Introduction

“Top-down skin injury” is an increasingly common term used to describe superficial cutaneous injury. These injuries result from damage beginning at the skin’s surface or soft tissue. In contrast, “bottom-up” injuries are often the result of ischemia. Top-down injuries are usually caused by mechanical forces, inflammation, or moisture. Medical adhesive-related skin injury (MARSI) is a frequently seen type of top-down skin injury that is almost always preventable. In this blog, I focus on preventing MARSI and describe the different techniques and adhesives (along with adhesive alternatives) available for use.¹

What Is MARSI?

MARSI is the abbreviation for medical adhesive-related skin injury, a term that was developed to describe and define a clinical problem. MARSI is defined as a condition characterized by erythema, vesicles, erosion, tears, or bulla persisting 30 minutes or more after removal of an adhesive dressing.¹ MARSI is often seen almost instantly and can at times be difficult to treat because of its location and the patient’s skin condition (already compromised). Adhesive use is common in health care settings. Adhesives secure dressings, medical devices, and equipment. Additionally, many medical devices have an adhesive that is used to adhere to the patient, such as:

• Ostomy pouches
• Condom catheters
• Catheter securement devices
• Electrodes
• Surgical drapes

The barrier function of these medical devices is highly dependent on the integrity of the stratum corneum. A break in the skin integrity of the stratum corneum will cause a risk for compromise in the skin barriers discussed earlier.¹ Adhesives play a significant role in most health care settings, as discussed previously. Assessment and selection of the best adhesive product based on clinical requirements and patient characteristics are key components of a MARSI prevention plan.

MARSI Prevention Plan Components

Assessment

A thorough assessment should be conducted initially and at routine intervals to identify risk factors associated with MARSI development. A focused patient history should be obtained as well to identify risk. It is important to note that patients in any age group with significant edema or distention are at risk for skin stripping or tension blister formation.¹

Selecting the Correct Adhesive Product

The clinician should be knowledgeable about adhesive selection and adhesion level, along with the ingredients in the backing or adhesive, and what level of adhesion they apply. Risk for mechanical injury, current integrity of the skin, microclimate, and elasticity should all be assessed before selecting and applying an adhesive product. Selection of the correct adhesive involves a thorough skin assessment of each specific patient and should be individualized. Patch testing can also be done beforehand, to check for any reaction, especially when applying adhesive to a larger surface area. The level of adhesion needed to secure the dressing or device should also be examined. Silicone adhesives are typically gentler adhesives, whereas polyester or silk adhesives typically provide a higher level of adhesion.

A cloth and/or paper combination provides a moderate level of adhesion. Adhesives are most effective when applied to a clean, dry, flat, and immobile surface. Effective skin preparation (cleansing, excess hair removal, etc) is also a critical element of a strong MARSI prevention bundle. Securement of critical devices (endotracheal tubes, vascular access devices, etc) should be done with high-adhesion products or more aggressive coatings because of the nature of the device they secure. Higher adhesion has been correlated with increased risk of skin injury and pain, and appropriate steps should be taken when applying and removing these adhesives, including correct skin preparation.¹

Use of Adhesive Alternatives

Adhesive alternatives should be explored for those patients with sensitive skin or an adhesive sensitivity. Tubular elastic dressing, netting, and conforming bandages are options. Abdominal binders may also be considered, depending on what needs to be secured. Sleeves used to protect or cover the arms and/or legs could also be used as an alternative to a secondary dressing with adhesive properties.

Education and Follow-Up

Staff education on prevention is important. Initial and ongoing education on new products, prevention, and treatment is a critical part of a strong skin prevention and treatment program, along with standardizing practices across care settings. Bundles, written protocols, standard operating procedures, and highlighting of key prevention techniques are important here. Involving key stakeholders with a collaborative approach is helpful not only for preventing MARSI but also for reducing waste and supply costs through more effective use of products.¹

Conclusion

MARSI is a preventable, top-down injury most commonly caused by the removal of adhesive dressings. It is essential that clinicians assess patients for risk of MARSI so that the appropriate adhesive dressing (or adhesive alternative) is selected for the patient’s individualized plan of care. Education of staff and the standardization of practices across care settings ensure that facility staff will have the tools to prevent MARSI collaboratively.

Reference

1. Thayer D, Rozenboom B, Baranoski S. “Top-down” injuries: prevention and management of moisture-associated skin damage (MASD), medical adhesive-related skin injury (MARSI), and skin tears. In: Doughty DB, McNichol LL, eds. WOCN Society Core Curriculum: Wound Management. Wolters Kluwer; 2016:281-312.

About the Author

Holly is a board certified gerontological nurse and advanced practice wound, ostomy, and continence nurse specialist at VA Northeast Ohio Healthcare System in Cleveland, Ohio. She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately ten years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention. She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation. She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible. She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes.