TREATMENT 

Overview

This topic covers management and prevention of skin tears (STs). For an introduction and assessment of STs including epidemiology, risk factors, etiology, pathophysiology, history, physical examination, diagnosis, differential diagnoses, documentation and ICD-10 coding, see topic "Skin Tears - Introduction and Assessment".

Background

STs are acute wounds, best managed with customized treatment plans based on the patient’s input and based on a comprehensive assessment that: 

• Identifies/controls any active bleeding
• Identifies presence and repositions any remaining skin flap, which in this context refers to a portion of the skin (epidermis/dermis) that is unintentionally separated from its original place due to shear, friction and/or blunt force (and not intentionally detached from its place of origin for therapeutic use).[7] 
• Classifies the ST using a validated classification system, such as the one developed by the The International Skin Tear Advisory Panel (ISTAP) 
• Identifies underlying causes and assesses risk factors contributing to the development of STs
• Differentiates from other types of wounds, which require different treatments 
• Identifies pertinent patient's/caregiver's concerns
• Determines ulcer prognosis or "healability", that is, the potential of the ulcer to heal with conservative treatment only.[8][9] For details, see 'Ulcer healability (Prognosis)' in "Skin Tear - Introduction and Assessment":

An adequate treatment plan for STs aims to[8][9]:

• Treat the cause and other factors impeding healing
• Assess patient's and caregiver's concerns
• Provide effective local wound care

If a healable ST does not show any signs of improvement within 7-21 days despite adequate treatment, treatment plan should be reassessed, differential diagnoses re-evaluated and adjunctive therapies considered.[2]

See Algorithm for Management of Skin Tears below (Algorithm 1)

Treatment Goals

• General treatment goals for STs include:
• • Bleeding control
  • Identification and prevention of underlying causes
  • Maintenance of moisture balance within the wound
  • Protection of periwound skin 
  • Prevention of trauma and infection
  • Pain management
  • Recovery of skin integrity
• Specific treatment goals vary according to the healability of a ST, that is, the potential for a ST to heal.[2]
• • Healable ST:A healable ST has adequate blood supply, and can be healed if the underlying cause is addressed. Treatment goals are listed above.[2]
  • Maintenance ST: Maintenance wounds have the potential to heal. However, the underlying cause of the wound cannot be corrected due to the patient's unwillingness to adhere to treatment, or to limitations, errors or barriers of healthcare resources (e.g., uncontrolled limb edema delaying/preventing healing of the ST, uncontrolled diabetes, malnutrition). These factors may change over time, so they should be monitored and re-evaluated periodically.[8] 
  • Non-healable ST: these ulcers lack healing potential due to terminal diseases or end-of-life status; these patients are usually under palliative care.[2]
  • • For patients under palliative care, the general treatment goals listed above also apply, to the extent desired/tolerated by each patient. [2] In addition, the presence of risk factors such as immobility, excessive moisture, nutritional deficiencies, friction and shearing and impaired activities of daily living, exposes these individuals to a high risk of STs. Thus, an individualized plan must be implemented in order to reduce risks associated with STs and prevent infection.[5]add table with management by ulcer stage

Treat the cause

• For all ST patients (with healable, non-healable or maintenance ST), expert consensus recommends that healthcare professionals identify and implement a personalized treatment plan that corrects the underlying causes or co-factors affecting skin integrity, and that takes into consideration the patient’s needs, the wound, and environmental/system challenges.[2] 

Correction of the underlying causes and prevention of new STs can be simultaneously achieved through implementation of the interventions illustrated in Tables 1-3, adapted from the ISTAP Skin Tear Prevention Strategies.[1][2][5] 

Table 1. ISTAP Skin Tear Prevention Strategies - General Health

Table 2. ISTAP Skin Tear Prevention Strategies - Mobility

Table 3. ISTAP Skin Tear Prevention Strategies - Skin [5]

Risk prevention strategies for healthcare facilities include:

• Implementation of a ST risk reduction program that contemplates strategies such as: 
• • Nutrition and hydration optimization
  • Increased awareness that some medications/polypharmacy increase risk for ST
  • Strategies to minimize risks associated with impaired mobility
  • Falls risk assessment and risk reduction
• Assessment of prevalence and incidence of STs in wound rounds/audit program.

Patient-centered concerns

For all patients (with healable, non-healable or maintenance STs), concerns should be addressed and plan of care adjusted accordingly.

Pain control

• It is recommended that clinicians manage pain by addressing the underlying causes of pain and administering analgesics.
• Pain management can be achieved with the following interventions/techniques [10]:
• • Use of appropriate dressing for each type of wound 
  • Atraumatic dressing removal: 
  • • Consider allowing patients to remove their dressings themselves
    • Administer pain medication as per institutional pain protocol
  • Bioburden control and prevention of infection, since infection leads to increased pain

Local wound care

STs are acute wounds - thus when treating STs, adequate local wound care is accomplished with the following steps [2][5]: 

1. Bleeding control
2. Wound cleansing
3. Repositioning/realignment of viable skin flap(s)
4. Classification and documentation of the ST according to the ISTAP Skin Tear Classification System (see section ‘Classification’ in topic "Skin Tear - Introduction and Assessment")
5. Debridement of nonviable skin flap(s), debris and other necrotic tissue
6. Bioburden control
7. Moisture balance
8. Tetanus immunoglobulin, administered depending on institution protocol

The sections below elaborate on each step. 

Bleeding control (hemostasis)

• As STs are acute wounds, the first step is to control any residual bleeding by: 
• • Applying pressure on the ST, after covering it with saline-moist gauze. 
  • Raising the affected limb, if the ST is on a limb and if no contraindications are present. 
  • Applying calcium alginate on the ST in addition to light pressure (calcium alginate has hemostatic properties)

Cleansing

• Expert consensus suggests cleansing STs with non-cytotoxic solutions (e.g. potable water, normal saline, nonionic surfactant cleanser) to remove debris, dried blood and exudate.[11]
• • Cleansing should be performed at a low pressure (<8 psi) to prevent damage to any remaining fragile skin tear flap (Type 1 or 2 skin tears) or the fragile periwound skin. [2][5] 
  • For uncomplicated STs, potable water is considered a reliable substitute for sterile saline.[11]

ST skin flap repositioning/realignment

• Upon cleansing, assess presence of any remaining skin flap (i.e. the skin is torn but still attached). If a viable skin flap is present, expert consensus recommends it be rolled back to its original position.[2][5]
• • Utilize a moist cotton tip applicator, gloved finger or forceps to reposition the skin flap.
  • If the skin flap is difficult to align, consider application of a moistened non-woven gauze compress on the ST for 5-10 minutes until the skin flap is rehydrated, and then attempt to reposition it again. 
  • A viable skin flap may not cover the entire wound bed, but it should be positioned to cover as much area as possible. 
• The repositioned skin flap should not be disturbed for at least five days so that it adheres to structures underneath it.

Classification of the ST and documentation

• After cleansing and repositioning any remaining skin flap(s), the ST can be assessed, classified, and documented. See section ‘Classification’ in topic "Skin Tear - Introduction and Assessment")

Debridement

• For all STs, expert consensus recommends debridement of non-viable tissue and debris.[2] 

• For STs with skin flaps (ISTAP types 1 and 2), expert consensus recommends debridement of any non-viable portions of the skin flap.[2]

• Rationale: Wound debridement is the process of removing devitalized tissue and infected or foreign material from the wound to promote wound healing.[2] Necrotic tissue serves as a nidus for infection and may lead to increased inflammatory reactions within the wound, which delays healing.

Indications and contraindications to debridement

See debridement indications and contraindications in section ‘General indications and contraindications’ in the topic “Debridement”

Caution

• Prior to debridement, if ST is on a lower limb, a thorough vascular assessment should be performed. See table with values and interpretations of non-invasive arterial tests in the topic "How to Select Adequate Compression Therapy Pressure Levels and Products"
• Tetanus vaccine prior to debridement: Administer tetanus immunoglobulin, according to institutional policy, to patients who have not been vaccinated with tetanus toxoid in the last ten years. The immunoglobulin should be given before debridement to prevent potential bacterial exotoxin release by wound manipulation.[2]

Debridement techniques

• Wound debridement may occur naturally by autolysis - enhanced by moisture-balanced dressings - or by other methods (chemical/enzymatic, biological/larval, mechanical, sharp conservative debridement, or surgical).[2] For more details on debridement methods, see topics " Debridement" and "How to Perform Conservative Sharp Wound Debridement".
• For STs with skin flaps (ISTAP types 1 and 2), differentiating between viable and non-viable portions of their skin flaps can be challenging. Often, skin flaps may simultaneously present with ecchymosis, senile purpura and hematomas. During debridement, care should be taken to ensure that viable skin flaps are left intact and fragile skin is protected.[2] 
• • To determine if the remaining skin flap is viable: 
  • • Inspect skin flap to assess tissue perfusion; viable tissue is warm and pink; however, nonviable tissue is dry and pale.[12]
    • Assess blood flow through the capillary refill test and observe bleeding patterns of the skin flap.[12]
    • If the ST is on an extremity and its skin flap has a length-to-width ratio beyond 1:1, there might be an inherent higher risk of necrosis.[13] A ST skin flap can be viewed as skin flap with random pattern vascularization. Random pattern flaps are based on the subdermal vascular plexus of the skin. For random pattern flaps to be viable, in the best of conditions, the maximum length-to-width ratio on the extremities should be 1:1.[13]
    • If in doubt, consult a wound specialist before debridement.[2]  

Bioburden control (infection/ inflammation)

STs are acute wounds. Thus, signs of inflammation on a ST may be due to the trauma that initially caused it. It is important that healthcare professionals be able to distinguish inflammation from infection prior to treating for infection.[2][5] 

• For local infection, topical antibiotics and antimicrobial dressings are recommended. Systemic or spreading infection requires treatment with systemic antibiotics in addition to topical antibiotics and antimicrobial dressings. [5] 
• Tetanus immunization status should be evaluated as well.[5] 

Soft tissue local infection

• The NERDS mnemonic (Nonhealing ulcer, increased Exudate, Red-friable tissue, Debris, Smell;) can help identify soft tissue infection. If any three NERDS are present, soft tissue infection is likely.[8] 
• For healable, locally infected STs: Debride the wound and collect wound specimen for culture and sensitivity. Topical antimicrobial agents may be used (e.g., silver sulfadiazine cream and other silver products, medical-grade honey, polyhexamethylene biguanide, cadexomer iodine). Topical dressings must be gentle on fragile skin in order to prevent further trauma.

• If there are no signs of infection, but no signs of wound healing (contraction or epithelialization) within 2 weeks from debridement: biofilm may be preventing wound healing (biofilm is a cluster of bacteria embedded in a matrix covering the wound).[14] 

Systemic infection 

• For healable/ non-healable/ maintenance individuals with clinical evidence of spreading or systemic infection (e.g., positive blood cultures and fever, cellulitis, fasciitis, osteomyelitis, systemic inflammatory response syndrome, or sepsis): initiate systemic antibiotics and topical antimicrobials.

Peri-wound care

• Care must be taken not to damage the periwound skin by:
• • Gently delivering local wound care
  • Protecting skin with moisture barrier products based on zinc, silicone or dimethicone, and/or skin protectants based on cyanoacrylate.[15][16] 
  • Selecting non-adherent dressings that do not cause trauma upon removal.

Moisture balance 

• 1CFor non-infected, healable STs, expert consensuses recommend clinicians apply a topical dressing that will maintain a moist wound bed, and protect the fragile periwound skin, with the least amount of dressing changes possible (Grade 1C)[2][5][1] 
• • Rationale: Most STs are dry, but may present as exudative wounds in some cases (e.g. ST on a limb with peripheral edema). Several experimental studies support the hypothesis that a moist wound bed increases wound healing when compared to a dry wound bed, by facilitating cell migration and matrix formation.[17][18] On the other hand, excessive moist/exudate may macerate the fragile periwound skin.
• For infected STs: regular inspection and assessment are needed. See Table 4 for dressing selection
• For non-healable/maintenance STs, if minimal or no exudate, a topical antiseptic may be used. If exudate management is needed, non-adherent dressings may be applied. 

Dressing selection

The ISTAP has developed a dressing selection guide based on expert consensus, specific for patients with STs.[1][19] Table 4 incorporates updates to the original version.[1][2]

Table 4. Dressing selection guide for skin tears. Adapted from LeBlanc, 2016 [19][1]

Products NOT recommended for use in Skin tears

• Iodine-based dressings: while iodine is an effective antimicrobial dressing, it also dries the wound and periwound skin. STs are usually dry, and healable STs require a moist wound bed for healing. [2]
• Film/Hydrocolloid dressings: these dressings have been reported to contribute to medical adhesive-related STs due to their strong adhesive component [2][22]
• Skin closure strips: once accepted method for ST primary closure, skin closure strips are no longer a preferred treatment option for STs. [19][23] 
• Gauze: plain gauze does not secure the flap and there is increased risk of flap displacement when changing the secondary dressing, increasing the risk of skin necrosis. [1]

Dressing application/removal techniques

Tips for dressing application 

The following tips may be helpful in promoting wound healing and preventing further injuries: 

• Use an emollient to soften and smooth wider skin area and prevent further tears. [1]
• Select dressings according to the specific indications described in Table 4. Opt for dressings with longer wear time if feasible/appropriate. 
• If a skin flap is present, start application by positioning the dressing over the pedicle of the skin flap first, then proceed towards the end of the skin flap. Mark the dressing with an arrow to indicate the correct direction of removal, along with the ST size, type and shape (Figure 1). Ensure that this is also clearly explained in the notes. [2][1]

Figure 1 – Dressing application on a skin tear

Tips for dressing removal

• Evaluate the wound upon each dressing change. 
• Carefully/slowly lift the dressing, so as to avoid disrupting the skin flap and damaging periwound skin. Consider using adhesive remover or saline to minimize trauma
• Cleanse the wound gently
• If the skin flap seems pale or darker, reassess the ST within 24-48 hours to determine if necrotic tissue is present and debridement is needed.
• Assess for signs of infection 
• If there is no improvement after 

Surgical procedures

Wound coverage with autologous skin graft

• 2CFor ISTAP type 2 STs, clinicians might opt to cover the wound bed with pieces of the ST skin flap (used as skin grafts) to promote wound healing (Grade 2C). [3][4] 
• • Rationale: In a ISTAP type 2 ST, there is partial flap loss and the skin flap cannot be repositioned to cover the whole of the wound bed. The remaining raw area is left to heal secondarily and may result in a chronic ulcer. However, case series have shown that when pieces of the ST skin flap are placed on the wound bed as autografts, complete epithelialization of the raw area was observed in most cases after 7-10 days.[3][4] Two techniques are summarized in Table 5.
  • Coverage: authors of one of the case series suggest CPT codes 15110 or 15100, for placement of an epidermal or split-thickness skin graft.[3][4] Depending on the level of trauma, either the epidermis alone or the epidermis and a portioned layer of dermis are included in the graft. 

Table 5. Techniques for autologous skin grafting for ISTAP Type 2 Skin Tears [3][4] 

Complications

Complications include: 

• Bleeding
• Infection (local, systemic, spreading)
• Delayed wound healing 

Plan Reassessment

STs are acute wounds. As such, STs should close in a timely fashion (7-21 days) as long as risk factors that can delay wound healing are controlled, such as: diabetes, nutritional issues and edema.[1] If healing does not occur within 7-21 days, the patient, wound and plan should be reassessed, following the checklist below[2]: 

• Check differential diagnoses
• Check if causes and co-factors affecting healing are being addressed: 
• • repeat trauma 
  • Comorbidities, medications that can be delaying wound healing
• Check for appropriate local wound care

If any goals are not met despite adequate diagnosis and care, more realistic goals should be set. [2]

Adjunctive Therapy

For healable STs that are refractory to adequately delivered comprehensive care, clinicians might consider adjunctive therapies. Comprehensive care includes treating the underlying causes, addressing the patient's concerns and providing adequate local wound care. Evidence supporting adjunctive therapy interventions are not sufficiently strong to justify them as primary therapy. Choice of adjuvant therapy is based on clinical findings, availability of resources, and cost-effectiveness. Patient and wound should be re-evaluated prior to initiating adjunctive therapy. (See 'Plan Reassessment' above). Of note, certain adjunctive therapy interventions might be against a patient's culture and beliefs.

Interventions that have been utilized as adjuncts in ST treatment are summarized below.

Biophysical interventions

Negative pressure wound therapy (NPWT)

• 2CFor healable ISTAP type 1 STs with bleeding that is difficult to control, or with high levels of exudate, clinicians might opt for NPWT as an adjunctive treatment to promote wound healing (Grade 2C)
• • Rationale: Although not a true skin graft due to the random pattern blood supply delivered through its pedicle, ST skin flaps can be treated as skin grafts. Low certainty evidence drawn from case reports supports the use of NPWT to bolster the skin flap to the wound bed and prevent shear and fluid accumulation, which can result in graft failure. Use of both traditional and disposable NPWT devices have been shown to result in successful skin flap survival and adherence to the wound bed after 5-6 days. [13][24][25] 

Wound Coverage

Cellular and/or tissue based products (CTP)

• For healable but refractory STs, clinicians might consider CTPs to promote healing.
• • There is a paucity of articles in literature supporting use of CTPs as adjunctive treatment for STs, however several CTPs are approved by the FDA to be used on traumatic wounds. It is important to note however, that Medicare only covers CTPs in the outpatient setting if the wound fails to respond to documented appropriate wound-care measures implemented for at least 4 weeks. See topic “Cellular and/or Tissue Based Products".

PREVENTION

Implementation of preventative measures should start upon first evaluation of each patient. Early recognition of individuals at risk for STs is essential for ST prevention. [5]

Prevention follows the same principles as risk factor identification [1] :

1. General health
2. Mobility
3. Skin

• 1CFor all patients, expert consensus recommends that clinicians perform a risk assessment for skin tears upon admission, daily (or periodically per facility policy) and after identification of an episode of ST to prevent new STs (Grade 1C).[2][1][6] 
• A Risk Assessment Pathway adapted from ISTAP is shown in Figure 2.  For an overview of ST risk factors, see ‘Risk Factors’ in topic “Skin Tears - Introduction and Assessment”

Figure 2 - Skin tear risk assessment pathway (adapted from LeBlanc et al, 2013) [5] 

• 1CFor patients at risk for STs, expert consensuses recommend implementation of a ST risk reduction program. (Grade 1C)
• Tables 1-3 above and Table 6 below summarize recommendations from the ISTAP risk reduction program and expert consensuses.
  

Table 6. General recommendations for skin tear risk reduction [2][5][1] 

APPENDIX

Summary of Evidence

SOE_Negative Pressure Wound Therapy

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