32 JCN 2019, Vol 33, No 2

Skin tears: a case-based and practical overview of prevention, assessment and management

Skin tears are a common type of tissue injury, which often go unrecognised and misdiagnosed. Furthermore, classification and documentation of skin is often poor, resulting in chronic wounds with associated adverse patient outcomes. The International Skin Tear Advisory Panel (ISTAP) recently updated the International Best Practice Guidelines and definition of a skin tear based on emerging evidence and expert discussion and consensus. This article presents a discussion of the epidemiology, risk factors and causes of skin tears. In addition, the most recent best practice recommendations for the prevention, assessment, and management of skin tears is summarised.

KEYWORDS: Arterial leg ulcers Assessment Atypical Chronic wounds Differential diagnosis Leg ulcers Venous leg ulcers

Patricia Idensohn, Dimitri Beeckman, Karen E Campbell, Mary Gloeckner, Kimberly LeBlanc, Diane Langemo, Samantha Holloway

WOUND CARE

Skin tears are common yet specific acute wounds, distinct from all other wound types

with a complex aetiology (LeBlanc et al, 2018). They are one of the most prevalent skin complications found among the extremes of age (Lichterfeld et al, 2015). Those with aged skin who have comorbidities are at particularly high risk of

Patricia Idensohn, CliniCare, Ballito, KwaZulu Natal, South Africa; Dimitri Beeckman, Skin Integrity Research Group, University Centre for Nursing and Midwifery, Department of Public Health and Primary Care, Ghent University, Belgium; School of Health Sciences, Örebro University, Sweden; School of Nursing and Midwifery, Royal College of Surgeons in Ireland, Ireland; Karen E Campbell, Western University, London, Ontario, Canada; Mary Gloeckner, Ostomy/Wound CNS UnityPoint Health, Rock Island, Illinois, USA; Kimberly LeBlanc, Wound Ostomy Continence Institute/Nurses Specialised in Wound, Ostomy and Continence, Western University, London, Ontario, Canada.Diane Langemo, Emeritus and adjunct professor, University of North Dakota College of Nursing; President, Langemo and Associates; Samantha Holloway, Reader, Centre for Medical Education, School of Medicine, Cardiff University, Wales

developing infections, causing chronicity and complications (Baranoski et al, 2012). While some skin tears are unavoidable, most are preventable (LeBlanc and Baranoski, 2011; LeBlanc et al, 2018: 19).

The recent International Skin Tear Advisory Panel (ISTAP) Best Practice Guidelines (LeBlanc et al, 2018) provide healthcare professionals with an update on the definition, prevalence, risk factors and causes of skin tears, while guiding the assessment, prevention and management in aged skin.

Often unrecognised, misdiagnosed and underreported, with confusion in terminology, the ISTAP have proposed an updated definition of a skin tear to characterise the injury as:

A traumatic wound caused by mechanical forces, including removal of adhesives. Severity may vary by depth (not extending through the subcutaneous layer).

(LeBlanc et al, 2018: 2)

Pain and decreased quality of life have been reported by individuals suffering from skin tears (LeBlanc et al, 2013a). As acute wounds, healing of a skin tear should follow a timely trajectory, however, it is often delayed as a result of numerous intrinsic and extrinsic factors. In these instances, the skin tear can develop into a chronic, non-healing, complicated wound (LeBlanc et al, 2018), resulting in adverse patient outcomes, and raising both human and economic costs. This is borne out in the case report presented in this article.

PREVALENCE, RISK FACTORS AND CAUSES OF SKIN TEARS

Age-related skin conditions are increasingly prevalent. Ageing is associated with anatomical and physiological skin changes, such as flattening of the dermo-epidermal junction, loss of cutaneous collagen, drying, and reduction in subcutaneous tissue, rendering the skin more fragile and less elastic (Lichterfeld et al, 2017).

Besides age-related skin changes, other factors such as immobility, sensory impairment, functional and cognitive disorders, multi-morbidities, and incontinence may render individuals more susceptible to developing a broad range of skin conditions, with skin tears being one of the most prevalent (Lichterfeld et al, 2015).

Skin tears occur most often in neonates, children and older patients (Bermark et al, 2018). They can occur on any anatomical site and are particularly common on the extremities (Serra et al, 2018).

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▼ Practice point

Although skin tears are among the most prevalent acute wounds in healthcare settings, their recognition as a unique condition remains in its infancy. Individuals are at risk of developing skin tears due to increased skin fragility and other contributing risk factors. In order to provide (cost-)effective prevention, patients at risk should be identified in a timely manner.

Although skin tears are regularly disregarded because of their shallow and merely traumatic nature, expert clinicians maintain that skin tears are more prevalent than pressure ulcers (Bermark et al, 2018). Research in acute care reports prevalence figures ranging between 3.3–17% (Santamaria et al, 2009); in long-term care, prevalence ranges between 3.9–26% (LeBlanc et al, 2013b). Prevalence data are limited, and most of the data has been collected in Australia, Canada, Asia and the USA (Bermark et al, 2018). Overall, agreement exists that skin tears are indeed not a marginal problem in health care and that prevention is of utmost importance.

Debates are internationally ongoing about accurate methods to predict skin-tear development and to identify patients at risk in a timely manner. As in other conditions, this remains challenging for researchers and clinicians. Epidemiological research identified both modifiable and non-modifiable risk factors for skin-tear development (LeBlanc et al, 2011). Non-modifiable risk factors include: Skin changes associated with

advanced age Presence of oedema and

ecchymosis, spasticity, haematoma

Impaired mobility

Dependence on others for activities of daily living, such as dressing and transfers

Evidence of a previously healed skin tear

Increased pressure ulcer risk History of falls Sensory deficits Cognitive impairment Aggressive behaviour.

Skin adhesives, poor nutritional intake, and polypharmacy have been reported as modifiable risk factors that contribute to the development of skin tears (LeBlanc et al, 2013a; Bermark et al, 2018).

skin tears may be associated with prolonged hospitalisation, intensive care needs, and high healthcare costs (LeBlanc et al, 2018).

PREVENTION OF SKIN TEARS

To prevent skin tears, it is important to accurately identify who is at risk, and why, with a view to reducing the incidence of avoidable skin tears (LeBlanc et al, 2018). This requires comprehensive skin assessment at the initial visit, with follow-up assessments at subsequent visits, ensuring that the findings are fully documented (All Wales Tissue Viability Nurse Forum, 2015). The Skin Tear Framework (Figure 1) provides a helpful summary of the important factors to consider when determining risk (LeBlanc et al,

Figure 1.Skin Tear Framework for Risk Identification and Prevention (© LeBlanc, 2018).

Mechanical skin trauma, i.e. shear, friction and/or blunt force trauma

Individual/caregiver/healthcare professional, i.e. knowledge of skin tear prevention strategies, attitude, practice, or approach to providing care

Physical environment/healthcare setting, i.e. skin tear audit programme, support for skin tear reduction programmes, interprofessional approach to care

RISK FACTOR CATEGORIESGeneral health Chronic/critical disease Agressive behaviour

Mobility Dependence for activities

of daily living History of falls

Skin History of previous skin tears Skin changes associated

with ageing Sun-damage

SKIN TEAR DEVELOPMENT

‘Skin tears are under-estimated and trivialised, leading to suboptimal prevention and delayed or inappropriate management (LeBlanc et al, 2011).’

Skin tears are underestimated and trivialised, leading to suboptimal prevention and delayed or inappropriate management (LeBlanc et al, 2011). The consequence of mismanagement can be serious, predisposing individuals to intractable pain, negative mood states (anxiety), delayed wound healing, infection, and diminished quality of life. From a health economic perspective,

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2013a). While some risk assessment tools adopt a scoring system to establish the level of risk, in developing this framework, ISTAP felt that the presence of one factor or more would put an individual at risk, which should then prompt actions to reduce someone’s risk. The Skin Tear Framework (Figure 1) outlines the considerations that need to be made in assessing patient risk and the Risk Reduction Programme (Table 1) are the actions to reduce someone’s risk.

Use of emollientsIn individuals with aged skin, emollient therapy is vital to maintaining skin integrity. In a study by Carville et al (2014), the application of an emollient twice daily in aged care residents

(n=420 in the intervention group, n=564 in the control group) across 14 facilities in Western Australia resulted in a reduction in incidence of skin tears by almost 50%. In the intervention group, the average monthly incidence rate was found to be 5.76 per 1,000 occupied bed days (a total of 450 skin tears over six months) compared to 10.57 per 1,000 occupied bed days (946 skin tears over six months) in the control group (P = 0·004) (Carville et al, 2014).

Emollient therapy might include the use of moisturisers (creams, ointments and lotions), bath oils, gels and soap substitutes (National Institute for Health and Clinical Excellence [NICE], 2015). Many of the simple emollients work

by ‘trapping’ moisture into the skin and reducing water loss by evaporation — very helpful in aged dry skin. Whereas emollients that contain humectants (e.g. urea), work by actively drawing water from the dermis to the epidermis and compensating for the reduced levels of natural moisturisers in the skin (All Wales Tissue Viability Nurse Forum, 2015).

In addition to the use of topical emollients, the patient’s bathing regimen should be considered, i.e. use of soap substitutes and avoiding the use of traditional soaps. Use of warm rather than hot water and soft cloths and towels are also important for maintaining skin integrity.

General healthSimple measures of improving the patient’s hydration level and nutritional status, considering those at the extremes of weight, can help to reduce the risk of skin tears. In addition, it is important to be aware of those patients with polypharmacy, who need particular attention, as do individuals with mental health issues, such as dementia or psychosis, where there may be associated aggression requiring additional measures to prevent skin damage.

Physical environment: clinical and homeAssessment of the clinical and home settings should be undertaken to identify and mitigate any risks. Relatively simple measures that can be addressed include careful manual handling, padding furniture and removing any obstacles, and avoiding sharp fingernails (patients’, carers’ and healthcare professionals’) or jewellery. In addition, a falls risk assessment should be undertaken, and special attention paid to patients who may be confused (NICE, 2015).

Involving the patient in the prevention of skin tears should be encouraged, with advice given on use of protective clothing, which can be as simple as wearing long sleeves/trousers to reduce the risk of mechanical trauma. Box 1

Table 1: Risk Reduction Programme checklist (adapted from LeBlanc et al, 2018)

Risk factor Risk categories ActionSkin Extremes of age

Dry/fragile skin Previous skin tear

Inspect skin and investigate previous history of skin tears If patient has dry, fragile, vulnerable skin, assess risk of accidental

trauma Manage dry skin and use emollient to rehydrate limbs,

as required Implement an individualised skin care plan using a skin-friendly

cleanser (not traditional soap) and warm (not hot) water

Prevent skin trauma from adhesives, dressings and tapes (use silicone tape and cohesive retention bandages)

Consider medications that may directly affect skin (e.g. topical and systemic steroids)

Be aware of risk due to extremes of age Discuss use of protective clothing (e.g. shin guards, long sleeves

or retention bandages) Avoid sharp fingernails or jewellery in patient contact

Mobility History of falls Impaired mobility Dependence for

activities of daily living

Mechanical trauma

Encourage active involvement/exercises if physical function is impaired

Avoid friction and shearing, using good manual handling techniques

Conduct a falls risk assessment Ensure that sensible/comfortable shoes are worn Apply clothing and compression garments carefully Ensure a safe environment — adequate lighting,

removing obstacles Use padding for equipment (as per local policy) and furniture Assess potential risk of skin damage from pets

General health

Comorbidities Polypharmacy Impaired

cognition Malnutrition

Educate patient and carers on skin-tear risk and prevention Actively involve the patient/carer in care decisions

(where appropriate) Optimise nutrition and hydration, refer to dietitian

if necessary Refer to appropriate healthcare specialist if sensory perception

problematic (e.g. peripheral neuropathy associated with diabetes) Consider possible effects of medications and polypharmacy on

the patient’s skin

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ISTAP Skin Tear Classification

shows a self-care checklist that may be appropriate to give to suitable patients to monitor their own skin health (All Wales Tissue Viability Nurse Forum, 2015; LeBlanc et al, 2018).

Education of healthcare professionalsPrevention of skin tears relies on increasing awareness of the problem initially, and subsequently providing education to all members of the multidisciplinary team — not just nurses, but also doctors, occupational therapists, physiotherapists and dietitians. Such education should include information on general skin health and maintaining skin integrity, as well as recognising and minimising risk. Equally important is the involvement of patients, carers and relatives to support the prevention of skin tears.

IDENTIFICATION AND ASSESSMENT OF SKIN TEARS

Holistic assessment of the patient and woundWhen a patient presents with a skin tear, initial assessment should include a full holistic assessment of the patient as well as the wound. It is also important to establish the cause of injury. The wound should be examined for the following factors and documented as part of wound assessment (LeBlanc et al, 2018): Cause of the wound Anatomical location and

duration of injury Dimensions (length,

width, depth) Wound bed characteristics

and percentage of viable/ non-viable tissue

Type and volume of exudate Presence of bleeding

or haematoma

Integrity of surrounding skin Signs and symptoms of infection Associated pain (Stephen-

Haynes and Carville, 2011).

Holistic assessment of the patient is vital, as their skin integrity and general health status are important for ongoing management. This should include factors such as (LeBlanc et al, 2018): Patient’s medical history Past history of skin tears General health status

and comorbidities Medications and

polypharmacy issues Mental health issues Psychosocial and quality of

life factors Mobility/dependence

on assistance for daily living activities

Nutrition and hydration (adapted from Wounds UK, 2012).

ClassificationClassification tools are currently available for healthcare professionals to use when assessing a patient sustaining a skin tear.

A systematic, standardised and validated approach is required, and as such the ISTAP classification system (LeBlanc et al, 2013a) is recommended for use. The ISTAP system was developed using a Delphi process and validated by 839 international healthcare professionals in practice. It uses a simple method to classify skin tears (Figure 2), categorising them

SELF-CARE CHECKLIST FOR PATIENTS AT RISK OF SKIN TEARS (ADAPTED FROM ALL WALES TISSUE VIABILITY NURSE FORUM, 2015)

Have I been given an individualised skin care plan? Am I using an emollient every day? Am I eating sensibly and drinking enough water? Am I keeping as active and mobile as possible? Have I thought about wearing clothing to protect my skin, e.g. long sleeves,

shin guards or tubular bandages? Has my environment been made as safe as possible, e.g. adequate lighting,

no obstacles, padding of furniture?

Box 1.

Figure 2.ISTAP Skin Tear Classification (LeBlanc et al, 2013).

Linear or flap tear which can be repositioned to cover the wound bed

Type 1: No skin loss Type 2: Partial flap loss Type 3: Total flap loss

Partial flap loss which cannot be repositioned to cover the wound bed

Total flap loss exposing entire wound bed

Treatment options in accordance with local wound conditions

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Total skin flap loss that exposes the entire wound bed.

The working definition of a flap in relation to skin tears specifically, proposed by ISTAP is:

A portion of the skin (epidermis/dermis) that is unintentionally separated (partially or fully) from its original place due to shear, friction, and/or blunt force.

MANAGEMENT OF SKIN TEARS

Where possible, treatment of skin tears should aim to preserve the skin flap and maintain the surrounding tissue, reapproximate the edges of the wound, and reduce the risk of infection and further trauma. Starting appropriate treatment as soon as possible will improve patient outcomes.

Using the ISTAP skin tear decision algorithm (Le Blanc et al,

2013a; Figure 3), it is important to consider the following initial goals of treatment (LeBlanc et al, 2018).

Control bleeding Apply pressure and elevate limb

if appropriate Specialised dressings may be

utilised to control bleeding (Table 2).

Cleanse and debride Remove haematoma or any

debris and cleanse/irrigate the wound as per local protocol

Debride skin flap if not viable (LeBlanc and Baranoski, 2011)

Ensure viable skin flaps are intact and edges approximated

Protect fragile skin Classify, measure and

document appropriately.

Manage infection/inflammation Check tetanus immunisation and

take further steps if necessary Distinguish wound

inflammation caused by trauma or from infection

Diagnose the stage of the continuum of infection, managing covert and overt infection with a topical antimicrobial, and spreading and systemic infection with both systemic and topical antimicrobials (International Wound Infection Institute [IWII], 2016)

Continue monitoring the wound for signs of infection (LeBlanc et al, 2018: 13).

Consider moisture balance/exudate control Moisture balance is essential to

promote wound healing Select an appropriate dressing

to manage the characteristics of the wound bed and protect the peri-wound skin from maceration.

Monitor wound edge/closureGenerally, skin tears follow an acute wound-healing trajectory of 14–21 days, depending on size and depth of the skin tear. If this does not occur, the wound/patient should be reassessed, ensuring all potential factors known to

Figure 3.ISTAP skin tear decision algorithm (LeBlanc et al, 2013).

Type 1: No skin loss Type 2: Partial flap loss Type 3: Total flap loss

Skin tears

Assess

Cleanse

Approximate wound edges

Goals of treatmentTreat the cause

Implement prevention protocol

Moist wound healing

Avoid trauma

Protect periwound skin

Manage exudate

Avoid infection

Pain control

Control bleeding

Classify (measure and document)

▼ Practice point

Prevention of skin tears should consider the use of emollients to maintain healthy skin. A discussion about the use of soap substitutes, warm water and soft towels should take place to identify any additional risks of injury. Patients should be encouraged to eat healthily and maintain hydration. Assessment of risks and advice provided should be documented.

as either: Type 1 skin tear: no skin loss. Linear tear where the skin flap

can be repositioned to cover the wound bed

Type 2 skin tear: partial flap loss. Skin flap cannot be repositioned

to cover the whole of the wound bed

Type 3 skin tear: total flap loss.

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Table 2: ISTAP skin tear product selection recommendations

Product categories Indications Skin tear type Considerations

Hydrogels Donates moisture for dry wounds 2, 3 Caution: may result in peri-wound maceration if wound is producing a high volume of exudate

For autolytic debridement in wounds with low exudate Secondary cover dressing required

Foam dressings Moderate exudateLonger wear time (2–7 days depending on exudate volume)

2, 3 Caution with adhesive border foams. Where possible, use non-adhesive versions to avoid periwound trauma

Non-adherent mesh dressings Dry or exudative wounds 1, 2, 3 Maintain moisture balance for multiple levels of wound exudate

Atraumatic removalMay need secondary cover dressing

2-octyl cyanoacrylae topical bandage (skin glue)

To approximate wound edges 1 Use in a similar fashion as sutures within first 24 hours post injury, relatively expensive, medical directive/protocol may be required

Acrylic dressing Mild-to-moderate exudate without any evidence of bleeding; may remain in place for an extended period of time

1, 2, 3 Care on removalShould only be used as directed and left on for extended

wear time

Calcium alginates Moderate-to-heavy exudate; haemostatic

1, 2, 3 May dry out wound bed if inadequate exudate volumeSecondary cover dressing required

Hydrofiber Moderate-to-heavy exudate 2, 3 No haemostatic propertiesMay dry out wound bed if inadequate exudateSecondary cover dressing required

Special considerations for infected skin tears

Ionic silver dressings Effective broad-spectrum antimicrobial action, including antibiotic- resistant organisms

1, 2, 3 Should not be used indefinitelyContraindicated in patients with silver allergyUse when local or deep infection is suspected or confirmedUse non-adherent products whenever possible to

minimise risk of further trauma

Methylene blue and gentian violet dressings

Effective broad-spectrum antimicrobial action, including antibiotic- resistant organisms

1, 2, 3 Non-traumatic to wound bedUse when local or deep infection is suspected or confirmedSecondary dressing required

Note: this product list is not all-inclusive; there may be additional products applicable for the treatment of skin tears (www.skintears.org)

▼ Practice point

Accurate identification of skin tears, holistic assessment and documentation of both patient and wound, including skin integrity, general health and classification of a skin tear, utilising a systematic, standardised, validated approach, is imperative for setting appropriate treatment goals to optimise management and healing of skin tears in clinical practice.

delay healing have been managed appropriately, e.g. peripheral oedema, diabetes, etc.

If the skin tear occurs on the lower leg, full vascular assessment is required before applying compression therapy, e.g. ankle brachial pressure index (ABPI) should be measured and be at least 0.90mmHg.

It is important to refer to a wound care specialist when the skin tear is infected or extensive (Le Blanc et al, 2016).

Manage pain Healthcare professionals should always assess the degree and nature of pain on an ongoing basis, using a validated tool to identify the most suitable treatment plan for

the patient (Stephen-Haynes and Carville, 2011).

2011). Dressings should always be removed slowly with an adhesive remover to minimise trauma (LeBlanc et al, 2018: 10). Further research regarding skin tears and associated pain is required (LeBlanc and Baranoski, 2017).

‘Skin tears should be covered with a topical wound dressing. The dressing selected should be removed in the direction of the pedicle... . Indicating the direction for dressing removal is a useful graphic message to promote flap viability.‘

Barriers to accurately assessing pain should also be identified, e.g. loss of sensation, with dressings selected that minimise pain on application and removal (Stephen-Haynes and Carville,

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Dressing selectionSkin tears should be covered with a topical wound dressing. The dressing selected should be removed in the direction of the pedicle, rather than against it. Indicating the direction for dressing removal on the dressing is a useful graphic message to promote flap viability (Holloway and Le Blanc, 2016) (Figures 4a and 4b).

It is vital that wound products chosen optimise wound healing and minimise the risk of further skin damage.

The ideal dressing should (LeBlanc et al, 2016): Control bleeding Be easy to apply and remove Not cause trauma on removal Provide a protective

anti-shear barrier Optimise the physiological

environment (moisture, bacterial balance, temperature, pH)

Be flexible and mould to contours

Provide secure, but not aggressive, retention

Afford extended wear time Optimise quality of life and

cosmetic factors Be non-toxic Be cost-effective (Carville

and Smith, 2004; Wounds International, 2017).

Following a systematic review to reach consensus,

ISTAP established a global product-selection guide (Table 2), identifying products which provide moist wound healing while protecting the fragility of the skin. ISTAP recognises that not all products are available or acceptable in every country and the guide is not all-encompassing.

Products not recommended for use with skin tearsThese include: Iodine-based dressings, owing

to their drying properties. Skin tears are usually dry by nature (LeBlanc et al, 2016)

Films/hydrocolloid dressings, due to their adhesive properties (LeBlanc et al, 2016)

Skin-closure strips (Holmes et al, 2013; Wounds UK, 2015; LeBlanc et al, 2016)

Gauze (Meuleneire, 2003).

Honey dressings were not recommended in the original ISTAP guidance (2016) due to the increased risk of peri-wound maceration. However, there is emerging evidence to suggest that Leptospermum honey-based dressings can be effective without causing maceration (Johnston and Katzman, 2015).

CONCLUSION

This review has highlighted that skin tears are unique wounds with a complex aetiology often associated with a number of underlying comorbidities.

Generally, these types of injuries are commonly found in the extremes of age and are mostly preventable with judicious skin care.

When a skin tear does occur, appropriate assessment is required to classify the degree of damage and subsequently to implement the most appropriate management plan. Where possible, the viable skin flap should be maintained, and appropriate dressings used to protect the wound from further damage.

Of equal importance is the prevention of infection and management of pain. While it is not possible to recommend one dressing as being preferable to another, current recommendations are that iodine-based dressings, film and hydrocolloid dressings, skin closure strips and gauze should not be used.

REFERENCES

All Wales Tissue Viability Nurse Forum (2015) All Wales Guidance for the prevention and management of skin tears. Available online: www.welshwoundnetwork.org/files/8314/4403/4358/content_11623.pdf (accessed February, 2019)

Baranoski S, Ayello E, Tomic-Canic M, Levine J (2012) Skin: An essential organ. In: Baranoski SA, Ayello EA, eds.

FigureS 4a and 4b.A useful graphic message indicating the direction of the pedicle for dressing removal to promote flap viability. Photographs by PJ Idensohn.

a b

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CASE REPORT

Mrs Jones is a 70-year-old female, living at home with her husband. She is a retired nurse, having spent the bulk of her career conducting research and mentoring other nurses. She describes herself as a fiercely independent person, who enjoys being organised and in control. She has no major medical complaints, but has had several squamous cell carcinomas removed from her arms and face and has noticed that her skin has become chronically dry and lost much of its elasticity. On 10 July 2018, she sustained a skin tear to her left lateral calf as a result of trauma caused by the corner of her car door. At the time of injury, she noted very little pain, despite having a semi-triangular area of tissue loss measuring 6x3.75cm (Figure 5). The wound extended to the subcutaneous layer of the skin. Her initial reaction was one of irritation. She applied a gauze pad secured with tape and checked her records to ensure that her tetanus vaccination was up to date.

Mrs Jones noted that in the days following the injury, the wound became very painful, especially during dressing changes. She noted no signs or symptoms of infection and became annoyed that such a simple wound should cause so much pain. Her annoyance increased when almost two months later the wound was still not healed (Figure 6).

At this point, Mrs Jones decided to speak with a colleague who specialised in wound management. She learned that her wound was a type 3 skin tear and that healing was delayed due to the type of dressing she was using and to her previously unrecognised lower leg oedema. Her ankle brachial pressure index (ABPI) of 1.2 demonstrated that she had adequate perfusion to support the use of compression therapy. Mrs Jones opted to wear 30–40mmhg compression socks. She also changed the dressing to a non-adherent silicone foam dressing, which she changed every three days. Her colleague also suggested that she moisturise her arms and legs two times per day in an effort to prevent future skin tears.

Mrs Jones remarked that her pain greatly decreased once she stopped changing the dressing daily and applied the silicone foam. One month later, three months since the time of injury, she noticed that the wound was almost closed. However, the new skin was very dry and looked as if it might tear easily (Figure 7). Mrs. Jones learned from this experience that skin tears are not inconsequential wounds, but rather painful wounds which can become chronic and complex if not managed appropriately.

Figure 5.Skin tear as of 10 July 2018.

Figure 6.Two months post-injury.

Figure 7.Three months post-injury.

Wound care essentials: Practice principles. 3rd edn. Wolters Kluwer, Lippincott Williams and Wilkins, Philadelphia, USA

Bermark S, Wahlers B, Gerber AL, Philipsen PA, Skiveren J (2018) Prevalence of skin tears in the extremities in inpatients at a hospital in Denmark. Int Wound J 15(2): 212–17

Carville K, Smith J (2004) A report on the effectiveness of comprehensive wound assessment and documentation in the community. Primary Intention 12(1): 41–9

Carville K, Leslie G, Osseiran-Moisson R, Newall N, Lewin G (2014) The effectiveness of a twice-daily skin-moisturising regimen for reducing the incidence of skin tears. Int Wound J 11(4): 446–53

Holloway S, LeBlanc K (2016) Dealing with Skin Tears. Nursing in Practice, 9 December 2016. Available online: www.nursinginpractice.com/article/dealing-skin-tears (accessed February 2019)

Holmes RF, Davidson MW, Thompson BJ, Kelechi TJ (2013) Skin tears: care and management of the older adult at home. Home Healthc Nurse 31(2): 90–101

International Wound Infection Institute (2016) Wound Infection in Clinical Practice. Wounds International, London. Available online: www.woundinfection-institute.com/wp-content/uploads/2017/03/IWII-Wound-infection-in-clinical-practice.pdf (accessed February, 2019)

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Having read this article, reflect on:

Your use of the updated ISTAP definition of a skin tear

How you differentiate between a skin tear and a superficial pressure ulcer occurring over a bony prominence

The prevalence of skin tears within the practice/setting where you work

Specific factors you consider to be modifiable to reduce the risk of patients developing skin tears

Your understanding of skin tear classifications

What you and your team can do to reduce the risk of skin tears in vulnerable patients

The educational resources that could be provided in your practice setting to raise awareness of skin tears

What you would do to manage a type 2 skin tear.

Then, upload the article to the free JCN revalidation e-portfolio as evidence of your continued learning: www.jcn.co.uk/revalidation

RevalidationAlert

KEY POINTS

Skin tears are among the most prevalent acute wounds in healthcare settings.

Skin tears are often unrecognised, misdiagnosed and underreported.

Patients at risk should be identified in a timely manner in order to reduce impact on health and financial cost.

Measures to prevent skin tears include discussing with patients the use of emollients to maintain healthy skin, and the importance of healthy eating and good hydration.

Comprehensive skin assessment and follow-up assessments are important to identify those at risks. Outcomes must be well documented.

It is vital that wound products selected to manage skin tears optimise wound healing and minimise the risk of further skin damage.

Johnston C, Katzman M (2015) A clinical minute: managing skin tears with Medihoney. Ostomy Wound Management. 61(6) Available online: www.o-wm.com/article/clinical-minute-managing-skin-tears-medihoney (accessed February, 2019)

LeBlanc K, Baranoski S, Skin Tear Consensus Panel Members (2011) Skin tears: state of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears. Adv Skin Wound Care 24(9 suppl): 2–15

LeBlanc K, Baranoski S, Christensen D, et al (2013a) International Skin Tear Advisory Panel: A tool kit to aid in the prevention, assessment, and treatment of skin tears using a Simplified Classification System. Adv Skin Wound Care 26(10): 459–76

LeBlanc K, Christensen D, Cook J, Culhane B, Gutierrez O (2013b) Prevalence of skin tears in a long-term

care facility. J Wound Ostomy Continence Nurs 40(6): 580–4

LeBlanc K, Baranoski S, Christensen D, et al (2016) The art of dressing selection: a consensus statement on skin tears and best practice. Adv Skin Wound Care 29(1): 32–46

LeBlanc K, Baranoski S (2017) Skin tears: finally recognized. Adv Skin Wound Care 30(2): 62–3

LeBlanc K, et al (2018) Best practice recommendations for the prevention and management of skin tears in aged skin. Wounds International. Available online: www.woundsinternational.com/uploads/resources/57c1a5cc8a4771a696b4c17b9e2ae6f1.pdf (accessed February, 2019)

Lichterfeld A, Hauss A, Surber C, Peters T, Blume-Peytavi U, Kottner J (2015) Evidence-based skin care: a systematic literature review and the development of a basic skin care algorithm. J Wound Ostomy Continence Nurs 42(5): 501–24

Lichterfeld A, Hahnel E, Blume-Peytavi U, Kottner J (2017) Preventive skin care during skin aging. In: Textbook of Aging Skin: 1601–12

Meuleneire F (2003) The management of skin tears. Nursing Times, 4 February. Available online: www.nursingtimes.net/clinical-archive/wound-care/the-managementof-skin-tears/205615.article (accessed February, 2019)

National Institute for Health and Care Excellence (2004) Tacrolimus and pimecrolimus for atopic eczema (TA82) Quick reference guide. NICE, London. Available online: www.nice.org.uk/guidance/ta82 (accessed February, 2019)

National Institute for Health and Care Excellence (2015) Falls in older people. Quality Standard (QS86). NICE, London. Available online: www.nice.org.uk/guidance/qs86 (accessed February, 2019)

Santamaria N, Carville K, Prentice J (2009) Woundswest: Identifying the prevalence of wounds within western Australia’s public health system. EWMA J 9(3): 13–18

Serra R, Lelapi N, Barbetta A, de Franciscis S (2018) Skin tears and risk factors assessment: a systematic review on evidence-based medicine. Int Wound J 15(1): 38–42

Stephen Haynes J, Carville K (2011) Skin Tears Made Easy. Wounds Int 2(4): 1–6

Wounds International (2017) Managing skin tears in practice. Wounds International, London. Available online: www.woundsinternational.com/resources/details/managing-skin-tears-in-practice (accessed February, 2019)

Wounds UK (2012) Best Practice Statement. Care of the Older Person’s Skin. Second edition. Wounds UK, London. Available online: https://bit.ly/2DQgvd9 (accessed February, 2019)