Monday, July 6, 2009

Preventing and Treating Skin Tears

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

If you work with elderly patients, then you have probably seen “skin tears.”  There is a nice basic article (see full reference below) on the topic that recently crossed my desk.  I’d like to share some of the information with you. (photo credit)
In considering the mechanism of skin tears, I love the way Dr Salcido (2nd reference below) puts it.  His paper explanation could be useful in explaining the problem to patients.
I will consider the etiologic factors associated with the development of skin tears through these 2 subdivisions:  pathomechanical & pathophysiological.
The French term la melodie de la peau de papier ("the melody of the little piece of paper") is useful to describe both the mechanical (human machine interface) and the pathophysiological (human) mechanisms of skin tears.
To make the point, try the following experiment. First, take a clean smooth piece of paper on a flat surface and run your hand and fingers over the top surface. There should be no drag or friction, and the surface tension should be minimal-a smooth ride, if you will.
Now take that same paper, fold it, make a tear in it, and, finally, wrinkle and moisten it. Now repeat the experiment by the hand motion. There is a significant increase in the drag coefficient (Cd) (increasing the resistance and shear forces), decreased surface tension, and further damage to the paper surface. In this experiment, the paper was the surrogate for the skin, and I consider this a model for explaining the mechanisms of mechanical forces and how they contribute to skin tears.

The main article has a nice list of risk factors for “skin tears” that should be considered when dealing with patients:
  • Advanced age (>85 years of age)
  • Sex (female)
  • Race (white)
  • Immobility (chair or bed bound)
  • Inadequate nutritional intake
  • Long-term corticosteroid use
  • History of previous skin tears; presence of ecchymoses
  • Altered sensory status or cognitive impairment
  • Stiffness and spasticity
  • Using assistive devices; Visual impairment
  • Applying and removing stockings
  • History of vascular, cardiac, and/or pulmonary problems

Many of the prevention strategies shared are common sense and focus on fall prevention – ie adequate lighting, removing clutter from a pathway, avoiding scatter rugs, making the bathroom safe for bathing.  Other strategies focus on removing sources of skin trauma – ie padding edges of furniture and equipment, avoiding adhesive products on frail skin, keeping fingernails and toenails cut short. 
Lift patients, do not drag them across sheets or surfaces.  Reduce moisture from incontinence or other sources.
Improved nutrition and hydration are important in prevention, as well as being gentle with the skin.

Once a skin tear has occurred, the same principles used to manage other wounds should be used.    First, the wound has to be assessed.  They suggest using the Payne-Martin classification of the skin tear.   However, the STAR consensus does not
Once again, the STAR consensus was to simplify the parameters of assessment and
a category 1a or 1b skin tear is one ‘where the edges can be realigned to the normal anatomical position
(without undue stretching)’.
A category 2a or 2b skin tear presents ‘where the edges cannot be realigned to the normal anatomical position (without undue stretching)’.
Whichever classification you use, remember these are acute wounds and have the potential to close by primary intention.
 Next,  the wound has to be cleaned -- removing bacteria and necrotic tissue.  When thinking about repair, it is usually best to avoid staples and sutures as the fragile tissue won’t hold.  So go straight to the next step – the dressing.
Most skin tears tend to achieve wound closure within 7 to 10 days using the following treatment plan:
  • Category 1a or b skin tears can be treated with adhesive strips anchor or Dermabond to the re-approximated edges
  • Category 2a or b skin tears can be treated with soft silicone or low tact foam dressing. 
All can be treated by using a  transparent film dressing (ie POLYSKIN* II) if there is minimal moisture.  The longer the dressing can be left unchanged, the better for the fragile skin.  It will often need changed every 3-7 days, but if the wound looks fine underneath consider leaving it another day or so.  If fluid develops under the transparent film dressing, then it will need to be changed promptly.

Prevention and Management of Skin Tears; Advances in Skin & Wound Care, 22 (7):  325-332, July 2009; LeBlanc, Kim BScN, RN, ET, MN; Baranoski, Sharon MSN, RN, CWOCN, APN, DAPWCA, FAAN
Deconstructing Skin Tears; Advances in Skin & Wound Care,  22(7):294-295,July2009;  Salcido, Richard MD
STAR: a consensus for skin tear classification; Primary Intention Vol. 15 N o. 1 FEBRUARY 2007; Carville K, Lewin G, Newall N, Haslehurst P, Michael R, Santamaria N & Roberts P


Anonymous said...

I'm mid 40's and have thin skin on the backs of my hands, as all the women in my family do. A month ago I started using tretinoin cream (.025%) on the backs of my hands every night just before bed.

My dermatologist said to expect it to be 6 months before I see thicker skin and that after the initial redness goes away I can increase to a stronger cream.

Will this make skin tears on the backs of my hands less likely if I continue it and use sunscreen daily?

rlbates said...

If your skin thickens, it will. As you are so young, I would consider your nutrition/diet. Are you eating a good diet?

Anonymous said...

rlbates: Yes, I eat a lot of fruit and vegetables, and I take 800 mg D and 1,000 mg fish oil every day. I just ordered some Biotin and plan to try that for a few months to see if it makes a difference with my fingernails.

Bianca Castafiore? said...

Thanks so much for this -- found it via Buckeye Surgeon. I've been on daily steroids since 1996, and will be forever, unfortunately, plus have CRPS in all four limbs. Oh, why not pile it on?! ----->> I've also just had 6 surgeries in the past year, 3 per shoulder. My skin has had it. Should I forget and rub too hard, or, God forbid, scratch -- well... who knew that skin could rip like paper? And, anonymous, I'll be asking about tretinoin cream when I get my latest batch of staples removed next week!

Ha! Word verification was: plighter! Somehow à propos...