Management of Skin Tears in Vulnerable Populations from Older Adults to Critically Ill Patients: ISTAP Part 2

INTRODUCTION This article follows “The Prevention of Skin Tears – A Focus on Vulnerable Populations from Older Adults to Critically Ill Patients: ISTAP Part 1,” which dealt with the prevention of skin tears in vulnerable populations.1 Infants and older adults are at risk of developing skin tears.2 In addition, critically ill patients, irrespective of age, are at increased risk of skin tears because of factors such as fluid imbalance, mobility impairment, sensory changes, pharmacologic therapies, and mechanical factors related to skin care practices.2,3 Thus, the goal of skin tear management in these individuals is to promote uneventful wound healing while preventing associated complications such as infection, development of chronic wounds, and tissue loss with resultant loss of function.2 The management of skin tears, irrespective of age, should be evidence-based and follow established guidelines, such as those recommended by the International Skin Tear Advisory Panel (ISTAP).4 It is recommended that a sequential approach be used in the management of skin tears. In this regard, a stepwise quick reference for daily clinical practice has been developed (Figure 1).5 Similarly, Carville et al3 recommended a systematic approach in the assessment and management of skin tears: cleansing through appropriate Selection of cleanser, Tissue alignment, Assess and dress, and Review and re-assess (STAR).FIGURE 1: STEPWISE APPROACH TO MANAGEMENT OF SKIN TEARSAdapted with permission from LeBlanc et al.5A comprehensive patient, skin, and wound assessment is necessary because it informs the treatment plan and overall management of the individual with a skin tear.4,5 A holistic patient-centered care approach through the implementation of the wound prevention and management cycle guides the clinician and facilitates the prevention and management of skin tears at the initial assessment.6 SKIN TEAR MANAGEMENT Optimize the Local Wound Environment The first aid measure is to control the hemorrhage by applying gentle pressure (being mindful that the tissues are very fragile), elevating the limb, and using an appropriate nonadherent dressing without compromising the skin flap.7 Thus, with regard to dressing choice, avoid the use of dry gauze or any adherent dressing.4 Assess the Skin Tear Remove debris or necrotic tissue to minimize the bacterial load.4 Coagulated blood from the wound surface and flap should be removed to promote wound healing. Tetanus toxoid may be necessary. Cleanse and Debride the Skin Tear The method of cleansing is dependent on the type of skin tear and the degree of debris or necrotic tissue on the wound bed or skin tear flap. In noncomplicated skin tears, that is, those without debris, a noncytotoxic solution such as water or 0.9% sodium chloride may be used to cleanse the skin tear. However, in complicated wounds, which may have a risk of contamination, debridement is necessary. In the absence of specialist skills to undertake debridement, the individual should be referred to a wound specialist.4 Debridement facilitates the removal of necrotic tissue and debris, and thus reduces bacterial colonization and improves tissue perfusion. The choice of appropriate debridement is dependent on the wound characteristics and the clinician’s expertise. It is also important to protect the viable flap (type 1 and 2 skin tears) during debridement. Reposition the Flap Reposition the remaining viable flap onto the wound bed as quickly and carefully as possible to avoid strangulation. Repositioning may be achieved with gloved fingers, a dampened cotton-tip applicator, or nontoothed tissue forceps.7 Due to the fragility of the skin, skin tears are generally not amenable to closure with skin staples or sutures.6 Similarly, skin closure strips are not appropriate for the management of skin tears because they do not provide adequate protection for the fragile periwound skin.7 Also, the clinician should be cognizant that the remaining skin tear flap may not necessarily cover the entire wound bed.8 The flap should not be disturbed for 5 days to facilitate adherence of the flap to the cellular structures.8 At initial positioning, the skin tear should be classified according to the ISTAP’s skin tear classification system.1,9 Wound Dressing Selection and Application The dressing selected should be compatible with vulnerable skin.4 Further, the clinician should assess the quantity of wound exudate and manage the moisture balance accordingly to promote healing. Thus, interactive dressings are recommended with consideration given to avoiding dressings with strong adhesives.6 In the pediatric population, precautionary measures should be taken with regard to the indications and contraindications of the selected wound dressing.6 The ISTAP created a selection guide for wound dressings that are appropriate for skin tears.7 After applying the dressing, indicate with an arrow on the wound dressing the direction of dressing removal (Figure 2).6 To maintain flap viability, dressing removal should occur in the direction of the flap and not against it.FIGURE 2: CORRECT WAY TO REMOVE DRESSINGAdapted with permission from LeBlanc et al.4Managing Moisture Balance The dressing should be chosen according to the characteristics of the wound bed and patient factors, such as the presence of peripheral edema.6,8 Exudate management is key to promoting wound healing; therefore, select an appropriate wound dressing to manage excess exudate while protecting the periwound skin from maceration using an alcohol-free liquid barrier.4,6,10 Managing Bacterial Balance Because skin tears are acute wounds, it is expected that inflammatory signs such as edema and pain will be present for 24 to 72 hours postinjury. Worsening pain or persistent edema past this period should warrant further investigation. The presence of infection, as determined by the clinical signs and symptoms, should be managed with appropriate wound dressings (Table 1). Generally, systemic antimicrobials are not indicated, but topical antimicrobials such as mupirocin, bacitracin, and neomycin may be used.11 TABLE 1 - PRODUCT SELECTION GUIDE Product Categories Indications Skin Tear Type Considerations Nonadherent mesh dressings (eg, lipidocolloid mesh,impregnated gauze mesh, silicone mesh, petrolatum) Dry or exudative wound 1, 2, 3 Maintains moisture balance for multiple levels of wound exudate; atraumatic removal; may need secondary cover dressing. Foam dressing Moderate exudate, longer wear time (2-7 days, depending on exudate levels) 2, 3 Take caution with adhesive border foams; use nonadhesive versions when possible, to avoid periwound trauma (not applicable to silicone border products). Hydrogels Donates moisture for dry wounds 2, 3 Maintains moisture balance for multiple levels of wound exudate; atraumatic removal; may need secondary cover dressing. Cyanoacrylate-based(2 octyl or n-butyl) topical bandage (skin glue) To approximate skin edge and repair the wound 1, 2, 3 Use in a similar fashion as sutures within the first 24 h postinjury; these surgical adhesives are relatively expensive; medical directive/protocol may be required. Solvent-free cyanoacrylate-based skin protectants Protection from moisture and friction damage for up to 7 d 1, 2, 3 Use as a skin protectant; chemically bonds to skin surface so cannot be removed once applied - will slough off over time; does not require a secondary bandage. Calcium alginates Moderate to heavy exudate,hemostatic for minor bleeding 1, 2, 3 May dry out wound bed if inadequate exudate; secondary cover dressing required. Gelling fibers Moderate to heavy exudate 2, 3 No hemostatic properties; may dry out wound bed if inadequate exudate; secondary cover dressing required. Acrylic dressing Mild to moderate exudate without any evidence of bleeding; may remain in place for an extended period. 1, 2, 3 Take care on removal; should be used only as directed and left on for extended wear time. Special consideration for infected skin tears Methylene blue and gentian violet dressings Effective broad-spectrum antimicrobial action, including antibiotic resistant organisms 1, 2, 3 Nontraumatic to wound bed; use when local or deep tissue infection is suspected or confirmed; secondary dressing required. Adapted from LeBlanc et al.4,7 Assessment of Outcomes A primary goal of skin tear management in vulnerable individuals is to promote uneventful wound healing while preventing associated complications; reassessing the patient and the wound is pivotal in determining the outcomes.6 In the absence of exacerbating factors, skin tears are expected to heal in a timely manner, usually within 7 to 21 days.4,6 Risk factors that may contribute to delayed wound healing should be addressed accordingly, including the avoidance of trauma to prevent the recurrence of skin tears. CONCLUSIONS Holistic wound management principles should be applied to the management of skin tears. In particular, clinicians should use a systematic approach that includes assessment, cleansing, and debridement, and re-approximation of the flap with appropriate dressing selection. Managing the moisture and microbial balance is also integral to the management of skin tears. Fundamentally, the prevention of skin tears is crucial, and the appropriate management of skin tears can potentially reduce associated complications such as infection and the development of complicated wounds.