Skin tears

Until recently, the healthcare community has largely ignored and neglected the significant clinical burden and high costs associated with skin tears, meaning that skin tears have been poorly researched, documented and managed. Recently, however, more attention has been directed towards skin tears, reflecting the establishment of an International Skin Tear Advisory Panel (ISTAP) and the availability of improved wound care dressings.

ISTAP defines a skin tear as: “a wound caused by shear, friction, and/or blunt force resulting in separation of skin layers that can be partial thickness separation of the epidermis from the dermis) or full thickness (separation of both the epidermis and dermis from underlying structures)."  

Commonly, skin tears are jagged and irregularly-shaped and, in most cases, are painful and slow to heal.

Aetiology

Although skin tears are found in all healthcare settings, they are most often found in elderly patients (>65 years of age), either at home, in hospital or in long-term care or retirement homes .

The most common anatomical locations for skin tears are arms (48%), lower legs (40%), and hands (12%). Possible aetiological factors included blunt trauma such as banging into objects (44%), trauma associated with activities of daily living (20%) and falls (12%) . Elderly individuals can simply be susceptible to skin tears as a result of critical or chronic conditions or even from unintentional rough handling . Many patients have multiple skin tears  . Around 50% of skin tears are found on the dorsal forearm and mostly in women .

There are not many studies describing prevalence rates in neonates, even though skin tears are common in this population  , the paediatric population, or for patients attending EDs (excluding patients brought in from care homes). Skin tears also occur in patients with advanced illness receiving palliative care  and in care homes for the blind and partially sighted .

Risk factors

Much still remains unknown about the risk factors for skin tears in the elderly, however the following six factors could be predictive in the development of skin tears :

• Bruising
• Senile purpura
• Haematoma
• Evidence of a previously-healed skin tear
• Oedema
• Inability to reposition oneself independently

Skin properties can predict the development of skin tears in elderly patients. Risk factors which there may be some control include   :

• Transfer and falls
• Inadequate nutrition
• Polypharmacy
• Use of assistive devices
• Application and removal of stockings
• Removal of tape or dressings
• Blood draws
• Prosthetic devices
• Skin cleansers

Risk factors for skin tears in neonates mainly relate to the securing of medical life-saving devices to the pre-term skin, which is thin and extremely fragile. Using the last adhesive product is imperative as there us diminished cohesion between the dermis and the epidermis which ca be less than the bond between the epidermis and an adhesive product , leading to stripping of the epidermis when the adhesive is removed i.e. a skin tear.

Skin tear management

ISTAP Skin tear Tool Kit is designed to allow healthcare individuals to implement a systematic approach to the prevention, management and treatment of skin tears . 

The role of dressings in the management of skin tears

Key nursing priorities for skin tears are to assess, classify and treat the wound appropriately, to avoid complications and to select the most appropriate dressing that promotes a therapeutic, undisturbed environment favourable to the fastest healing. It is imperative to select a dressing that will allow for moist wound healing, create a seal around the wound edges in order to prevent leakage and minimise maceration. All the while respecting the fragile nature of the surrounding skin . Moisture-retentive dressings are recommended that are available in various shapes, and sizes, including dressings made of mesh, silicone, foam acrylic, hydrogel, calcium alginate and hydrofibre . In order to avoid skin stripping, aggressive adhesives are to be avoided in skin tear dressings   .

In relation to patient needs, ideally, they would have a short hospital stay with as much as comfort and as little trauma to the wound as possible while the skin tear heals .

Health economics

The usage of cyanoacrylate skin protectant offers savings in terms of reduced dressing costs and usage time compared with a daily petrolatum-impregnated gauze, positively impacting labour and resource utilisation  . Using the cyanoacrylate dressing leads to reduction in cost per skin care treatment, from US $32.74 to US $11.19. Nurses caring for patients reported a high satisfaction with the cyanoacrylate dressing, commenting that it was easy to use, easy to access the skin tear, and required fewer dressing changes .

Dressing adhesive and its impact on the stratum corneum is key in health economics, particularly in relation to the ISATP recommendations not to use heavy fixators    . While silicone tapes and other advanced medical adhesives may have a higher initial purchase price compared with conventional adhesives, their “gentleness” has the advantage of preserving skin integrity, hence avoiding financial costs associated with skin injuries induced by conventional tapes  .