All Wales
Tissue Viability
Nurse Forum
Best Practice Statement
The Assessment
and Management
of Skin Tears
Endorsed by
Fforwm Nyrsys Hyfywedd
Meinwe Cymru Gyfan
Supported by an unrestricted
educational grant from
IN ASSOCIATION WITH
The All Wales Tissue Viability Forum
This guideline for Best Practice has been written by Menna Lloyd Jones, Senior Nurse Tissue Viability, Betsi Cadwaladr University Health
Board, and Clare Morris, Former Tissue Viability Nurse Advisor, Betsi Cadwaladr University Health Board.
The guideline has been reviewed and endorsed by the All Wales Tissue Viability Forum, February 2011.
The All Wales Tissue Viability Forum was formed in September 2003 and has the following aims within the six key principles from the
Institute of Medicine (Welsh Assembly Government, 2005):
Safety, Effectiveness, Patient-Centred, Timely, Efficient and Equitable
1. To raise awareness of tissue viability in order to improve patient outcomes
2. To raise awareness of the impact of tissue viability in health economics
3. To promote evidence-based practice in tissue viability and influence appropriate policy across Wales
4. To be recognised by the Welsh Assembly Government as a knowledgeable and valuable resource
5. To contribute to the body of knowledge by initiating and participating in tissue viability research and audit
6. To improve patient outcomes by maintaining the links with academia and disseminating knowledge relating to tissue viability to all
healthcare providers
7. To work in partnership with industry in order to improve patient care
8. To provide peer support to all tissue viability nurses working in Wales.
2
Guidelines for the Assessment and Management of Skin Tears
The Prevention and Management of Skin Tears
Background
A review of the tissue viability nurse’s caseload within Betsi
Cadwaladr University Health Board identified an increase in the
incidence of skin tears throughout the local population of elderly
patients. In an attempt to reduce the incidence and ensure the
provision of appropriate care, the tissue viability nurses (TVNs)
undertook a literature search using CINHAL between 1995 and
2010. The literature review identified gaps and weaknesses. There
was no standardised prevention strategy and there was confusion
with regard to the appropriate management of skin tears.
Purpose
The purpose of this Best Practice Statement is to provide
appropriate knowledge in order to prevent the development of
skin tears and/or to facilitate appropriate treatment of category
1 and 2 skin tears (Payne and Martin, 1993). It is not the
intention of this document to discuss the treatment of deep
pretibial lacerations or other deep category 3 skin tears, which
may require surgical intervention.
Guidelines for the Assessment and Management of Skin Tears
Introduction
Skin tears are defined as a traumatic wound resulting from
separation of the epidermis from the dermis, as a result of
friction and/or shearing forces (Malone et al, 1991; Fleck,
2007). Skin tears represent a significant problem affecting the
elderly with prevalence rates of between 14% and 24%. An
estimated 1.5 million skin tears occur in elderly residents of
institutions in the United States every year (Baranoski, 2005).
The majority of skin tears are caused as a result of trauma,
where the epidermis is displaced but still retains a blood
supply. (Carville et al, 2007). Approximately 80% of all skin
tears are predominately seen on the arms and dorsal aspect of
the hands, and less frequently the lower limbs (Baranoski,
2003). With an increasing elderly population, it is estimated
that the incidence of skin tears will become one of the largest
problems in wound care. Identifying the risk and providing
evidence-based care is therefore paramount (Beldon, 2006;
Benbow, 2009).
3
Table 1. Summary of the function of skin that
declines with age
l Epidermis becomes thinner and flatter, uneven distribution of
melanocytes leading to uneven pigmentation
Anatomy and physiology of the skin
In order to prevent skin tears it is important to have a basic
understanding of the anatomy and the effects of ageing on the
skin, as well as being able to recognise and address factors that put
the patients at risk of developing skin tears.
The skin is the largest and most visible organ in the body, and is
made up of two main layers; the epidermis and the dermis. Lying
beneath the dermis is the subcutaneous layer, or hypodermis
(Timmons, 2006).
The epidermis is the outermost layer of the skin and is very thin,
with a thickness of only 0.1 mm. The epidermis receives oxygen
Classification of skin tears
No skin tear classification system has been accepted or validated
universally (Henderson, 2007). Classification systems are important
in the assessment process to assist the nurse in assessing and planning
treatment (Battersby, 2009). The most widely cited classification
Category I: Skin tear without tissue loss.
Category IIa: Scant tissue loss. Partial thickness in which 25% or
less of the epidermis flap is lost and at least 75% or more of the
dermis is covered by the flap.
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l Flattening of the dermal–epidermal junction, increased
susceptibility to friction/shearing forces, resulting in blistering and
minor injuries
l Dermis has decreased bulk owing to collagen atrophy
l Decreased tactile sensitivity and pain perception, leading to
increased danger of injury
l Skin becomes wrinkled owing to depletion of elastic fibres
l Decreased capillary loops in the dermis increase dangers of both
hypo- and hyperthermia
l Skin becomes dry as a result of atrophy of sebaceous glands
Adapted from: Baranoski (2003); Beldon (2006)
system is the Payne and Martin Classification, which was developed
in the late 1980s and revised in 1993 (Payne and Martin, 1993;
Baranoski, 2003).
Using the Payne and Martin Classification system (1993) skin
tears can be classified as follows:
Category IIb: Moderate to large tissue loss. Partial thickness
wound, in which more than 25% of the epidermal flap is lost and
more than 25% of the dermis is exposed.
Category III: Skin tears with complete tissue loss. Epidermal flap
is absent.
Guidelines for the Assessment and Management of Skin Tears
Epidermis
Dermo-epidermal junction
Dermis
Capillaries
Hypodermis
Larger blood vessels
Figure 1
and all its nutrients by diffusion from the dermis (Butcher and
White, 2005). The epidermis is firmly attached to the dermis at
the dermo–epidermal junction (Figure 1).
The dermis is made up of two layers, predominately comprising
fibrous proteins, collagen and elastin (connective tissue),
which give the skin its strength and elasticity (Flanagan,
1997). Below the dermis lies the subcutaneous layer, or
hypodermis. The subcutaneous layer is made up of adipose
tissue, connective tissue and the larger blood vessels. This
layer provides support to the dermis and the fat stored in the
subcutaneous layer provides protection to the internal structures
(Timmons, 2006).
The effects of ageing on the skin
The age-related changes to the skin are both visible and
structural. For example, there is an overall thinning of the
epidermis, which is particularly noted after the age of 70 years,
and is more prevalent in women than in men (Desai, 1997).
This results in the possibility that the skin becomes more
Figure 2
Guidelines for the Assessment and Management of Skin Tears
susceptible to damage from mechanical forces such as moisture,
friction and trauma (Wounds UK, 2006). There is also a
flattening out of the dermo–epidermal junction, which
makes it more fragile and more susceptible to shearing damage
(Desai, 1997).
The paper-thin appearance of the skin is a common sign of
ageing and can be attributed to an estimated 20% reduction in
the thickness of the dermis. The thinning of the dermis results
in a reduction in the blood supply, nerve endings and collagen,
which in turn leads to a decrease in sensation, temperature
control, rigidity and moisture retention (Wounds UK, 2006).
The collagen and the elastic fibres which provide the strength
and elasticity of the skin loses some of its elasticity, which in
turn results in the skin becoming less elastic, less resilient and
more lax. Sebaceous glands atrophy and the skin becomes dry.
The outward visible signs of the effects of ageing are the
appearance of wrinkles and skin folds (Desai, 1997; Burr and
Penzer, 2005).
Assessment for prevention
Ousey (2009) stated that in order to give appropriate preventive
care, it is important to identify those factors that put the patients
at risk of developing skin tears, which are listed below.
Preventing skin tears
The literature review demonstrated that little has been written
with regard to preventing skin tears. Baranoski (2003) suggests
that preventing skin tears is predominately taking a common
sense approach to patient care, and identifying and addressing the
relevant risk factors, which can be separated into four categories:
general principles (Table 2); patient handling (Table 3); skin care
(Table 4); dressings (Table 5).
Skin tears management guideline
The aim of this best practice statement is to examine the more
conservative treatment options for category 1 and 2 injuries only.
Skin tear treatment is dependent on the category of the tear.
Figure 3
5
Table 2. General principles
Risk factor
Preventive strategy
l History of previous skin tears
l Check for previous history of skin tears
l Presence of ecchymosis (discoloration of an area of skin
l
caused by leakage of blood into the subcutaneous tissues as
a result of trauma to the underlying blood vessels). Clinical
appearance: bruising or petechiae (tiny purple or red spots)
(Figure 2)
l Poor quality nutritional intake either over- or under-nutrition
Assess/recognise fragile, thin, vulnerable, ecchymotic skin, and be
aware of the risk of self-harm
l Provide adequate nutrition and hydration. MUST (Malnutrition
Universal Screening Tool) screening and treatment in accordance
with MUST guidance (Johnston, 2007)
l A healthy, balanced diet can help maintain tissue viability. Obese and
under-nourished patients can be at risk of adverse affects—both on
tissue/body structure and function. Malnutrition will result in impaired
and prolonged healing of damaged skin, and leave the patient
vulnerable to infection (Johnston, 2007)
l Dehydrated skin
l Meet fluid requirements 1500 ml daily (equates to 8–10 cups or
glasses)
l Dehydrated skin is more fragile and is more susceptible to
breakdown. Also leads to tissue profusion by blood, limiting oxygen
and nutrient supply (Johnston, 2007)
l Prolonged use of corticosteroids
l Be aware of the effect of steroids on the skin and plan appropriate
skin care
l Impaired sensory perception (e.g. diabetics) and disease
l Establish current medical history
processes (e.g. renal failure, chronic heart failure)
l Cognitive impairment/dementia and involuntary movements
l Upholster sharp borders of furniture and bed surroundings etc with
soft material
l Visual impairment
l Remove obstacles such as low furniture (i.e. coffee tables, chairs) in
the immediate surroundings
6
Guidelines for Faecal Management Systems
Table 3. Patient handling
Risk factor
l Impaired mobility and dependency on others for care, such as
bathing, transferring and positioning
Preventive strategy
l Ensure patient and staff wear comfortable shoes to prevent falls
l Provide a safe environment to prevent trauma
l Provide adequate lighting
l Ensure patient and staff have short fingernails
l Apply clothing and compression stockings carefully
l Exercise extreme caution and a gentle touch when bathing, dressing
and/or transferring individuals at risk (most skin tears occur during
routine patient care activities)
l Exercise extreme caution when patients get in and out of
wheelchairs. e.g. footrests
l Ensure patient and staff avoid wearing jewellery that could snag the
skin
l Transport patients carefully (e.g. appropriate selection of sling types),
be aware and avoid protruding components of the hoist and apply
appropriate hoist use
l Presence of friction, shearing and pressure
l Employ good manual handling technique (e.g. slide sheets; follow
local manual handling protocol)
Table 4. Skin care
Risk factor
l Presence of ecchymosis (discoloration of an area of skin
caused by leakage of blood into the subcutaneous tissues as
a result of trauma to the underlying blood vessels). Clinical
appearance: bruising or petechiae (tiny purple or red spots)
(Figure 2)
l Dry skin/dehydration
Preventive strategy
l Assess/recognise fragile, thin, vulnerable, ecchymotic skin
l Consider the potential risk of skin damage from pets, especially cats
l Be aware of the risk of self-harm
l Regularly review medication, e.g. asprin and steroids
l Protect fragile skin by covering with, e.g. stockinet, long sleeves
l Use emollient to rehydrate limbs at least twice every day
l Avoid the use of soap which can cause drying of the skin
l Advanced age
l Assess for risk factors and plan preventive strategy
Table 5. Dressings
Risk factor
l Inappropriate use of adhesive dressings.
Preventive strategy
l Traditional adhesives should always be avoided when the skin has
been assessed to be at risk. Use gentle atraumatic dressings, e.g.
Allevyn Gentle Border, Mepilex or Mepilex Border
l If additional fixation is needed, consider securing dressing with
tubular dressings (e.g. Tubifast). If it is necessary to secure the
dressing with tape. Do not apply the adhesive tape directly on to the
skin, but ensure that the dressing is large enough to cover the limb
and apply adhesive tape on to the dressing only
l If an adhesive dressing has been applied and is difficult to remove,
support the skin while removing the dressing; gently grasp one edge
and slowly peel the dressing from the skin in the direction of hair
growth. Avoid skin trauma by peeling the dressing back rather than
pulling it up from the skin
l Consider saline or solvents (e.g. Appeel) to loosen the bond
Guidelines for the Assessment and Management of Skin Tears
7
Figure 4
Figure 5
Cooper (2006) states that the most effective way of treating
a skin tear is to use the skin flap as a dressing and where
possible, bring the wound edges together. To optimise healing,
management of these wounds is best undertaken at the time
of injury (Wounds UK, 2006). However, the best treatment
options for the most serious type 2 and 3 tears may be
surgical intervention and/or referral to a plastic surgeon.
Assessment of skin tear categories should always be completed
by qualified competent practitioner.
Aims of treatment
Management
Assessment should include a full history of the wound:
l Underlying disease process (e.g. diabetes, peripheral
vascular disease)
l The cause of the injury
l Time of injury
l Previous skin injury
l Status of surrounding skin
l Nutritional status
l Medication
l Wound location
l Size and category of wound.
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l To stop the bleeding
l Preventing wound infection
l Minimising pain and discomfort
l Reestablishing skin integrity.
Step-by-step management of category 1
and 2 skin tears
l Cleanse the wound with warm irrigation fluid as appropriate
l Without pulling or applying tension, gently unfold and smooth
out the flap completely over the wound (Figures 4 and 5)
l Place an atraumatic contact layer (e.g. Silflex or Mepitel) or
atraumatic all in one dressing (e.g. Mepilex Border or Allevyn
Gentle Border) over the flap, keeping the flap in place. The use
of paper adhesive tapes (i.e. Steristrips) or sutures may cause
additional traction and trauma, which can lead to further
damage (Meuleneire, 2002). If using an atraumatic all-inone dressing to ensure that the flap is not disturbed during
removal, always mark the dressing with an arrow to indicate
the direction of removal
l The atraumatic dressing should remain in place for a minimum
of 5 days to allow the flap to adhere to underlying tissues
Guidelines for the Assessment and Management of Skin Tears
l Where required, a non-adhesive dressing pad is placed over the
contact layer to absorb exudate. Do not use atraumatic all in
one dressings with atraumatic contact layers
l Where required, the dressing pad is held in place by a tubular
bandage and changed as necessary
l Monitor wound frequently for signs of wound infection,
especially for the at-risk patients (e.g. diabetics or
immunocompromised). Signs of wound infection are increased
pain and exudate levels, redness, heat oedema and malodour
l From day 6, the atraumatic contact layer/dressing can be
removed. Remove in the direction of skin flap indicated by the
arrow (Figure 6).
NB if the skin flap becomes necrotic refer to tissue viability nurse or
seek medical advice.
First aid treatment for carers
and non-nursing staff
Providing fundamental care places the healthcare assistants/carers
and other health professionals in an ideal place to prevent and
administer safe and prompt treatment, as well as encouraging
patients to adopt strategies that will keep their skin well hydrated
and prevent the development of skin tears.
Treatment
l Ensure that the patient is safe from further trauma
l With any skin tears prompt treatment is essential with
category 1 and 2 tears in order to ensure that the flap remains
viable. It is important to replace the flap as soon as possible. It
is therefore vital that the injury is reported to a registered nurse
or patient taken to Accident and Emergency (A&E)/Minor
Injuries Unit (MIU) as soon as possible; do not attempt to
remove or replace the damaged tissue
l Do not apply any adhesive dressings on to category 1 or 2 skin
tear. Cover with a clean piece of cling film or similar; place
gently over the wound, making sure that it is not wrapped
around the limb and refer to a registered nurse or GP
l With category 3 skin tears it is safe to apply an atraumatic
wound dressing and inform the GP or registered nurse as soon
as possible. If there is extensive tissue loss or profuse bleeding,
refer immediately to a registered nurse or take the patient to
A&E/MIU as per bullet point 2.
Figure 6
Skin flap rolled upward to cover wound
Guidelines for the Assessment and Management of Skin Tears
Any dressing over the skin flap should be
removed in the same direction
9
References
Baranoski S (2003) How to prevent
and manage skin tears. Adv Skin
Wound Care 16(5): 268–70
Baranoski S (2005) Meeting the
Challenge of Skin Tears. Adv Skin
Wound Care 18(2): 74–5
Battersby L (2009) Exploring best
practice in the management of skin
tears in older people. Nurs Times
105(16): 22–6
Beldon P (2006) Skin Trauma. In:
White R, Harding K. eds, Trauma
and Pain in Wound Care. Wounds
UK, Aberdeen
Benbow M (2009) Skin Tears. Journal
of Community Nursing 23(01): 14–8
Wounds UK (2006) Best Practice
Statement: Care of the Older
Person’s Skin. http://tinyurl.
com/69dynck (accessed 28 February
2011)
10
Butcher M, White R (2005) The
structure an function of the skin.
In: White R. ed, Skin Care in
Wound Management: Assessment and
Treatment. Wounds UK. Aberdeen
Burr S, Penzer R (2005) Promoting
Skin Health. Nurs Stand 19(36):
57–65
Carville K. Lewin G. Newall N et al
(2007) STAR: a consensus for skin
tear classification. Primary Intention
15(1): 18–28
Cooper P (2006) Managing the
treatment of an older patient who
has a skin tear. Wounds Essential 1:
119–20
Desai H (1997) Ageing and wounds.
Part 2: Healing in old age. J Wound
Care 6(5): 237–9
Flanagan M (1997) Wound
Management. Churchill Livingstone,
London
Fleck CA (2007) Preventing and
treating skin tears. Adv Skin Wound
Care 20(6): 315–20
Henderson V (2007) Treatment
options for pretibial lacerations. J
Wound Care 12(6): S22, S24–6
Johnston E (2007) The role of
nutrition in tissue viability. Wound
Essentials 2: 10–21
Malone ML. Rozario N. Gavinsli M.
Goodwin J (1991) The epidemiology
of skin tears in the institutionalized
elderly. J Am Geratr Soc 39(6):
591–5
Meuleneire F (2002) Using a soft
silicone-coated net dressing to
manage skin tears. J Wound Care
11(10): 365–9
Payne RL, Martin ML (1993) Defining
and classifying skin tears: need for a
common language. Ostomy Wound
Manag 39(5): 16–26
Timmons J (2006) Skin Function and
Healing. Wound Essentials 1: 8–17
Welsh Assembly Government (2005)
Designed for Life-Creating World
Class Health and Social Care for
Wales. Welsh Assembly Government,
Cardiff
Guidelines for the Assessment and Management of Skin Tears
Guidelines for the Assessment and Management of Skin Tears
11
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Guidelines for the Assessment and Management of Skin Tears