate the edges of the wound (without excessive stretching); and
• Reduce the risk of further infection or injury.

(Wounds International 2018)

The process of treating skin tears is as follows:

1. Control any bleeding.

• Apply pressure to the wound.
• Elevate the affected limb if possible.

2. Cleanse the wound.

• Remove residual debris or haematoma with a non-woven swab.
• Cleanse the wound with warm, sterile isotonic saline (sodium chloride 0.9%) or water.
• Gently pat the surrounding skin dry; the wound itself should be left to air dry.

3. Approximate the skin flap.

• If the skin flap is viable (category 1 or 2), gently ease it back into place to use as a dressing (using a gloved finger, dampened cotton tip, tweezers or silicone strip).
• If this is difficult, rehydrate the flap using a moistened non-woven swab for 5-10 minutes.
• Do not excessively stretch the flap during approximation.
• If the skin flap is non-viable or necrotic it should be debrided. Ensure this is performed by an experienced nurse.

4. Dress the wound.

• An appropriate non-adherent dressing should be chosen depending on the wound characteristics and classification. The chosen dressing should:
  • Maintain a moist healing environment;
  • Protect the wound and surrounding skin from further trauma and dressing removal;
  • Manage any exudate and/or infection;
  • Be easy to apply;
  • Be able to stay in-situ for a long period of time; and
  • Be cost-effective.
• Apply the dressing, securing it with a non-adhesive silicone-interfaced dressing material (e.g. arm/leg protector, flexible netting).
• Mark the dressing with an intended removal date and an arrow indicating the removal direction.
• Films and tapes should not be used on fragile skin.

4. Monitoring and Reassessment

• Leave the initial dressing in-situ for no longer than five days.
• If the skin flap is pale, dusky or darkened, it should be reassessed within 24 to 48 hours.
• The wound should be monitored for any infections or changes. If there is an infection or exudate present, the dressings should be changed more frequently.
• If there is no sign of infection or deterioration after the initial dressing, subsequent dressings should be left in-situ for about five days.
• If there is no improvement after four reassessments, refer the patient to a specialist.

(Wounds International 2018; VIC DoH 2018)

Complications

If skin tears are not properly treated, complications such as pain, delayed healing, infection, cellulitis or sepsis may arise (LeBlanc 2014).

If a skin tear does not heal within four weeks, it is considered chronic (Wounds International 2018).

Conclusion

Despite being common among older adults, skin tears are preventable and treatable. However, thorough patient assessment and the ability to recognise and categorise skin tears is essential.

Note: This article is intended as a refresher and should not replace best-practice care. Always refer to your facility's policy on preventing and managing skin tears.

Additional Resources

• Curtin University of Technology, Skin Tear Audit Research (STAR) classification system, http://direct.ch2.net.au/direct_static/product_documents/promo-229-Skin%20Tear%20assessment%20and%20management%20guidelines.pdf
• ISTAP Skin Tear Classification system, http://www.skintears.org/wp-content/uploads/2020/01/Ten-Years-of-ISTAP-2.pdf
• International Skin Tear Advisory Panel (ISTAP), http://www.skintears.org/
• Victorian Government Department of Health, Skin Tears: Standardised Care Process, https://www2.health.vic.gov.au/Api/downloadmedia/%7B6EA2ACFE-644B-4459-8523-D9A52249FF6E%7D
• Wounds International, Best Practice Recommendations for the Prevention and Management of Skin Tears in Aged Skin, https://www.woundsinternational.com/uploads/resources/57c1a5cc8a4771a696b4c17b9e2ae6f1.pdf
• Wounds International 2020, Best Practice Recommendations for Holistic Strategies to Promote and Maintain Skin Integrity, http://www.skintears.org/wp-content/uploads/2020/05/best-practice-recommendations-holistic-strategies-promote-and-maintain-skin-integrity-ISTAP-2020.pdf

References

• Clothier, A 2014, Assessing and Managing Skin Tears in Older People, Independent Nurse, viewed 12 May 2020, https://www.independentnurse.co.uk/clinical-article/assessing-and-managing-skin-tears-in-older-people/63411/
• Horng, H et al. 2017, ‘Estrogen Effects on Wound Healing’, Int J Mol Sci., vol. 18 no. 11, viewed 18 May 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5713294/
• LeBlanc, K 2014, Skin Tears, Wound Source, viewed 12 May 2020, https://www.woundsource.com/patientcondition/skin-tears
• Regional Wounds Victoria 2018, Skin Tears Update, Regional Wounds Victoria, viewed 12 May 2020, https://www.vicniss.org.au/media/1919/skin_tears_aged_care_-monika-samolyk.pdf
• Victorian Government Department of Health 2015, Classifying Pressure Injuries and Skin Tears, Victorian Government Department of Health, viewed 12 May 2020, https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/older-people/skin/skin-classifying
• Victorian Government Department of Health 2018, Skin Tears: Standardised Care Process, Victorian Government Department of Health, viewed 12 May 2020, https://www2.health.vic.gov.au/Api/downloadmedia/%7B6EA2ACFE-644B-4459-8523-D9A52249FF6E%7D
• Western Alliance 2018, Skin Tears in the Elderly, Western Alliance, viewed 12 May 2020, https://www.westernalliance.org.au/2018/08/skin-tears-in-the-elderly
• Wounds International 2018, Best Practice Recommendations for the Prevention and Management of Skin Tears in Aged Skin, Wounds International, viewed 12 May 2020, https://www.woundsinternational.com/uploads/resources/57c1a5cc8a4771a696b4c17b9e2ae6f1.pdf
• Wounds International 2020, Best Practice Recommendations for Holistic Strategies to Promote and Maintain Skin Integrity, Wounds International, viewed 12 May 2020, http://www.skintears.org/wp-content/uploads/2020/05/best-practice-recommendations-holistic-strategies-promote-and-maintain-skin-integrity-ISTAP-2020.pdf

(Answers: a, c, b)