Introduction

According to the definition from the International Skin Tear Advisory Panel (ISTAP), “a skin tear is a traumatic wound caused by mechanical forces, including removal of adhesives. Severity may vary by depth (not extending through the subcutaneous layer).”¹Skin tears can be partial thickness (separating the epidermis from dermis) or full thickness (separating the epidermis and dermis from underlying structures).² The skin tear may have a flap of skin attached that may or may not be viable or may have full flap loss. These tears are usually irregular in shape. Although some skin tears can be quite extensive, most skin tears heal rather quickly with prompt and proper treatment.

What Causes Skin Tears?

Skin tears are acute, traumatic wounds that result from some mechanical force such as shearing and/or friction or some type of traumatic injury such as from a fall, equipment, or dressings. Those who are at the highest risk for skin tears are geriatric patients, the critically ill, and very young patients because their skin is fragile and more vulnerable to injury.^3-4 Although skin tears can occur on any part of the body, the most common areas are the extremities, in particular the upper extremities.¹Many factors contribute to the causes of skin tears in older adults. As skin ages, the epidermis begins to thin, and the production of collagen and elastin is decreased, as is subcutaneous tissue, thus making the skin more vulnerable to injury. Many older adults are prone to falls, which can lead to traumatic skin tears.

Pharmacologic agents such as corticosteroids, chemotherapeutic agents, and blood thinners can cause issues with the skin that increase the vulnerability to injury. In the very young, the skin is still not fully developed and has deficiency in the stratum corneum, as well as a lack of epidermal-dermal cohesion.

Skin Tear Classification

The Payne-Martin classification system was developed in the early 1990s as a way of grading skin tears.¹ As a result of some issues with this classification system, the Skin Tear Audit Research Classification System, or STAR, was developed in 2007.² Both systems were later replaced by the ISTAP classification system, and this system remains the recommendation for use to classify skin tears. Skin tears are classified by the ISTAP as follows:

• Type 1 skin tears involve no skin loss with a linear or flap tear in which the skin flap can be utilized to cover the wound bed.
• Type 2 skin tears involve partial flap loss in which the skin flap cannot be repositioned to cover the entire wound bed.
• Type 3 skin tears involve total flap loss with exposure of the entire wound bed.²

Prevention

ISTAP advises that patients in populations typically at risk for skin tears should receive a comprehensive risk assessment. According to ISTAP, “A comprehensive risk assessment should include assessment of the individual’s general health (chronic/critical disease, polypharmacy, and cognitive, sensory, visual, auditory, and nutritional status), mobility (history of falls, impaired mobility, dependent activities, mechanical trauma), and skin (extremes of age, fragile skin, previous skin tears).”⁴

Once a comprehensive risk assessment has identified a patient as at risk, wound care professionals need to be mindful of certain details of prevention. Caregivers need to pay close attention to keep fingernails trimmed and not wear any jewelry that could inflict a skin tear. Padding of furniture or equipment that could cause injury can help prevent bumping into these surfaces. The use of sleeves, light gloves, skin guards, or other apparel can help reduce the incidence of skin tears caused by friction or shear. Proper nutrition and hydration, as well as moisturizing the skin on a regular basis, will help keep the skin supple and less prone to injury.

Avoid the use of direct contact of strong adhesives and tape to fragile skin. Fall prevention measures should be initiated in those who are prone to or at risk for falls. Avoid friction and shear during transfers. Exercise safe handling of older adult patients, especially during transfers, by using the palms instead of fingers.³

Treatment

First and foremost, control any active bleeding. Cleanse with normal saline or a gentle wound cleanser according to your facility protocol. If the skin flap is viable, it can sometimes be realigned to cover all or part of the wound bed. The flap and/or wound then can be covered with a nonadherent dressing. If the flap is not viable, it will need to be carefully removed according to facility protocol. The following types of dressings can be used for skin tears:

• Nonadherent dressings provide a moist healing environment while allowing atraumatic removal.
• Nonadherent foam dressings can be utilized for more heavily exudating skin tears.
• Hydrogels can provide a moist healing environment but will necessitate a nonadherent secondary dressing.

In addition to dressings, an antimicrobial gel or cream can provide moist skin healing as well as protection against infection. These substances can be covered with one of the nonadherent dressings to provide atraumatic removal. It is best not to utilize a drying agent or dressing, even those with absorbent or antimicrobial properties, because these can cause further damage on removal. For the same reasoning, adhesive dressings and plain gauze are not recommended.

Conclusion

Skin tears are preventable, acute wounds. Because skin tears often occur in the geriatric population, it is essential to implement a comprehensive assessment and subsequent prevention measures. Those in the geriatric population often struggle with various comorbidities and extrinsic risk factors that can complicate treatment and lead to wound chronicity. Regardless, a working knowledge of treatment and facility protocols can prepare wound care professionals to manage skin tears for best outcomes. With this knowledge, in the words of the International Skin Advisory Panel, wound care professionals can “[w]ork towards a world without skin tears.”⁴

References

1. LeBlanc K, Campbell K, Beeckman D, et al. Best practice recommendations for the prevention and management of skin tears in aged skin. Wounds International. 2018. Accessed June 22, 2022. https://www.woundsinternational.com/uploads/resources/57c1a5cc8a4771a696b4c17b9e2ae6f1.pdf
2. Thayer D, Rozenboom B, LeBlanc K. Prevention and management of moisture-associated skin damage. In: Doughty D, McNichol L, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum Wound Management. Wolters Kluwer; 2022:344-349.
3. Bryant R. Types of skin damage and differential diagnosis. In: Bryant R, Nix D, eds. Acute and Chronic Wounds Current Management Concepts. 5th ed. Elsevier; 2016:85-87.
4. International Skin Tear Advisory Panel (ISTAP). Accessed July 7, 2022. https://www.skintears.org/.

About the Author

Cathy Harmon, DNP, MSN, FNP-BC, CWON, CFCN is a Nurse Practitioner at the VA Medical Center in Lake City, Florida. She is the Wound Care Provider in the Out-Patient Clinic serving the Veteran Population of North Florida and South Georgia. Cathy is certified in wound, ostomy and foot care. In addition to her wound care experience, she also has experience in acute care, pediatrics, home health, long-term care and has served as a Professor of Nursing. Cathy’s passion for wound care began while she was working in the long-term care setting as an RN. She serves the veteran population as a memorial to her dad, a combat wounded WWII Veteran.