Skin Tears

Recommendations

Identify and Treat the Cause
1 Assess elderly patients for risk of skin tears. Level of Evidence
Not Assessed


Address Patient-centered Concerns
2 Educate the patient and family about the risk and prevention of friction and shear when handling patients. Level of Evidence
Not Assessed
3 Provide a safe environment for elderly patients. Level of Evidence
Not Assessed


Provide Local Care
4 Develop a protocol for prevention and management of skin tears Level of Evidence
Not Assessed
5 Moisturize dry skin, especially arms and legs, twice daily. Level of Evidence
Not Assessed
6 Maintain patient nutrition and hydration. Level of Evidence
Not Assessed
7 Protect patients from self-injury and injury during routine care. Level of Evidence
Not Assessed
8 Classify the skin tear using the Payne-Martin system. Level of Evidence
Not Assessed
9 Assess the size of the skin tear regularly. Level of Evidence
Not Assessed
10 Manage skin tears using atraumatic techniques for cleansing, protecting, and dressing wounds. Level of Evidence
Not Assessed


Provide Organizational Support
11 Facilitate healthcare professionals to gain relevant knowledge and skills to provide appropriate prevention and management. Level of Evidence
Not Assessed


Background

Skin tears are common preventable traumatic wounds more common in the elderly. Long term steroid use, chronic sun exposure and numerous age-related changes increase the fragility of the skin. Turning or lifting immobile patients, dressing changes, and bumping into furniture can all cause skin tears. Approximately half of all skin tears have no apparent cause. Although most skin tears occur on the limbs, tears on the back or buttocks may be mistaken for pressure ulcers.

The most important risk categories for skin tears are patients dependent on caregivers for total care; ambulatory patients, especially those with edema, purpura and ecchymosis; and patients with impaired vision.

The Payne-Martin Classification System for Skin Tears defines skin tears as traumatic wounds due to separation of epidermis from the dermis (partial-thickness wound) or of the epidermis and dermis from underlying structures (full-thickness wound). These wounds occur primarily on the extremities of older individuals and result from friction or friction plus shear. Skin tears are classified as follows:
• Category I: Linear and flap tears without tissue loss. In linear tears, the epidermis and dermis are pulled apart, with an appearance similar to an incision. In flap tears, the epidermis covers the dermis to within a millimetre of the wound edge.
• Category II: Tears with scant or moderate-to-large tissue loss. With a scant tissue loss tear, no more than 25% of the epidermal flap is lost. With a larger tear, more than 25% of the epidermal flap is lost.
• Category III: Tears with complete tissue loss. The entire epidermal flap is lost.

Preventing skin tears is a challenge for clinicians. Preventive strategies include assessing risk in individual patients, providing a safe environment with adequate lighting, ensuring that patients’ extremities are protected by clothing, padding bedrails and wheelchair arms, supporting patients’ arms and legs with blankets or pillows, using transfer techniques that prevent friction and shear, choosing nonadherent dressings, and using emollient soaps or gentle cleansers.

Appropriate management of skin tears includes gentle cleansing with saline; air drying; approximation of the skin flap; application of ointment, steri-strips or moist, nonadherent dressings secured by stockinette or gauze wrap; and regular assessment.

References

Essential Publications
1 Skin tears classification Quality Indicator
 Type: Scale Description
Payne RL, Martin, M. Defining and classifying skin tears: need for a common language. Ostomy Wound Management. 39(5):16-20, 22-4, 26, 1993 Jun.
This article presents the classification system that is commonly used to describe skin tears.
2 Skin tears – at risk population Quality Indicator
 Type: Correlation study
McGough-Csarny, J. Kopac, C A Skin tears in institutionalized elderly: an epidemiological study. Ostomy Wound Management. 44(3A Suppl):14S-24S; discussion 25S, 1998 Mar.
This descriptive correlational study indicates the population at-risk for skin tears in long-term care facilities, suggesting that the following variables are associated with skin tears: stiffness and spasticity, sensory loss, limited mobility, poor appetite, use of multiple drugs and assistive devices, presence of bruising, and history of skin tears. Unfortunately, since multivariable analyses were not conducted, the relative contribution of each of these variables to the occurrence of skin tears is not known. Nevertheless, this information may be helpful for prevention programs being established by caregivers.
3 Tissue adhesives Quality Indicator
 Type: Systematic review
Farion KJ, Russell KF, Osmond MH, Hartling L, Klassen TP, Durec T, Vandermeer B. Tissue adhesives for traumatic lacerations in children and adults. CochraneDatabase of Systematic Reviews 2001, Issue 4. Art.No.:CD003326.DOI: 10.1002/14651858.CD003326.
This well-conducted systematic review of RCTs, undertaken in 2001 and updated in 2007 (2 studies added) to compare tissue adhesives (TAs) with standard wound closure (SWC) and TAs with other TAs in managing traumatic lacerations in children and adults. . No significant difference was found between TAs and SWC at any of the time points examined using the Cosmetic VAS (CVAS) or the Wound Evaluation Score (WES). When TAs were compared with TAs, no differences were found. Significant differences favouring TA were all pain scores results (parent, patient, physician, nurse) and time to complete the procedure (mins). Significant differences for complications: dehiscence favouring SWC, NNH 40, 95% CI 20 to 1168; and erythema favouring TA, NNH 10, 95% CI 5 to 239. From a cosmetic perspective, either TAs or SWC can be used for simple traumatic lacerations. TAs require less procedure time and produce less pain, but have an increased rate of dehiscence.
4 Tissue adhesives Quality Indicator
 Type: Systematic review
Farion KJ, Osmond MH, Hartling L, Russell KF. (2003). Tissue adhesives for traumatic lacerations: A systematic review of RCTs. Academic Emergency Medicine 2003;10(2):110-118.
This well-conducted systematic review provides a shorter report of the Cochrane review above (9 pages rather than 50). It was undertaken to compare tissue adhesives (TAs) with standard wound closure (SWC) and TAs with other TAs in managing traumatic lacerations in children and adults. No significant difference was found between TAs and SWC at any of the time points examined using the Cosmetic VAS (CVAS) or the Wound Evaluation Score (WES). When TAs were compared with TAs, no differences were found. Significant differences favouring TA were all pain scores results (parent, patient, physician, nurse) and time to complete the procedure (mins). Significant differences for complications: dehiscence favouring SWC RD 0.04, 95%CI 0.01 to 0.07, NNH 25, 95% CI 14 to 100; and erythema favouring TA RD -0.12, 95%CI -0.23 to -0.01, NNH 8, 95% CI 4 to 100. From a cosmetic perspective, either TAs or SWC can be used for simple traumatic lacerations. TAs require less procedure time and produce less pain, but have an increased rate of dehiscence.
5 Prevention and treatment of skin tears Quality Indicator
 Type: CPG (Clinical Practice Guideline)
LeBlanc K, Christensen D, Orsted HL, Keast DH. Best practice recommendations for the prevention and treatment of skin tears. Wound Care Canada 2008;6(1):14-30.
Recommendations for the management of skin tears are presented in this paper. The authors recommend managing skin tears by treating underlying causes, managing patient concerns, and following best practice guidelines for local wound care.


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