Skin Tears Made Easy
21/11/11 | Assessment and diagnosis, Complex wounds, Skin integrity
How should skin tears be assessed?
The initial assessment should include a comprehensive assessment of the patient and his/her wound. It is important to determine the patient's age and medical history, any underlying comorbidities, general health status and potential for wound healing.
Assessment must establish the cause of injury: when, where and how it occurred.
In addition, a full assessment of the wound is required to determine the following:
- Anatomical location and duration of skin tear
- Dimensions (length, width depth)
- Wound bed characteristics and percentage of viable/non-viable tissue
- Type and amount of exudate
- Presence of bleeding or haematoma
- Degree of flap necrosis
- Integrity of surrounding skin
- Signs and symptoms of infection
- Associated pain.
The skin tear should then be categorised and all information be carefully documented.
Skin tear classification systems
As is the case with pressure ulcer staging, there is no universally accepted classification system for the assessment of skin tears. Payne and Martin developed the first classification system in 1990 and this was updated in 1993.
The Payne and Martin system provides classifications by degree of severity. It has three categories and two sub-categories:
- Category I: Skin tear without loss of tissue. The epidermal flap either completely covers the dermis or covers the dermis to within 1mm of the wound margin
- Ia: Linear type
- Ib: Flap type
- Category II: Skin tears with partial tissue loss
- IIa: Scant tissue loss (25% or less)
- IIb: Moderate to large loss of tissue (more than 25% loss of the epidermal flap)
- Category III: Skin tears with complete tissue loss.
Problems associated with inter-rata reliability testing of the Payne and Martin classification system and its poor utility in Australia, led to a study that resulted in the Skin Tear Audit Research (STAR) Classification System. This system comprises three categories and two sub-categories of skin tears as outlined below. The STAR Classification System is commonly used in Australia, with evidence of implementation reported within the UK.
What principles should guide treatment?
There is a lack of robust research into the prevention and management of skin tears. Experiential evidence has been used predominantly to develop skin tear guidelines or best practice statements in the USA, Canada and the UK. Although these guidlines are considered to be important for guiding practice in the assessment and care planning process, there is a lack of uptake within clinical practice reported in the literature[5,12].
A recent international survey involving 1127 clinicians from 16 countries found that around 80% of respondents admitted to not using any tool or classification system, while around 90% favoured a simplified method for assessment and documentation. This underpins the need for a systematic approach involving the multidisciplinary team to optimise the management and prevention of skin tears.
Key principles for management include:
- Assess and document the wound
- Classify using a recognised tool (eg Payne and Martin2 or the STAR Classification System3)
- Manage using an appropriate dressing
- Prevent further trauma.
How to manage skin tears
The main aims of management are to preserve the skin flap and protect the surrounding tissue, reapproximate the edges of the wound without undue stretching, and reduce the risk of infection and further injury. The principles of moist wound healing are promoted in the following general guidelines:
Control bleeding (haemostasis)
- Apply pressure and elevate the limb if appropriate.
- Clean the wound
- Use warm saline or water to irrigate the wound and remove any residual haematoma or debris
- Gently pat dry the surrounding skin to avoid further injury.
Approximate the skin flap
- If the skin flap is viable, gently ease the flap back into place using a dampened cotton tip or gloved finger, tweezers or a silicone strip and use the flap as a 'dressing' if viable
- If the flap is difficult to align, consider using a moistened non-woven swab. Apply for 5-10 minutes to rehydrate the flap
- Categorise the skin tear and perform a wound assessment. Document findings
- Apply a skin barrier product as appropriate to protect the surrounding skin.
Apply the dressing
- Select an appropriate dressing (see Dressing selection). If considering the use of adhesive wound closure strips, allow space between each strip to facilitate drainage and avoid tension over flexure sites (this could compromise vascularity)
- Tissue glues may be used to secure the flap. Sutures and staples are generally not recommended due to the fragility of the skin. However, they may be required in the treatment of deep, full-thickness lacerations
- If possible, leave the dressing in place for several days to avoid disturbing the flap
- If an opaque dressing is used, mark with an arrow to indicate the preferred direction of removal and record in the notes.
Review and reassess
- At each dressing change, gently lift and remove the dressing, working away from the attached skin flap, as indicated by the arrow drawn on the dressing. Consider using saline soaks or silicone-based adhesive removers to minimise trauma to the periwound skin[34,35]
- When cleaning the wound take care not to disrupt the skin flap
- Monitor for changes in the wound and maintenance of skin integrity. Where the skin or flap is pale and dusky/darkened, it is important to reassess within 24-48 hours. Debridement is usually required on non-viable flaps
- Observe the wound for signs and symptoms of infection (especially in patients with diabetes), including increased pain and exudate, erythema, heat, oedema and malodour
- Implement preventative skin care interventions to avoid further skin tears (see How to prevent skin tears).