Skin Tears Made Easy
21/11/11 | Assessment and diagnosis, Complex wounds, Skin integrity
Skin tears occur in those with fragile skin, including neonates and more frequently in the elderly. Some skin tears are unavoidable but many are considered to be preventable1. It is important that clinicians have a good understanding of the effects of ageing on the skin and take appropriate measures to reduce the risk of patients developing skin tears. For those with skin tears, good assessment skills and documentation are important for effective management. This article will focus on why skin tears occur, the classification tools available and offers a practical guide to the prevention and management of skin tears.
What are skin tears?
Skin tears are traumatic injuries, first defined by Payne and Martin in 1993 and more recently by an international consensus group, which can result in partial or full separation of the outer layers of the skin[1-3]. These tears may occur due to shearing and friction forces or a blunt trauma, causing the epidermis to separate from the dermis (partial thickness wound) or both the epidermis and the dermis to separate from the underlying structures (full thickness wound)[1,2].
Skin tears are perceived by some to be minor injuries. However, they can be significant and complex wounds; complications such as infection or a compromised vascular status can increase morbidity or mortality risks.
Where do skin tears occur?
Skin tears can occur on any anatomical location. In the elderly they are often sustained on the extremities such as the upper and lower limb and on the dorsal aspect of the hands. Skin tears in neonates with immature skin tend to be associated with the use of adhesives or device trauma and often occur on the head, face and extremities.
Which patients are at risk?
Patients who are elderly or dependent on others have a higher risk of sustaining skin tears[2-7]. Skin can become very fragile with age and even the simplest bump or knock can cause tissue damage. In addition, patients who are very young and have immature skin or those who are critically ill and/or have multiple risk factors are also more likely to develop skin tears.
What are the risk factors for skin tears?
Skin tears are associated with falls, blunt trauma, handling and equipment injuries. A number of risk factors have been reported[1,7-12], including:
- Age and gender
- History of previous skin tears
- Dry, fragile skin
- Medications that thin the skin such as steroids
- Echymoses (bruising / discolouration of the skin caused by leakage of blood into the subcutaneous tissue as a result of trauma to the underlying blood vessels)
- Impaired mobility or vision
- Poor nutrition and hydration
- Cognitive or sensory impairment
- Comordities that compromise vascularity and skin status, including chronic heart disease, renal failure, cerebral vascular accident
- Dependence on others for showering, dressing or transferring.
What is the prevalence of skin tears?
Although skin tears are perceived to be common among the frail elderly, these wounds often go unreported, especially in the community[3,9,13,14]. Most prevalence and incidence studies have been conducted in the United States (USA) and Australia (Box 1).
Studies confirm that skin tears are common3 with an estimated 1.5 million skin tears occurring in elderly residents of institutions in the USA annually; a three-year, annual, state-wide survey of all public hospitals in Western Australia found skin tears to be the third largest group of wounds.
More recently, a review of 114 long-term care facilities in the USA found that 22% of patients (average age 83 years) had a skin tear, despite good wound care practices. In the UK, one primary care trust with a dedicated tissue viability nurse, reported a reduced incidence, with 49 out of a total of 2200 patients (average age 76 years) from 52 care homes developed a skin tear in a 12-week audit period.
Why do skin tears occur?
Intrinsic and extrinsic factors increase the risk of skin tears.
As the skin ages, pathological skin changes occur, such as: thinning and flattening of the epidermis; loss of collagen and elastin; and atrophy and contraction of the dermis, causing wrinkles and folds to appear. Decreased sebaceous gland and sweat gland activity causes the skin to dry out, while arteriosclerotic changes in the small and large vessels causes thinning of vessel walls and a reduction in the blood supply to the extremities[25,26]. This results in the skin becoming more fragile, furrowed and wrinkled and more prone to skin tears (see Table 1).
In neonates the dermis does not fully develop until after birth and at full term it is only 60% of adult thickness. In addition, the fibrils connecting the epidermal/dermal junction are reduced in number and are more widely spaced. This decreases skin elasticity and the skin is more likely to be damaged by shear forces.
The need for assisted transfers, showering or other activities of daily living increases the risk of skin tears among dependent individuals. Carers and patients can reduce these risks by keeping fingernails trimmed, not wearing jewellery, padding bed rails and wheelchairs, and taking care when transporting patients. In addition, a good skin care regimen is important to maintain skin integrity.