Although skin tears are difficult to prevent and treat, caregivers can limit their impact by adhering to a few key objectives.

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kin tears represent a major problem affecting the elderly and compromised individuals. It is estimated that at least 1.5 million skin tears occur in institutionalized elderly each year,¹ with prevalence rates between 14–24%.² Ultimately, they cause the patient to suffer pain, the caregiver to waste precious time, and the facility to lose money and other resources. The anatomy of the skin has much to do with the etiology and the cause of skin tears.

Figure 1

A cross-section view of the skin's three major layers.

Although skin tears are thought to be difficult to prevent and treat, this article will share tips and products to offer assistance with these bothersome wounds.
       There are three functional and anatomic layers of the skin (see Figure 1):
1. The epidermis (outermost layer comprised of five separate strata)
2. The dermis (the thicker second layer that houses the hair follicles, sweat glands, and nervous intervention
3. The subcutaneous tissue (the fatty layer beneath the skin that provides cushioning and protection).

Anatomy

       Between the epidermis and dermis is the basement membrane, a moving junction that both separates and attaches the epidermis and the dermis (also known as the dermal-epidermal junction). This junction provides structural support and allows for the exchange of fluid and cells between the skin layers.³
       The epidermis has an irregular shape resembling downward, finger-like projections called rete ridges or pegs. The significance of this is that the dermis has upward projections. These upward and downward projections fit together, very much like “tongue and groove” wood, anchoring the epidermis to the dermis. This connection helps to prevent the epidermis from sliding back and forth across the dermis with normal movement and skin manipulation. The two move as one in healthy young skin. As the skin ages, however, these rete ridges or pegs begin to flatten between that dermal-epidermal junction. We tend to see this epidermal-dermal flattening by the

Table 1

sixth decade of one’s life.⁴ With this anchoring now diminished, there is an increased potential for the epidermis to detach from the dermis, leading to tearing of the skin, especially in the elderly population.⁵ (See Table 1 for the Payne-Martin classification system for skin tears.)
       Long-term care facilities may find this information helpful when developing plans of care, fostering more detailed documentation and assisting in improved tracking of outcomes.

Risk

       Persons at risk for skin tears include those of advancing age as well as those with a history of previous skin tears, compromised nutrition, fluid volume deficit, confusion, limitations in mobility, lack of independence, and ecchymotic or bruised skin. Senile purpura of the skin often causes a decrease in pain perception, and certain medications make skin more prone to injury. These medications include steroids, which cause further thinning of skin as well as suppression of the immune system. Many changes of the skin occur with aging. That thin, “tissue paper” appearance of aged skin occurs because dermal tissue loses 20% of its thickness. Wound healing progresses more slowly in the elderly because of several factors, including: decreased inflammatory response, delayed angiogenesis (ie formation of new blood vessels), slower epithelialization, decreased function of sebaceous glands, decreased collagen synthesis, alternation in melanocytes (resulting in skin discoloration), and thinning of all the skin layers. There is less adipose tissue, decreasing insulation and protection. There is also atrophy of subcutaneous tissue in very specific areas, such as the face, hands, skin, and feet.⁷
       When injury occurs, there is an increase in energy absorbed by the skin. Skin tears most commonly occur in the upper extremities, with 80% of them on arms and hands. Skin tears of unknown origin make up one half of the total skin tear population. Of skin tears whose causes are known, however, 25% result from wheelchair/geri-chair injuries. Another 25% occur from accidents involving bumping into objects, and 18–24% occur due to transfers and falls.⁸

Plan of Care and Treatment Choices

       Basic strategies (eg, clothing residents in long sleeves and long pants, the use of gentle adhesives, the judicious use of pillows, and staff education on using a gentle hand) are all good first steps.⁹ Wrapping vulnerable arms and legs in rolled gauze might be a tempting approach to decrease the incidence of skin tears, but it could cause family members to become concerned and uncomfortable. It could also become a visual indicator for surveyors that there are skin care problems.
       Patients and residents who are totally dependent on others for activities of daily living (ADLs) are at the highest risk for sustaining skin tears.¹⁰ Use great care while providing full or partial assistance with ADLs. These tasks increase contact with the skin, thus increasing the potential for the skin to tear.¹¹ Use of appropriate equipment (ie, lifts, walkers, transfer and turn aides, etc.) to assist with toileting and transferring can be helpful in decreasing the chance of developing skin tears. Improper handling can cause an increase in skin tears due to trauma. Gentle handling of the skin is important. Keeping the patient well hydrated by increasing fluid intake (unless the patient is fluid-restricted) can also be the difference between a bruise from a bump and that bump breaking skin. Frequent topical moisturization and emoliation is also necessary.¹²
       Advanced skin care products that deliver endermic nutrition as well as antioxidants can provide a for nourished skin, topically—even if the patient or resident is not receiving adequate nutrition from oral, enteral, or parenteral nutrition.¹³ A recent quasi-experimental study looked at skin tear incidence in a 100-bed long-term care facility and showed a reduction from 180 skin tears in a six-month time period to two skin tears in a six-month time period.¹⁴ This particular facility used a gentle, advanced skin care line with pH-balanced soap and surfactant-free cleansers; moisturizers containing amino acids and free-radical scavengers like grape-seed extract, vitamin C (ascorbic acid), and hydroxytyrosol (from olives); essential fatty acids like omega-3, -6, and -9; and tenacious skin protectants containing sophisticated combinations of silicones.

Effective Topical Products

       There are several good topical products that can help alleviate the discomfort of skin tears while protecting the area to allow healing. Transparent films, a traditional dressing option, sometimes do not handle fluid well; since most skin tears tend to be wet the first 24–48 hours, causing pooling and leaking of the fluid onto the surrounding skin, this can cause problems. In addition, transparent films are adhesive, and the skin on which these dressings are applied is extremely compromised. This can cause secondary epidermal stripping or tearing of the skin upon removal of the transparent film. Other imperfect yet popular dressing choices include non-stick Telfa-type pads with topical antibiotics applied twice a day.
       One alternative dressing is a hydrogel sheet. This advanced product looks like a thin slice of sticky gelatin and is gentle to the periwound skin, but it can handle the initial fluid from the wound for the first 24–48 hours. Topical emoliation can be applied right up to the wound margin prior to the application of the dressing. Therefore, by the time the skin tear is healed the skin will be in better condition. The hydrogel sheet can stay on for 3–5 days and may be held in place with elastic net dressing, roll gauze, or a tubular-type dressing.
       The use of protective sleeves or elastic tubular support bandages that come on a roll is cost-effective, holding dressings in place without making them the focus of the patient. Using elastic tubular support bandages and cutting a hole for the thumb, ensuring that the

Figure 2

An example of a skin tear with an intact flap of skin.

sleeves go all the way up to just below the axilla, will help to anchor the dressing and protect the patient who is prone to picking at the dressing. It also looks more natural. If the skin tear has a flap of skin that is intact (see Figure 2), approximate the edges and apply adhesive closure strips—then apply the hydrogel sheet. To further protect the injury and assist your colleagues at the next dressing change, indicate in which direction the dressing should be removed by drawing an arrow on the top of the dressing. If there is no skin flap, just apply the hydrogel sheet. It is important to look at your dressing choices and choose products that allow you to avoid adhesives, decrease dressing changes, and maintain an optimally moist wound healing environment.

Figure 3

A dressing schematic.

Conclusion

       It is important to remember that hydration and the appropriate dressing are the key objectives to healing and preventing the recurrence of skin tears. Choose dressings that keep the wound optimally moist without causing further trauma,¹⁴ and remember key measures such as cleaning, moisturizing, and nourishing the skin with advanced skin care products. Keep it simple. With proper patient handling and appropriate treatments, your facility has the potentially to be virtually free of skin tears.