Wound healing is a complex process that is highly dependent on many skin cell types interacting in a defined order. With chronic wounds, this process is disrupted, and healing does not normally progress. Although there are different types of chronic wounds, those occurring from injury, such as skin tears or pressure injuries, are some of the most common. These injuries are a result of repeated mechanical irritation. Moisture-associated skin damage is another condition that can contribute to chronicity.¹ Understanding the causes and contributors to these injuries can help to minimize patients’ risk of developing them. It can also aid in the formation of an optimal treatment plan for when injuries do occur, which reduces the healing time and leads to better patient outcomes.

Moisture

Moisture-associated skin injury, such as perineal dermatitis, diaper rash, and incontinence-associated dermatitis are caused by long-term, repetitive moisture that disrupts the normal pH of skin. Although moisture can come from many sources, fecal and urinary incontinence, wound drainage, and perspiration are the most common. This moisture will erode the epidermis and lead to the macerated appearance of the skin. Eventually, the moisture alone, or in conjunction with friction, will cause a break in the surface of the skin that allows pathogens to enter, making moisture-associated injuries very vulnerable to infection. Treatment of these types of injuries can include the following actions:¹

• Identify the cause of the moisture and try to prevent it when possible.
• Look for patterns in the time of day when incontinence may occur to minimize prolonged exposure to the moisture.
• Avoid foods that may trigger incontinence, such as citrus, caffeine, spicy foods, and carbonated beverages.
• Incontinence may also be treated surgically or with medication when appropriate.
• Add fiber or yogurt cultures to the patient’s diet.
• Use skin cleanser to clean the wound.
• Barrier ointments may also be applied to the affected area.
• If secondary infection is present, it should be treated appropriately.

Skin Tears

Skin tears are “wounds caused by shear, friction, and/or blunt force resulting in separation of skin layers. A skin tear can be partial-thickness (separation of the epidermis from the dermis) or full-thickness (separation of both the epidermis and dermis from underlying structures.”² The mechanical force created in these conditions will eventually lead to a wound, such as a skin tear. Tears are classified based on their severity. A type 1 tear has no skin loss, with a linear or flap tear that can be positioned to cover the wound bed. Type 2 involves partial skin loss, with a partial flap that cannot fully cover the wound. Type 3 wounds have a complete loss of the flap and a fully exposed wound bed.³

Skin tears can occur on any part of the body and are more common in vulnerable populations, such as older adults, infants and children, individuals with obesity or malnourishment, or those who are critically or chronically ill. Other risk factors include impaired mobility, falls or other accidental injuries, previous skin tears, cognitive deficit or dementia, and dependence in transfers.⁴ To manage and treat skin tears properly, many aspects of patient care must be considered, including coexisting factors, nutrition, pain management, local wounds, and the optimal dressing. The wound should be assessed and categorized. Other treatment steps include²:

• Controlling bleeding
• Cleansing the wound with saline or wound surfactant
• Removing debris and necrotic tissue
• Positioning the skin flap over the wound (unless necrotic – then remove)
• Assessing the surrounding skin
• Addressing concerns about infection
• Treating the patient’s pain.
• Considering healing and comfort when selecting the appropriate dressing
• Administering tetanus immunoglobulin (as dictated by institutional protocol)
• Applying skin care treatment or barrier creams to protect from further damage

Pressure Injuries/Ulcers

Pressure injuries, or pressure ulcers, are caused by shearing, friction, moisture, and pressure. These injuries affect many patients every year, particularly those who have limited mobility. Risk factors for pressure injuries are the same as for skin tears. Also like skin tears, these injuries can be prevented when proper practices and technologies are in place that provide turning and repositioning strategies at an interval based on the patient’s individual tissue tolerance, ideally every two hours or less.⁵ Several examples of best practices for pressure injury prevention can include⁵:

• Using alarms or music to cue caregivers on when to turn and reposition
• Placing charts at the nurse’s station that track repositioning efforts
• Placing labels on the chart, bed, or door that indicate pressure injury risk to cue turning
• Implementing a sign-off system that requires two signatures (e.g., nursing assistant/nurse or nurse/charge nurse)

In addition to best practices, there are many devices and technological innovations that can be used to limit the risk of pressure injuries by removing the conditions necessary for these injuries to develop. These devices include those that can help monitor the patient’s status, such as a pressure visualization system that tracks the body position and monitors pressure on all 12 bony prominences and can provide feedback and alerts, as well as devices that assist with moving and repositioning the patient. Sensor socks and wireless sensor monitoring systems also work to track the conditions that may lead to the development of a pressure injury. There are also advanced technologies that help manage pressure, such as therapeutic linens, powered covers, and mattresses with built-in systems that work to maintain ideal pressure.⁵ Preventing a pressure injury is much easier than treating one. Ongoing patient education, as well as a periodic assessment of clinical best practices regarding pressure injuries, can aid in the reduction of pressure injuries as chronic wounds.

Conclusion

Skin injuries can lead to chronic wounds. With careful assessment and best practices, however, many chronic wounds can be prevented, and those wounds that do become chronic can be treated, for optimal healing outcomes.

References

1. Zulkowski K. Diagnosing and treating moisture-associated skin damage. Adv Skin Wound Care. 2012;25(5):231–6.

2. LeBlanc K, Baronoski S, Christensen D, et al. International Skin Tear Advisory Panel: putting it all together, a toolkit to aid in the prevention, assessment and treatment of skin tears. Adv Skin Wound Care. 2013;26(10):459–76.

3. WoundSource. Skin tears. 2019. https://www.woundsource.com/patientcondition/skin-tears. Accessed on February 22, 2019.

4. Strazzieri-Pulido KC, Peres GRP, Campaili TCGG, de Gouveia Santos VLC. Incidence of skin tears and risk factors: a systematic literature review. J Wound Ostomy Continence Nurs. 2017;44(1):29–3.

5. Carver C. Tools to maximize turning and repositioning programs for pressure injury prevention. WoundSource. 2016. https://www.woundsource.com/blog/pressure-injury-prevention-managing-sh…. Accessed on February 22, 2019.