A skin tear is defined as a traumatic wound caused by mechanical forces or by the removal of adhesives. Skin tears have a high risk of becoming a complex hard-to-heal wound. It is suggested that skin tear prevalence rates are equal to or greater than those of pressure ulcers (LeBlanc et al, 2018).
Lower leg problems in older people
Older people can experience a variety of skin problems including skin tears, leg ulcers, pressure ulcers and oedema. The National Wound Care Strategy Programme (NWCSP) (https://tinyurl.com/rqh5kfw) includes a lower limb strategy, and draft recommendations are now available (NWCSP, 2020) The NWCSP aims to reduce unwarranted variation in care of leg wounds, improve outcomes and safety and optimise the patient experience.
A leg ulcer is defined as a long-lasting (hard-to-heal) sore that takes more than 2 weeks to heal (NHS website, 2020). Lower limb ulcers are estimated to affect 1.5% of the population, or about 730 000 patients (Guest et al, 2015). The NWCSP (2020) lower limb recommendations outline a pathway of care based on a rapid diagnosis and appropriate therapeutic interventions and escalation to the relevant clinical specialist for those requiring more complex care, including vascular assessment and the application of compression therapy.
Advice for patients, families and nurses in relation to lower leg health is available from Legs Matter (https://legsmatter.org/).
What: skin tear classification
The International Skin Tear Advisory Panel (ISTAP) (2020a) is an interprofessional collaboration that is dedicated to improving outcomes for individuals at risk and/or experiencing skin tears across the continuum of care through education, research and advocacy (Beeckman et al, 2020). ISTAP classifies skin tears into three types (LeBlanc et al, 2013; ISTAP, 2020a):
Having an internationally agreed definition is essential for understanding skin tears and for future research. The prevalence remains largely unknown due to the lack of data collection for this wound type and, historically, a lack of a universally accepted definition. The severity of the skin tear relates to the depth of the skin layers, but excludes the subcutaneous layer (LeBlanc et al, 2018). This is important and supports health professionals in their differential diagnosis because skin tears may be misdiagnosed as pressure ulcers or leg ulcers, depending on location.
Pretibial lacerations can occur as a result of fragility of the skin, especially in older people. They can sometimes be caused by even the smallest knock to the shin. They may be slow to heal and require very specific care, including a lower limb assessment. Carville et al (2014) noted that the majority of skin tears are the result of trauma, where the epidermis is displaced but still retains a blood supply. Thus awareness of the anatomy and physiology of the skin is essential. The dermo–epidermal junction attaches the epidermis to the dermis and, as skin ages, this interface becomes ‘flattened’. This flattening, along with the natural thinning of the skin, begins after 70 years of age, and increases skin susceptibility to moisture and friction while reducing its resistance to shear forces (Desai, 1997; Voegeli, 2010). Areas of skin that have the most exposure are more at risk, including the lower limb, arms and hands.
Who
Older people and neonates with fragile skin are at greatest risk of skin tears. Older people at risk will have issues related to three main areas: general health, mobility level and skin issues (ISTAP, 2020b).
General health
General health issues that can increase the risk of skin tears include:
Mobility level
Mobility issues that can increase the risk of skin tears include:
Skin-related issues
These include:
Why
In older people, skin tears may occur in those requiring assistance with personal care and moving and handling. Thus, patients in care homes and those receiving care visits in their own homes, are at risk. Nurses, healthcare assistants and carers have an important role to play in skin tear prevention, as well as in the assessment and management of this wound type (Stephen-Haynes and Carville, 2011). Skin tears are considered to be largely preventable. The implementation of key principles in clinical practice can reduce their occurrence and maintain skin integrity. The importance of skin tear prevention increases in health and social care as the population ages.
How
Skin assessment
It is essential for a skin assessment to be undertaken and the person must be reassessed if their condition changes. Skin assessment should include an inspection for damage, and should involve the following:
There are several skin changes associated with ageing including atrophy with decreased collagen and fibroblasts, seen as wrinkles. Skin may also become drier with age (xerosis) due to a reduction in oil production by the sebaceous glands. Dry skin can become itchy, leading to scratching that can cause skin tears. Emollients should be used regularly to keep the skin moist. In severe cases, topical steroids and/or antipruritic creams may also be helpful.
Ecchymosis, which is seen as flat bruising due to capillary leaking, is usually caused by an injury. However, this may also be a sign of a more serious condition, including abnormal haemostasis or alteration to the structural integrity of the blood vessels and surrounding subcutaneous tissue and it is important to undertake a full history and physical examination; laboratory studies involving a blood test may be required (Wang and Kraut, 2020).
As ageing causes the skin and blood vessels to become more fragile, acitinic purpura can result, characterised by ecchymosis (dark purple patches on the skin). Although individuals may consider them unsightly, there is no specific treatment unless it is of great concern, when a topical retinoid may be used to thicken the skin (Ceilley, 2017).
Haematoma, a collection of blood outside a blood vessel, normally raised, can occur after injury. The application of ice packs and elevation of the limb may help but, if it is severe or not responding to this treatment, a referral for draining may be required (Karthikeyan et al, 2004).
Older people with fragile skin are also susceptible to pressure ulcers caused by pressure, shear friction or a combination of these. Pressure-relieving cushions and mattresses will help prevent such injuries.
Older people may also have stellate pseudoscars, white star-shaped scars, on the forearms. These are a sign of photo-ageing, and are considered to be harmless (Kaya and Saurat, 2007).
Protection of the skin is vital in maintaining its integrity. It is important to keep the skin well-hydrated by maintaining nutritional intake and fluid balance. Patients with dry skin will benefit from the application of an appropriate pH-balanced moisturising cream twice a day. It is important to:
The use of emollients is essential because well-moisturised skin is less likely to break down. Carville et al (2014) reported a 50% reduction in skin tears when pH-balanced, perfume-free emollients were applied twice daily.
It is important to document each skin assessment and the subsequent skin care plan should reflect that assessment.
Assessment of skin tears
Skin tears should be documented and assessed using the ISTAP classification. A practical guide to management is available from ISTAP (LeBlanc et al, 2020).
How: management of skin tears
The aim of skin tear management is to close the wound and to minimise the risk of infection. Initial first aid should be initiated, including stopping bleeding. The focus should be on:
Moist wound therapy dressings can enhance the wound-healing environment by maintaining optimal moisture levels, promoting cell growth and thus healing. Optimal wound healing can only occur when surface slough, biofilms and foreign debris have been removed, lowering the bioburden (Sibbald et al, 2007). Saline or water should be used to clean the wound with attention given to controlling any bleeding, as well as removing dirt or grit. The surrounding skin should then be gently patted dry. If the skin flap is viable, the edges should be brought together, with the flap gently eased back into place using a silicone dressing or a gloved finger, which is usually an easier method than using tweezers or forceps. Once the skin flap is in place, any remaining gap should be estimated and recorded.
In the case of flaps that are more challenging to align, rehydrate the area by applying a moistened, non-woven swab for 5–10 minutes to the skin tear and surrounding skin. Wound closure strips should be used to secure large skin flaps; sutures and staples are not recommended due to the fragility of the skin. A skin barrier product may be applied to the surrounding area.
How: general care
Frequent reviews of current treatments and medications should be undertaken and the impact of these on the risk for the patient of skin tears and other wounds.
Adhesive bandages and tapes should be avoided because they are likely to cause trauma to fragile skin and alternatives such as retention bandages should be considered. If an adhesive dressing must be used, the clinician should choose a silicone medical adhesive remover to support its removal.
Consideration should be given to the cause of the skin tear. A tear caused by a fall in a garden, for example, could be contaminated so it is important to ensure that the patient's tetanus vaccination schedule is up-to-date.
How: prevention
Clothing should cover the extremities, with consideration given to ease of putting it on and taking it off. Shoes should be well fitting and supportive. Care should be taken with the application and removal of compression garments, using aids and appliances if necessary. Jagged edges on fingernails and jewellery with sharp edges should be avoided in case they snag the garments.
How: patient involvement
Nurses should consider each individual's risk factors and how the patient and their carers and relatives can be actively involved and educated to help reduce the risk of skin tears. Where there are sensory issues, nurses should ensure the patient's home or care home environment is well lit and be aware of potential obstacles, with padding applied to furniture with sharp edges. Care should also be taken with any pets. Although cats and dogs are important companions, their claws can cause skin tears.
Conclusion and way forward
Care home staff and relatives need education on caring for older people's skin and the prevention of skin tears. Clinicians in all settings are encouraged to undertake local audits and ensure that preventive strategies are adopted and evaluated. A prevalence study data collection sheet with instructions is available from ISTAP (https://tinyurl.com/y2b352hx).