Review

The current management of skin tears

Xiaoti Xu BS, Kwan Lau MD, Breena R. Taira MD, Adam J. Singer MD?

Stony Brook University Department of Surgery, Stony Brook, NY 11794, USA

Stony Brook University Department of Emergency Medicine, Stony Brook, NY 11794, USA

Received 7 April 2008; revised 20 May 2008; accepted 21 May 2008

Abstract Each year, there are more than 1 million skin tears among the elderly and disabled. Because of their fragile nature, management of skin tears can be very challenging. Methods of wound closure should minimize additional trauma to the skin and promote an optimal wound healing environment while minimizing the risk of infection. The current article reviews the etiology, risk factors, classification, and therapeutic options for treating skin tears. We also review preventive measures to help reduce the incidence of skin tears.

(C) 2009

Introduction and the anatomy of skin

A skin tear is a separation of the epidermis and dermis secondary to friction or a shearing force. It is a problem that affects all people but is especially common in the elderly and chronically ill individuals. In a retrospective study of a large urban, long-term-care facility, Malone et al [1] estimated that there are approximately 1.5 million skin tears annually in nursing homes, with a rate of 0.92 tears per year. A more recent study estimates that the prevalence rate of skin tears in nursing homes ranges between 14% and 24% [2].

The human skin is the largest organ in the body and serves multiple functions including protection against infection and evaporation, thermoregulation, excretion, storage, metabo- lism, absorption, sensation, immune surveillance, and body image. The skin is divided into 3 anatomical layers [3]-the epidermis, dermis, and subcutaneous layers (hypodermis). The epidermis is the most superficial layer of skin that is composed of stratified squamous epithelium. The dermis is

* Corresponding author. Department of Emergency Medicine, HSC-L4- 080, 8350 SUNY, Stony Brook, NY 11794-8350, USA. Tel.: +1 631 444

7856; fax: +1 631 444 9719.

E-mail address: [email protected] (A.J. Singer).

the second layer of skin and contains blood and lymphatic vessels, nerves and nerve endings, glands, and, except for glabrous skin, hair follicles. The subcutaneous layer is the innermost layer and is primarily an irregular layer of connective tissue [3].

The epidermis contains downward thickenings that resemble fingerlike projections that reach into the dermal layer. These structures are called rete ridges or intrapapil- lary ridges and serve to anchor the epidermis and dermis so the 2 skin layers move together. As we age, the rete ridges begin to flatten between the epidermal-dermal junction, increasing the susceptibility of the epidermis to detach from the dermis. Aging has also been to shown to decrease skin elastin fibers and loss of dermal and epidermal thickness, further predisposing the elderly to skin tears [4].

Etiology, risk factors, and classification of skin tears

The most common identifiable cause of skin tears is minor trauma. In the Geriatric population, minor trauma includes wheelchair/geriatric chair injuries, bumping into objects, transfer, falls, and tape removal [5]. Nearly half of all skin

0735-6757/$ - see front matter (C) 2009 doi:10.1016/j.ajem.2008.05.015

tears, however, occur without apparent cause [5]. The most common location for skin tears is the upper extremities, with 80% of skin tears occurring there. Other common areas for skin tears are the lower extremities, back, and buttocks.

Patients who are especially at risk for skin tears include the elderly, a person with a history of skin tears, those who use adhesive dressings, patients requiring frequent transfer, patients with cognitive impairment, patients who are dehydrated, those with poor Nutritional status, and patients on corticosteroids. Not only does aging increase the fragility of skin but also is associated with delayed wound healing. Age-associated changes include a decreased inflammatory response, delayed angiogenesis, and decreased ability to synthesize collagen. In addition, steroids can lead to skin tears by thinning the skin and suppressing the immune system.

To better plan for management of skin tears, Payne and Martin [6] developed the Payne-Martin Skin Tear Classifica- tion System in 1993. The system created taxonomy according to the extent of epidermal loss and classified all skin tears into 3 categories. The scheme defined category I tears as skin tear without tissue loss. Category I tears is further subdivided into linear tears and flaps. Linear tears are when the epidermis and dermis are pulled together, whereas flaps are epidermal tears that completely cover the dermis to within 1 mm of the wound edge. Category II tears are tears that are associated with partial tissue loss. These can also be subdivided into scant and moderate. Scant loss occurs with loss of less than 25% of epidermal flap. Moderate loss occurs with loss of more than 25% of the epidermal flap. Category III tears are defined as skin tears with complete tissue loss. These tears are characterized by a complete absence of the epidermal flap.

Prevention of skin tears

Preventive measures aim to reduce the causes of skin tears and minimize conditions that predispose the epidermis to injury. Minor trauma is protected against by padding bed rails, wheelchair arms, and leg supports; having patients wear long sleeves and pants; and placing patients in a well-lit environment. In a study of the effects of implementation of preventive skin care strategies in a 209-bed urban nursing and rehabilitation center, Bank et al [2] found that the number of skin tears fell from a preintervention mean of 18.7 to a postintervention mean of 8.73 per month (P b 0.001). Preventive measures in the study included staff education, skin sleeves and padded side rails for high-risk patients, gentle skin cleansers, and application of skin lotion. The authors estimated that the average monthly reduction in nosocomial skin tears would reduce the dressing and labor costs of managing these wounds by an average of $1698 per month ($18 168.60 annually) [2].

Proper Transfer of patients also decreases the incidence of minor trauma. This includes proper positioning, turning,

lifting when transferring patients, gentle handling of skin, avoidance of harsh movements, and use of pillows to support extremities. Use of ceiling-mounted lifts that help transfer patients (eg, the Guldmann ceiling-mounted hoist system) is now mandated in hospitals by several states to help reduce health care worker and patient injuries [7]. Experts suggest that lift systems are likely to play an important role in the reduction of skin tears [7], but their impact has not been well studied. Hospitals (including emergency departments), nursing homes, and hospices should all be required to adopt these systems to help reduce skin tears. Factors that predispose the skin to injury can be countered by encoura- ging the patient to keep hydrated, applying agents to keep the skin moist, and using paper tape or nonadherent dressings. Hydration has also been shown to be important in maintaining the skin’s elasticity and resilience.

Choice of cleansing agents can also aid in prevention of skin tears. Mason et al [8] studied the use of nonemollient vs emollient soap to bathe residents of a long-term care facility. The authors found that use of emollient soap improved skin quality and reduced tears. The incidence of skin tears decreased by 33% to 37%; although not statistically significant, the authors argued that the use of emollient soap was clinically significant in reducing the number of skin tears. Furthermore, in a study of 29 bed-bound residents at a long-term care facility, the effects of changing bathing practice on skin tears was studied. In this study, the staff switched from bathing with bar soap and water to a no-rinse body wash [9]. Skin tear rates were observed to decrease from 13 in the first month to 1 by the fourth month of the study. The authors concluded that using the no-rinse body wash would save their institution an annual cost of $2446.

Management of skin tears

The basic principle in skin tear management is to both protect the skin from further injury and possible infection as well as provide an optimal moist environment to promote healing. Various dressings have been proposed to provide protect and facilitate healing. They include gauze, hydrogels, transparent films, foams, hydrocolloids, and Steri-Strips (3M, St Paul, MN) (Table 1).

A general protocol for management includes first gently cleaning the skin tears with 0.9% normal saline or a nontoxic wound cleanser and then allowing the area to dry. The skin tear flap/tissue should then be approximated as closely as possible, and the type of skin tear should be documented. A moist dressing should be applied and a nonadherent dressing should be secured with gauze or tubular nonadhesive wrap. Furthermore, the direction that the dressing should be removed should be noted (opposite to the direction of the tear at the time of the application). The dressing should be changed according to the manufacturer’s recommendations. Hydrogels, for example, generally need to be changed daily, whereas hydrocolloids are changed weekly or as needed.

Dressing Advantages	Disadvantages	clinical applications	Examples
Gauze Inexpensive Hydrogel Prevent fluid accumulation and conform to surface anatomy; atraumatic application and removal Films Conform to surface anatomy, can serve as a secondary dressing Foams Requires weekly dressing change, provide thermal insulation Hydrocolloids Requires weekly dressing change Silicon Base can be left in place 7-10 d Steri-Strips ease of application and removal; faster wound healing	Poor barrier, require daily changing Requires daily changing Promote fluid accumulation, adhesive property can result in further skin tearing Promote absorption of malodorous exudate Promote fluid absorption, adhesive property can result in further skin tearing Expensive Cannot be used in areas with hair or moisture (palm or armpit)	Packing of deep wounds Superficial, moderately exudating wounds, painful wounds Superficial to deep, lightly exudating wounds Superficial to deep, heavily exudating wounds Superficial, lightly exudating wounds, painful wounds Painful wounds, fragile, newly granulating wounds Superficial, lightly exudating wounds.	Curity gauze sponge (Covidien, Mansfield, MA) Curagel (Covidien, Mansfield, MA) Tegaderm HP (3M, St Paul, MN) 3M adhesive foam (3M, St Paul, MN) Comfeel Plus (Coloplast, Minneapolis, MN) Mepitel (Molnlycke Health Care, Newton, PA) Steri-Strips (3M, St Paul, MN)

Foams are also changed weekly. With healing of the wound, the patient, family, and staff should be educated on how to avoid skin tears in the future, and Prevention strategies should be initiated.

Table 1 Comparison of selected dressing, advantages, disadvantages, and clinical application

Studies have shown that there is no Optimal treatment and that efficacy is often institution dependent. The ideal wound closure device however should be simple, rapid, painless, comfortable, and washable. The material should also function as a microbial barrier and be strong and flexible enough but not hinder the activities of daily living. Most important, it should provide optimal cosmetic results by enhancing healing, reducing pain, and reducing scarring. The transparent films have been shown to exacerbate skin tears by causing pooling of fluids in the wound [10]. Further removal of the adhesive found in the film can cause additional injuries. For these reasons, transparent films are typically not recommended in the treatment of skin tears. A better alternative to transparent films are hydrogel sheets. The hydrogel sheet can be applied gently to the periwound skin and is better at managing fluids from the skin wound. The hydrogel also has the benefit of atraumatic application and removal. A study comparing transparent film, hydro- colloid, polyurethane film, and Steri-Strip with cellulose polyester material showed that wounds treated with a nonocclusive dressing such as Steri-Strip healed more quickly than those dressed with occlusive dressings [11]. The other benefits of Steri-Strips include its ease of application and ease of removal. In addition, recently, silicone-based dressings have been described for the treatment of skin tears. Mepitel (Molnlycke Health Care, Newton, PA), for instance, is a porous, nonadherent contact layer soft silicon dressing. Topical ointments can penetrate

the wound, and drainage can pass through to the outer absorbent dressing of choice. The base dressing, therefore, can be left in place over the wound for 7 to 10 days, whereas the cover dressing can be changed as needed [12].

A recent breakthrough development in wound healing has been the development of topical skin adhesives cyanoacry- lates-based adhesives. Cyanoacrylate derivates demonstrate many of the properties of an ideal wound closure device. Studies have shown ease of use, optimal cosmetic results, and ability to act as a microbial barrier of the cyanoacrylate products. Synthesized in 1949, these materials were first used medically in 1959. These adhesives are liquid monomers that polymerize in contact with the wound moisture to form a solid bond. The adhesive is used to hold the apposed wound edges together. However, with type II and III skin tears, the adhesive may be applied directly to the wound bed forming an in situ dressing. There are multiple derivates of the basic cyanoacrylates, each differing in the side chain and additives, with octylcyanoacrylate being the most widely used.

A study of 814 patients with surgical incisions and traumatic lacerations comparing the efficacy of Octylcyanoa- crylate (OCA) vs standard wound closure (SWC) methods showed no difference in the rates of infection and wound dehiscence between the 2 closure methods. Furthermore, at 3-month follow-up, there was no difference in the percentage of wounds with optimal appearance (OCA, 82% vs SWC, 83%; P = .67) [13]. OCA has also been shown to be effective in the treatment of minor cuts and scrapes. A randomized study of 162 patients comparing OCA and band-aids showed that there was no difference in healing rates and that OCA provided better hemostasis and pain relief [14].

The microbial barrier function of OCA has been demonstrated in 2 separate studies. An in vitro strike through study was conducted to determine the ability of bacteria to penetrate OCA adhesive that coated agar media [15]. Of the 600 test samples, 598 were free of signs of microbial growth after 72 hours. A separate study showed the effectiveness of OCA-based liquid occlusive dressing as a microbial barrier in vivo. In this study, standardized deep excisional wounds were created on the flanks of pigs. The wounds were randomly treated with an OCA-based dres- sing, a hydrocolloid dressing, or a gauze and then swabbed with an infectious inoculum of Staphylococcus aureus (10⁶ bacteria/g). None of the OCA treated wounds became infected, whereas the control and hydrocolloid wounds showed evidence of infection. The study also found that the OCA dressing was a superior hemostatic agent and caused fewer foreign body reactions when compared to the hydrocolloid dressing. They were both equally effective at promoting reepithelialization [16].

A recent prospective study evaluated the Clinical effectiveness of OCA in the treatment of skin tears.

Fig. 1 Class I skin tear (upper) treated with octylcyanoacrylate after irrigation and reapproximation of the wound edges (lower).

Twenty patients with Payne-Martin category II and III skin tears were treated with a formulated 2-octylcyanoacrylate topical bandage and followed up on a weekly basis [17]. Eighteen patients reported complete healing with one application of 2-octylcyanoacrylate, and there were no incidents of cellulitis or infection. In addition, of the 20 patients enrolled in the study, only 1 patient reported pain. Importantly, this treatment does not interfere with the patient’s daily routines such as showering. Physicians reported a high satisfaction with the use of the product because of the ease and speed of application as well as lack of repeated dressing changes.

The following protocol is recommended for the application of OCA in the treatment of skin tears. After assessing the patient for associated trauma and medical conditions, the area of injury is rinsed with normal saline, and then patted dry with sterile gauze. Next, the depth of tissue injury is assessed to determine injury beyond the dermis, in which case OCA application is contraindicated. After assessment of the wound, the wound edge is approximated using a gauze pad. Excess blood and serum under the approximated edges is expressed by applying pressure to “milk” out the wound. Once the wound is dry, a thin layer of OCA adhesive is applied over the wound margins by painting over the entire area extending to approximately 1 to 2 cm beyond the margins of the wound (Fig. 1). Care should be taken not to disrupt any approximated edges, if present. The first layer of the adhesive is then allowed to dry for 30 seconds. A second layer of OCA is then applied and also allowed to dry for

30 seconds. After the application of a second layer, no additional covering or dressing is needed, and patients may get the area wet.

Within the week, the wound may scab. It is advisable to warn the patient that it is normal for the wound to develop dark purple or black coagulum of blood at the site. The area does not need to be covered and will contract and eventually shed. If the wound begins to ooze, the adhesive can be reapplied as frequently as once a week if needed. No ointments or creams should be applied to the adhesive. The patient can be allowed to shower but should be warned against prolonged soaking or scrubbing. If adhesive must be removed, petrolatum-based ointment or silver sulfadiazine should be used.

Conclusions

Skin tears are common in hospitalized patients, especially in the geriatric and chronically ill populations. Besides the medical ramifications, skin tears also bring to bear a Financial burden to the health care system that is largely preventable. Implementation of simple measures such as proper patient handling, moisturizing the skin, and use of proper cleansing agents have been shown by multiple studies to be effective in preventing skin tears [2,8,9]. The same studies have also

shown that there can also a substantial monetary benefit in applying these preventive protocols.

Once they have occurred, the management of skin tears involves the use a variety of commercially available wound dressings or topical skin adhesives that protect the wound from further trauma, optimize the wound healing environ- ment, and prevent further bacterial contamination.

References

1. Malone ML, Rozario N, Gavinski M, Goodwin J. The epidemiology of skin tears in the institutionalized elderly. J Am Geriatr Soc 1991;39 (6):591-5.
2. Bank D, Nix D. Preventing skin tears in a nursing and rehabilitation center: an interdisciplinary effort. Ostomy/Wound management 2006;52(9):38-40, 4, 6.
3. Lawton S. Anatomy and function of the skin, part 1. Nursing times 2006;102(31):26-7.
4. Humbert P, Sainthillier JM, Mac-Mary S, Petitjean A, Creidi P, Aubin

F. Capillaroscopy and videocapillaroscopy assessment of skin microcirculation: dermatologic and cosmetic approaches. J Cosmet Dermatol 2005;4(3):153-62.

1. McGough-Csarny J, Kopac CA. Skin tears in institutionalized elderly: an Epidemiological study. Ostomy Wound Manage 1998;44(3A Suppl):14S-24S discussion 5S.
2. Payne RL, Martin ML. Defining and classifying skin tears: need for a common language. Ostomy/Wound Management 1993;39(5):16-20, 2-4, 6.
3. Edlich RF. A tribute to a gifted scholar, Anne Hudson, who has made revolutionary advances in healthcare and patient safety in our nation. J Long Term Eff Med Implants 2006;16:201-22.
4. Mason SR. Type of soap and the incidence of skin tears among residents of a long-term care facility. Ostomy Wound Manage 1997;43 (8):26-30.
5. Birch S, Coggins T. No-rinse, one-step bed bath: the effects on the occurrence of skin tears in a long-term care setting. Ostomy Wound Manage 2003;49(1):64-7.
6. Baranoski S, Ayello EA. Skin: an essential organ. Wound care essentials: practice principles. Philadelphia: Lippincott Williams & Wilkins; 2004.
7. Edwards H, Gaskill D, Nash R. Treating skin tears in nursing home residents: a pilot study comparing four types of dressings. Int J Nurs Pract 1998;4(1):25-32.
8. Kennedy-Evans KL. An innovative solution for skin tears: a case study. Ostomy Wound Manage 2004;50(2):9-10.
9. Singer AJ, Quinn JV, Clark RE, Hollander JE. Closure of lacerations and incisions with octylcyanoacrylate: a multicenter randomized controlled trial. Surgery 2002;131(3):270-6.
10. Eaglstein WH, Sullivan TP, Giordano PA, Miskin BM. A liquid adhesive bandage for the treatment of minor cuts and abrasions. Dermatol Surg 2002;28(3):263-7.
11. Bhende S, Rothenburger S, Spangler DJ, Dito M. In vitro assessment of microbial barrier properties of Dermabond topical skin adhesive. Surg Infect 2002;3(3):251-7.
12. Singer AJ, Nable M, Cameau P, Singer DD, McClain SA. Evaluation of a new liquid occlusive dressing for excisional wounds. Wound Repair Regen 2003;11(3):181-7.
13. Milne CT, Corbett LQ. A new option in the treatment of skin tears for the institutionalized resident: formulated 2-octylcyanoacrylate topical bandage. Geriatr Nurs 2005;26(5):321-5.