Getting your skin torn off sounds like something we only see in horror movies, but it can in fact happen in reality. Skin tears are a common occurrence among those with fragile skin, mainly the elderly and newborns. This injury requires a thorough assessment and ongoing wound care by a qualified healthcare provider. Surgical intervention may be needed for deep and severe wounds.
Our Skin
Many may not know this, but our skin is actually the largest organ of our body (yes, the skin is an organ). While only the top layer of skin is visible, there are actually 3 major layers in total.
- Epidermis: The top layer that you can see and touch. It consists of another 5 sublayers underneath to protect your body from external harm and to retain moisture.
- Dermis: The middle layer which is thicker than the epidermis. This is where your sweat glands, hair follicles, nerves, and blood vessels are situated.
- Hypodermis: The bottom layer is made up of fats attached to your muscles and bones, which function to support the top two layers.
What are Skin Tears?
Skin tears are avulsion wounds or injuries, meaning they happen when the layers of your skin get torn or ripped away.
The tear wound can be either in :
- Partial-thickness – the first layer of skin (epidermis) is torn from the middle layer (dermis)
- Full-thickness – both epidermis and dermis are torn from the underneath tissues.
Causes of Skin Tears?
Skin tears are caused by traumas to the skin on any parts of the body—mainly arms, hands, knees, elbows, and legs.
Traumatic wounds can be caused by :
- Blunt force – accidentally bumping into furniture, hitting something solid, or physical attack
- Shearing – grazing (friction) against a surface, like a wall or furniture, as an attempt to reduce the impact of falling
- Aggressive skin contact – removing band-aid/adhesive too quickly or rubbing skin intensely
These situations are normally quite harmless, inflicting only acute injuries, which means they can heal easily within at least 4 weeks.
However, they may become severe and chronic for those with delicate skin, especially ageing adults, newborn babies, as well as people with extremely dry skin.
Types of Skin Tears
Several assessment systems have been developed over the years to classify different cases of skin tears. The Payne-Martin classification system was the first guideline introduced in 1993, followed by the Skin Tear Audit Research (STAR) in 2007.
Today, the International Skin Tear Advisory Panel (ISTAP) remains the most widely recognised system used to identify the severity of skin tears, based on three main categories.
Category/Type I
This type of skin tear can appear in two forms:
- linear (in one straight line)
- skin flap (a piece of the ripped skin)
The skin flap (or epidermis) can still be readjusted to cover the dermis completely, or at least leave a 1mm gap between the ends of the skin flap and the wound edges.
There is no loss of skin, which allows for a quicker healing process that takes about 10 days only.
Category/Type II
Skin tears show a moderate level of severity. The skin flap is lost partially and therefore does not have enough portion or length to cover most of the dermis. It may heal within 14 days.
Category/Type III
This is the most severe type of skin tear. The skin flap is completely lost and no longer attached to the body, leaving the wound exposed. The healing process can take about 21 days or much longer, depending on the size of exposure and depth of the wound.
Risk Factors of Skin Tears
ISTAP breaks down the risk factors of skin tears into 3 groups: Skin Health, Mobility, and General Health.
Skin Health
Ageing
Our skin health slowly declines as we age. Cell turnover becomes slower, the epidermis gets thinner, and the skin can no longer retain high amounts of moisture. The proteins that make your skin elastic and firm (elastin and collagen) also deplete. All of these in turn develop weaker and dry skin that is susceptible to skin tears.
Neonatal
As newborns are still at the early stage of developing their physical organs and functions, their skin has not fully matured. Premature babies especially have extremely fragile skin, which can get easily wounded.
Dry skin
The drier your skin is, the more friction it can cause. Apart from ageing, you may develop dry skin due to various reasons: extreme environments, skin conditions like psoriasis or eczema, and the use of harsh cleaning products.
History of skin tears
Old skin tears can get damaged again, if not managed properly.
Mobility
Activities of daily living (ADL) dependence
ADL involves basic self-care such as eating, dressing, personal hygiene, toileting, and walking. Some elderly and those with impaired mobility (due to chronic illness, severe injuries, medical conditions, or congenital disability), require assistance to carry out these tasks.
Such a routine may include the use of a wheelchair, replacing bandages or wound dressings, and transferring from one place to another—which increases the risks of accidents as well as skin traumas.
History of fall
You are more likely to get tears again if there is a record of previous falls.
General Health
Chronically ill
Certain chronic illnesses—such as stroke and postural hypotension—can cause imbalance when standing up or while walking, which can lead to fall risks. Fatigue and weakened immunity as a long-term effect may also low down the process of wound healing.
Medications
Several types of medications like blood pressure and cholesterol drugs, if used extensively, can lead to dry skin. Other drugs including antibiotics and anticoagulants may also result in thin skin.
Impaired vision
Our eyesight can get worse the older we get. For older adults, age-related eye complications, like cataracts, can start creeping in. Not being able to see clearly is a major disadvantage when moving around, as we can knock ourselves by accident.
Lack of nutrition
Nutrition deficiency can result in a lack of hydration and necessary vitamins that are vital for promoting healthy skin, as well as supporting the healing process. Seniors are a common victim of poor diet due to loss of appetite and oral discomfort.
How to Assess Skin Tears?
Determining the condition of the tears requires a full examination of both the patient and the wound. Assessment of the tears is important to determine treatment strategies later on.
Step 1: Assessing the patient
Before examining the wound, it is a crucial first step to review the patient’s background. The purpose is to find out any existing risk factors based on the 3 main categories in the previous section: Skin Health, Mobility, and General Health.
We can also further determine if the patient is at risk or has no risk at all and whether they belong to the high-risk group.
Step 2: Assessing the wound
Experts from ISTAP have presented an outline of different aspects to look out for when inspecting the skin tear:
- Location of the tear
- Cause of the tear (when, where, and how)
- Size and depth of the tear
- Condition of wound bed and tissue (viable or non-viable)
- Type and amount of exudate (fluid)
- Presence of bleeding
- Integrity or condition of the surrounding skin
- Symptoms and signs of infection
- Level of pain
Step 3: Classify the type of tear
It is important for the skin tear to be categorised according to the ISTAP system, under either Type 1, Type 2, or Type 3. Knowing the classification can determine proper treatment plans.
IMPORTANT: All information gathered from the patient and wound examination, as well as the classification of skin tear, should be written down as notes to monitor the progress of healing.
Skin Tears Treatment
The main goals when treating tears are to protect the tissue of the skin flap and its surroundings, to reduce or prevent secondary infections, and to minimise additional trauma to the skin as well as pain.
Treatment for skin tears focuses more on how to manage the wound, rather than prescribing medications.
Here is the basic procedure:
- Keep the bleeding under control by applying pressure on the wound with gauze, or elevating the affected body part
- Cleanse the wound and skin flap gently by using warm clean water or saline water to remove remaining debris, thus preventing infection.
- Lay the skin flap back to its place with great care to ensure it remains attached and not further torn. If viable or healthy, the skin flap can be reused as a dressing to cover the wound. Avoid using any adhesive on the skin.
- Control the amount of exudate to avoid excessive or too little moisture.
- Closing the wound with appropriate dressing and preferably left undisturbed for a few days to allow the flap to stay intact. The type of dressing may differ based on the condition of the tear. You can also mark an arrow on the dressing to avoid removing the flap in the opposite direction.
- Change the dressing after 5 to 7 days, or 1 to 2 days if it is wet due to blood or exudate.
- Repeat assessment of the wound at least up to 4 times to check for any changes, to update new treatment plans.
- Proceed with surgical review if the skin tear develops a full-thickness wound.
Skin tears can usually be treated at home. However, if the wound is severe and you do not have knowledge of first aid, it is advised to seek initial treatment from a trained healthcare professional immediately to increase the chance of faster healing.
Skin Tears Prevention
ISTAP Risk Reduction Programme provides a comprehensive checklist for healthcare assistants and caregivers to follow through when handling skin tear patients.
You or your caregiver can also observe the following at home:
Patient care
- Apply emollients (moisturising products) twice a day, particularly on fragile areas, to combat dryness.
- Shower or bathe with room temperature water and opt for PH-balanced products which are gentle to the skin. Practise patting with a non-abrasive towel, instead of wiping.
- Wear long clothing like sleeves, pants, or socks as physical protection. Be careful of the buttons, zippers, and tags that can tug on your skin.
- Eat healthily and drink lots of water to nourish your body. Pay attention to ingredients that promote healthy and strong skin such as vitamin C, antioxidants, and fatty fish.
- Use non-adhesive bandages when changing wound dressings.
- Avoid wearing jewellery.
- Keep your nails short.
- Use slide sheets instead of bed sheets to reduce friction when transferring or moving patients.
Environmental precaution
- Provide adequate lighting at home to support a clear view of your surroundings.
- Place furniture to the sides or corners of the room, so there is nothing blocking in your path. Keep a minimal amount of furniture around the house.
- Cover the edges of furniture and other dangerous parts by installing foam pads or cushions for safety.
- Remove items on the floor like rugs, toys, and stationery that can cause you to trip over.
- The use of a wheelchair should be assisted. Caregivers should not allow the patient, especially those who are at risk, to use the wheelchair without supervision.
Wound Care Right at Home for Skin Tears
Having to endure discomfort and pain of skin tears, unfortunately, compromises the quality of life. You might be unable to move around and complete chores without depending on a caregiver’s assistance.
At Homage, we provide home nursing services so you can receive consistent wound care from our trained nurses (potentially saving you from fall risks and casual accidents at home).
Provide the best care to your loved one today! Fill up the form below for a free consultation with our Care Advisory team.
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