5/1/2020

Building Skin Tear Knowledge to

Enhance Your Clinical Practice
Karen Campbell PhD, MScN, RN, NSWOC
Content Provider:
Kimberly LeBlanc PhD, RN, NSWOC, WOCC (C)

CONFLICT OF INTEREST DISCLOSURE

I do not have any relevant relationships to disclose.

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Objectives
• To update and review the International Best Practice
Recommendations from ISTAP
• Discuss the updated definition of skin tears from ISTAP
and validation of the ISTAP classification system
• Review risk assessment of skin tears
• Discuss prevention of skin tears
• Review assessment and management of skin tears

Survey results
• A total of 1127 healthcare professionals from 16 countries completed an
online survey.

• More than half (69.6%) of respondents reported a problem with current

assessment and documentation of skin tears in their practice settings.

• The vast majority (89.5%) favored a simplified method for documenting and
assessing skin tears.

• A total of 80.9% of respondents admitted to not using any tool or

classification system for assessing and documenting skin tears.

LeBlanc et al 2014

International Skin Tear Advisory Panel

ISTAP Members Panel Members:

President: Karen Campbell (Canada) Mary Gloeckner (USA)
President-Elect: Dimitri Beeckman (Belgium) Samantha Holloway (UK)
Past President: Kimberly LeBlanc (Canada) Diane Langemo (USA)
Ann Williams (USA)
Patricia Idensohn (South Africa)
Yee Yee Chang (Singapore)
Ann Marie Dunk (Australia)
Steven Smet (Belgium)
Vera Lucia Conceicao de Gouveia Santos (Brazil)
Heidi Hevia Campos (Chili)
Gulnaz Tariq (UAE)
Kevin Woo (Canada)

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Prevalence Of Skin Tears

• Studies in Long-Term Care 3.9% - 26%
(Koyano et al., 2014; LeBlanc, VanDenKerkhof, Woodbury & Woo, 2017; LeBlanc, Christensen, Cook & Gutierrez, 2013; Skiveren, Wahlers, Bermark, 2017; Woo et al., 2015)

• Studies of community settings 4.5%-19.5% across all age

groups
(Carville, Lewin,1998; LeBlanc & Christensen 2009)

• Prevalence in the acute care setting 6.2%-11.1%

(Hsu & Chang, 2010; McErlean et al., 2004; Santamaria, Carville & Prentice, 2009)

• Palliative Care Settings 3.3%-14.3%

(Amaral, Pulido & Santos, 2012; Maida, Ennis & Corban, 2013)

• Paediatric: Hospitalized children 17% --80% were 6 months of

age or younger (McLane et al., 2004)

• Intensive Care Settings: Prevalence is not known

Incidence of Skin Tears

• Limited incidence studies in the literature

• Reported incidence in LTC between 2.2% and

18.9%
(McErlean et al., 2004; Carville et al., 2014; LeBlanc, VanDenKerkhof, Woodbury & Woo, 2017; Payne& Martin 1990, Sanada et al., 2015)

• An early study suggested that more than 1.9

million institutionalized adults would develop a
skin tear each year in the United States (Malone et al., 1991)

UPDATED: International Skin Tear Advisory Panel:

Skin Tear Definition

“A skin tear is 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

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Skin Tear Risk Factors

2017 Prevalence and Incidence Study in a LTC

Population
Prevalence and Incidence of Skin Tears
Frequency Percent (95% CI) with continuity correction

Prevalence 79/380 20.8% (16.9% - 25.3%)

Incidence A 72/380 18.9% (15.2% - 23.3%)
1-month rate of new STs in the total
study sample

Incidence B 24/301 7.9% (5.3% - 11.7%)

1-month rate of new STs in the study
sample with no ST at baseline

Incidence C 48/79 61.0% (50.3% - 72.5%)

1-month ST rate of new STs in the
study sample with a ST at baseline

© Kimberly LeBlanc 2017

Extrinsic Reported Causes of STs

Extrinsic Reported Causes of Frequency Percent (95% CI)
STs (reported by individual or (n=184) with continuity
healthcare professional) correction
During Activities of Daily 53 28.8 % (22.5%-36.0%)
Living (ADLs)
Blunt Force Trauma 40 21.7% (19.5%-32.6%)
Fall 38 20.8% (15.2%-27.4%)
Unknown cause 28 15.1% (10.5%-21.4%)
Resisting Care or Aggressive 18 9.8% (6.1%-15.3%)
Behavior
Medical Adhesive Related 7 3.8% (1.6% - 7.9%)
Skin Injury (MARSI)

© Kimberly LeBlanc 2017

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Relative Risk of developing a Skin Tear Based on Incidence A

Modified Poisson Regression (using a robust error variance)
Variable Sig. Relative 95% C.I. for
Risk Relative Risk
Lower Upper
ST Prevalence (yes versus no) .002 1.84 1.25 2.70
(History of ST)
Skin Changes associated with <.001 1.60 1.43 1.79
aging (Skin changes)
Aggressive Behaviour Scale (ABS) .001 1.06 1.02 1.10

Activities of Daily Living (ADLs) <.001 1.13 1.08 1.18

Charlson Comorbidity Index (CCI) .018 1.17 1.03 1.32

© Kimberly LeBlanc 2017

Skin Changes Associated with Aging

• Skin Atrophy
• Ecchymosis
• Senile Purpura
• Hematoma
• Stellate Pseudoscars
• Photo Damage

Individual Factors Mediating Factors

Skin Tear
Framework

© Kimberly LeBlanc 2017

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Skin Tear Risk Reduction

Skin Tear Prevention

• Education is a key component. It is

important for all staff and
caregivers to be aware of proper
techniques for providing care
without causing skin tears

• A comprehensive falls assessment

and prevention program is
imperative

www.skintears.org

ISTAP Skin Tear Classification

Type 1: No Skin Loss Type 2: Partial Flap Loss Type 3: Total flap loss

Linear or Flap Tear which Partial Flap loss which Total Flap loss exposing
can be repositioned to cannot be repositioned entire wound bed
cover the wound bed to cover the wound bed

LeBlanc et al 2013

www.skintears.org

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Type 1 Skin Tear

Type 2 Skin Tear

Type 3 Skin Tear

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LW [2]1

Not a pressure injury!

Definition of a “Skin Flap”

• ISTAP concluded that in order to simplify the classification of skin
tears, a consensus should be reached on the definition of a “skin
flap”

• Van Tiggelen et al., developed a definition based on a literature

review and a 2-phase Delphi process

“A flap in skin tears is defined as 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. This concept is not to be
confused with tissue that is intentionally detached from its place of origin
for therapeutic use e.g. surgical skin grafting”.
LeBlanc et al. 2018; Van Tiggelen et al Pending publication: British Journal of Dermatology

•
•
Arabic
Chinese
ISTAP Skin Tear Classification
• Czech
• Danish
• Dutch Type 1: No Skin Loss Type 2: Partial Flap Loss Type 3: Total flap loss
• English
• French
• German
• Hebrew
• Italian
• Japanese
• Portuguese
• Spanish Linear or Flap Tear which Partial Flap loss which Total Flap loss exposing
• Swedish can be repositioned to cannot be repositioned entire wound bed
• Turkish cover the wound bed to cover the wound bed

LeBlanc et al 2013

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Slide 22

LW [2]1 story needed

Lorne Wiesenfeld, 9/21/2017
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Managing Skin Tears

www.skintears.org

Re-approximate Wound Edges

1 2

www.skintears.org

Type 1
3 4 5 Skin Tear

Approximate Wound
Edges

www.skintears.org

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Managing Skin Tears

• Skin tears are acute wounds that
have the potential to be closed by
primary intention
• Traditionally, wounds closed by
primary intention are secured
with suture or staples

• Given the fragility of the elderly

skin sutures and staples are not a
viable option, and other methods
are required
www.skintears.org

Dressing Selection Specific to

Skin Tears
When skin tears can occur it
is paramount that wound
care products are chosen
that will optimize wound
healing and not increase
the risk of further skin
damage

www.skintears.org

Managing Skin Tears

• Do not add new risks for trauma
• Assess co-morbidities (Venous disease, arterial disease, pressure)

Choose a dressing that will:

 Decrease trauma
 Provide moist wound healing
 Manage pain

www.skintears.org

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Debridement
• If the skin flap is present
but not viable, it may
need to be debrided

• Care should be taken

during debridement to
ensure that viable skin
flaps are left intact and
fragile skin is protected
www.skintears.org

Infection / Inflammation
• Wound inflammation from
trauma should be
distinguished from wound
infection
Inflamed

• Wound infection can result

in pain and delayed wound
healing. Diagnosis of
infection should be based
on clinical assessment
Infected
www.skintears.org

•Skin Tears are acute wounds which

typically should proceed to wound
closure in a timely fashion and
follow an acute wound closure
trajectory of 14-21 days
• Ensure that all potential factors
which could delay wound healing
(i.e.: diabetes, peripheral edema)
have been addressed

www.skintears.org

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Protect the tissue flap /

pedicle

www.skintears.org

CONSIDER TETANUS
STATUS
• Tetanus is an acute, often fatal disease caused by wound contamination
with Clostridium tetani
• Human tetanus immunoglobulin (TIG) should be given to all individuals
with interruption of the skin integrity by a non-surgical mechanism who
have not received a tetanus toxoide (Td) inoculation in the past 10 years
• The TIG should be given before wound debridement because exotoxin
may be released during wound manipulation
**** This may not be the policy in all healthcare settings

Carden, DL. Tetanus. In: Tintinalli, JE. Kelen, GD. Stapczynski, JS. Emergency Medicine: A comprehensive Study
Guide, Sixth Edition. American College of Emergency Physicians. 2004.

www.skintears.org

ISTAP Skin Tear Product Selection recommendations

© ISTAP 2015

Product Categories Indications Skin Tear Type Considerations

2-octyl cyanoacrylate topical • To approximate wound edges 1 • Use in a similar fashion as

bandage (skin glue)
Acrylic dressing
• Mild to moderate exudate
without any evidence of
bleeding, may remain in place
for an extended period of time
sutures within first 24 hours
post injury, relatively
expensive, medical directive/
protocol may be required
1,2,3 • Care on removal
• Should only be used as
directed and left on for
extended wear time

Calcium Alginates • Moderate to heavy exudate 1,2,3 • May dry out wound bed if
Hemostatic inadequate exudate
• Secondary cover dressing
required
Hydrofibre • Moderate to heavy exudate 2,3 • No hemostatic properties
• May dry out wound bed if
inadequate exudate
www.skintears.org • Secondary cover dressing
required

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ISTAP Skin Tear Product Selection recommendations

© ISTAP 2015
Product Categories Indications Skin Tear Type Considerations

Hydrogels • Donates moisture for dry 2,3 • Caution: may result in peri
wounds wound maceration if wound is
exudative
• For autolytic debridement in
wounds with low exudate
• Secondary cover dressing
required
Foam dressing • Moderate exudate 2,3 • Caution with adhesive border
• Longer wear time (2-7 foams, use non-adhesive
days depending on versions when possible to avoid
exudate levels) peri-wound trauma

Non-Adherent Mesh • Dry or exudative wound 1,2,3 • Maintains moisture balance for
Dressings multiple levels of wound
exudate,
• Atraumatic removal
• May need secondary cover
dressing
www.skintears.org

ISTAP Skin Tear Product Selection recommendations

© ISTAP 2015

Special Consideration for Infected Skin Tears

Product Indications
Categories
Ionic Silver Dressings • Effective broad spectrum
antimicrobial action
including antibiotic
resistant organisms
Skin Tear Type Considerations
1,2,3 • Should not be used indefinitely.
• Contraindicated in patients with silver allergy
• Use when local or deep infection is suspected
or confirmed
• Use non-adherent products whenever possible
to minimize risk of further trauma

Methylene Blue and • Effective broad spectrum 1,2,3 • Non-traumatic to wound bed
Gentian Violet antimicrobial action • Use when local or deep tissue infection is
Dressings including antibiotic suspected or confirmed
resistant organisms • Secondary dressing required

*****This product list is not all inclusive; there may be additional products applicable for the treatment of skin tears
www.skintears.org

Products NOT Recommended for use in Skin Tears

Iodine based dressings:

• Iodine has been used in various forms in wound care since 1882 for
the prevention treatment of infected wounds with great success
Queen, 2011).
(Sibbald, Leaper,

• Iodine based dressings did not receive 80%.

• Iodine causes drying of the wound and peri-wound skin. The

international review group maintained that as a major risk factor for
skin tear development is listed to be dry skin, iodine based products
should not be used for the management of skin tears or for those
who are deemed at risk for skin tears (LeBlanc et al., 2016).

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Products NOT Recommended for use in Skin

Tears
Film/ Hydrocolloid dressings:

• Films and hydrocolloids have traditionally been used for partial thickness wounds and
as secondary dressings, however they did not receive 80% agreement and were not
included as a result in the ISTAP product guide (LeBlanc et al., 2016).

• Films and hydrocolloid dressings have a strong adhesive component and have been
reported to contribute to medical adhesive related skin tears (McNichol, Lund, Rosen & Gray, 2013).

• Films and hydrocolloid dressings are not recommended for use in those who are at
high risk for or who have a skin tear.

Products NOT Recommended for use in Skin

Tears
Skin Closure Strips:
• Expert opinion suggest that adhesive
strips are no longer a preferred treatment
option of choice for skin tears
Roberts, 2015; Holmes, Davidson, Thompson, & Kelechi, 2013; Ellis & Gittins, 2015)
(LeBlanc et al., 2016; (Rayner, Carville, Leslie, &

• Quinn et al, (1993) reported that topical

skin glue was a faster and less painful
method with better scar management
compared to sutures or skin closure strips
for managing skin tears and lacerations in
children.

Special Consideration:
Peripheral Edema
• Lower leg edema is well documented to contribute to
delayed wound healing, regardless of the wound etiology
.
(Lindsay & White, 2007)

• When skin tears occur on the lower limb, the risk and
cause of potential peripheral edema should be assessed
(LeBlanc et al., 2016; Ellis & Gittins, 2015).

www.skintears.org

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Key Points

What are Skin Tears?

• Skin tears are initially wounds of an acute

• Skin tears are an adverse event that should

be reported whenever it compromises the
safety of the patient

What are Skin Tears?

• Skin tears can be full thickness and can occur
anywhere on the body – most commonly seen
on the hands, arms and lower extremities

• Skin tears can be considered to be

uncomplicated (heal within 4 weeks) or
complicated (complex/chronic)

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What are Skin Tears?

• It is estimated that prevalence of skin tears may be
underreported and in fact be greater than pressure
ulcers/injuries – to date, prevalence data and the associated cost
to patients and healthcare systems is not fully known

• The ageing population translates into recognition that the

incidence of skin tears is increasing (elderly patients have fragile
skin and are at increased risk)

What are Skin Tears?

• Skin tears can be painful and distressing for the patient and their
relatives

• Skin tears may increase the length of hospitalisation (particularly

if related to the lower extremities and involving underlying
pathology), increase health costs and have an impact on quality
of life

Questions?

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