A skin tear is a traumatic wound that is caused by a mechanical force. The mechanical force could be shear or friction, or it could be the result of removing an adherent dressing.¹

Skin tears can lead to partial or full separation of the skin’s outer layers (epidermis and dermis). They can also lead to a separation of both the epidermis and the dermis from the underlying structures (a full-thickness wound). The severity of a skin tear varies, depending on the depth of the wound. However, skin tears do not extend through the subcutaneous layer of the skin.¹  

They can occur on any part of the body, but are most common on the hands, arms and legs.¹

Our skin is the body’s first line of defence. It acts as a protective barrier, and prevents damage to our internal tissues and organs. However, if our skin becomes frail or fragile, it’s more likely to be damaged. This increases the risk of skin tears, as less force is needed to cause a traumatic injury.²

While skin tears can happen in a variety of patients, the elderly population is particularly at risk. As we age, our skin becomes more fragile. The skin’s ability to heal itself slows down, which can make it even more vulnerable to skin tears.² 

If an elderly patient needs help to carry out daily tasks, such as moving around or washing, this can increase the risk of skin tears. Additionally, elderly patients who have other illnesses, are undergoing certain medical treatments (e.g. chemotherapy) or are on certain medications (e.g. steroids), can have an even higher risk of developing skin tears.¹

To prevent your patient from getting a skin tear, you can take two steps. One, find out if your patient is at risk. And two, take steps to minimise your patient’s risk. Let’s look at two tools that can help you to do this.

Tool #1: The Skin Tear Risk Assessment Protocol

To find out if your patient is at risk, you can use the Skin Tear Risk Assessment Protocol (See Figure 2).¹

This protocol looks at three main risk factors:

1. skin,
2. mobility, and
3. general health.

Figure 2: Skin Tear Risk Assessment Protocol¹

Tool #2: The Risk Reduction Programme Checklist

If you find out that your patient is at risk, use the Risk Reduction Programme Checklist (See Table 2). This will help you protect your patient from skin tears. The checklist gives you a list of tips and suggestions based on the same three factors as the risk assessment: skin, mobility and general health. By controlling the risk factors around your patient, you can help them maintain skin health and avoid injury.¹

The epidermis is the outermost, visible part of the skin.¹⁹. It is a highly specialised structure that adapts to environmental conditions.^19,28

It provides a physical and chemical barrier to block entry of foreign substances and triggers an immunological response against any pathogens that penetrate the barrier.^19,28

It has a thin layer of cells varying in thickness from 0.05 mm on the eyelids to 1.5 mm on the palms and soles.⁸

Function of the epidermis:¹⁹

• Barrier function
• Control of water loss

Protection against UV light, bacteria and allergens

The dermis is the middle layer of the skin and is approximately 15-40 times thicker than the epidermis.^4,35

The dermis consist of connective tissue. A semi-fluid substance mainly consisting of collagen and elastin fibres.^4,35 

The dermis contains:

• Nerve endings
• Blood vessels
• Skin appendages (e.g. hair follicles, sebaceous glands and sweat glands)^4,35

The subcutaneous tissue (subcutis) is the lower layer of the skin between the dermis and fascia.³⁵

Subcutaneous fatty tissue can often be visible in the base of deep wounds such as pressure ulcers or traumatic wounds.⁵

Functions of the subcutis include:³⁵

• Insulation
• Cushions
• Retains moisture

Chronic wound exudate is rich in: ¹

• Growth factors that which promote healing
• Dead white cells, bacteria, high levels of inflammatory mediators and proteases which can disrupt the normal wound healing process

High protease content of chronic wound fluid causes maceration and breaks down of the stratum corneum.^19,39

Failure to manage exudate adequately can lead to exposure of the periwound skin to moisture resulting in maceration of the periwound skin.39

ITD is an inflammatory dermatosis occurring as a consequence of moisture, friction and bacteria trapped between two skin surfaces.⁶

In skin folds, there is a risk that sweat can get trapped leading to build-up of moisture and when the skin rubs together it becomes painful due to skin excoriation. ³⁷

This increases the risk of secondary infection by fungi and bacteria and leads to intertrigo.³⁷

Peri-stomal skin damage occurs when skin is exposed to effluent from an ostomy, resulting in inflammation and erosion.³⁸

Lipases and proteases produced by faecal bacteria break down protein in keratinocytes, contributing to skin breakdown.⁶

Incontinence Associated Dermatitis (IAD) is a complex mechanism that is not fully understood but involves an interaction between, urine and faeces on the skin, humidity, mechanical irritants and frequent use of soap and water.¹⁹

If the skin is exposed to urine, faeces and detergents for a longer time the skin pH becomes more alkaline disturbing the acid mantle and increasing skin damage.¹⁹

In the sacral area, even experts have difficulty identifying if skin damage is due to pressure damage or moisture damage.²²

An example is patients who are at risk for IAD. They are also at risk for pressure ulcer development, due to impaired tolerance to friction and sheer when IAD is present.⁶

Stage I pressure ulcers are often mistaken for mild/moderate IAD as both conditions present as erythema of intact skin.^6,19

1. Adderley, U. J. (2010) Managing wound exudate and promoting healing. British Journal of Community Nurses, 15(3), 15-20.
2. Baranoski, S., Ayello, E., Tomic-Canic, M. (2008). Chapter 4: Skin: An essential organ. In Baranoski, S.(Editor) and Ayello, E. (Editor). Wound Care Essentials. Practice Principles (pp. 47-63). 2nd ed. Philadelphia: Lippincott Williams & Wilkins.
3. Babb-Tarbox, M., Bergfeld, W. F. (2008). Chapter 11: Alopecia and Thyroid Disease. In Heymann, W. R. (editor). Thyroid Disorders with Cutaneous Manifestations (pp. 499-528). London: Springer.
4. Baroni, A., Buommino, E.,  De Gregorio, V., Ruocco, E., Ruocco, V., Wolf, R. (2012). Structure and function of the epidermis related to barrier properties. Clinics in Dermatology, 30; 257-262.
5. Beeckman, D., Schoonhoven, L., Fletcher, J., Furtado, K., Gunningberg, L., Heyman, H., Lindholm, C., Paquay, L., Verdú, J. and Defloor, T. (2007). EPUAP classification system for pressure ulcers: European reliability study. Journal of Advanced Nursing, 60(6); 682-691.
6. Black, J. M., Gray, M., Bliss, D. Z., Kennedy-Evans, K. L., Logan, S., Baharestani, M. M., Colwel, J. C., Goldberg, M. and Ratliff, C. R. (2011). MASD Part 2: Incontinence-Associated Dermatitis and Intertriginous Dermatitis. Journal of Wound Ostomy & Continence Nursing, 38(4); 359-370.
7. Brown, A., Flanagan, M. (2013). Chapter 4: Assessing Skin Integrity. In M. Flanagan (Editor), Wound Healing and Skin Integrity. Principles and Practice (pp. 52-65). West Sussex: John Wiley & Sons, Ltd. 
8. Burian, E. A. (2017). Chapter 1: Huden. In B. Ø. Melby (editor), Bermark, S. (Editor). Sår og sårbehandling. En grundbog I sygeplejen (pp12-27). Copenhagen: FADL's Forlag.
9. Chamlin, S. L., Tremblay, E. A. (2010). Chapter 1 You and the Skin You’re In. In Living with Skin Conditions (pp 1-13). New York: Facts on File, Inc.
10. Ersser, S. J., Getligge, K., Voegeli, D. and Regan, S. (2005). A critical review of the inter-relationship between skin vulnerability and urinary incontinence and related nursing intervention. International Journal of Nursing Studies, 42; 823-835.
11. Grove, G. L., Zerweck, C., Pierce, E. (2002). Chapter 23: Noninvasive Instrumental Methods for Assessing Moisturizers. In Leyden, J. J. (editor), Rawlings, A. V. (editor). Skin Moisturization (pp. 499-528). Boca Raton: CRC Press.
12. Harding, C. R., Watkinson, A., Rawlings, A. V. (2000). Dry skin, moisturization and corneodesmolysis. International Journal of Cosmetic Science, 22; 21-52.
13. Janninger, C. K., Schwartz. R. A., Szepietowski, J. C., Reich, A. (2005). Intertrigo and Common Secondary Skin Infections. American Family Physician, 72 (5); 833-8.
14. Johnson, A. W. (2002). Chapter 1: The Skin Moisturizer Marketplace. In Leyden, J. J. (editor), Rawlings, A. V. (editor). Skin Moisturization (pp. 1-30). Boca Raton: CRC Press.
15. Joshi R. Immunopathogenesis of psoriasis. Indian J Dermatol Venereol Leprol 2004;70:10-2
16. Kennedy, R., Crowle A. (2017). Key Differences in Infant Skin. The Royal Children’s Hospital Melbourne. March 2017.
17. Korting, H. C. (1990). Marchionini's Acid Mantle Concept and the Effect on the Skin Resident Flora of Washing with Skin Cleansing Agents of Different pH. In Braun-Falco, O., Flanagan, M. (Editor), Korting, H. C. (Editor). Skin Cleansing with Synthetic Detergents (pp. 87-96). Berlin: Springer-Verlag. 
18. Langøen, A. and Bianchi, J. (2013). Chapter 2: Maintaining Skin Integrity. In Flanagan, M. (Editor), Wound Healing and Skin Integrity. Principles and Practice (pp. 18-32). West Sussex: John Wiley & Sons, Ltd. 
19. Lokmic, Z., Musyoka, J., Hewitson, T. D., Darby, I. A. (2012). In Jeon, K. W. International Review of cell and molecular biology, volume 296 (pp 140 - 173). Oxford: Elsevier Inc.
20. Lumbers, M. (2018). Moisture-associated skin damage: cause, risk and management. British Journal of Nursing, 27 (12); 6-14.
21. Mahoney, M., Rozenboom, B., Doughty, D. and Smith, H. (2011). Issues Related to Accurate Classification of Buttocks Wounds. Journal of Wound Ostomy & Continence Nursing, 38(6), 635-642.
22. Martin, M. (2013). Chapter 3: Physiology of Wound Healing. In Flanagan M. (Editor), Wound Healing and Skin Integrity. Principles and Practice (pp. 33-51). West Sussex: John Wiley & Sons, Ltd
23. Muldoon (2013). Chapter 10: Chronic Ulcers of the Lower Limb. In Flanagan M. (Editor), Wound Healing and Skin Integrity. Principles and Practice (pp. 155-174). West Sussex: John Wiley & Sons, Ltd
24. Norman (2008). Chapter 12: Xerosis and Pruritus in the Elderly – Recognition and Management. In Norman, R. A (Editor), Diagnosis of Aging Skin Diseases (pp 151). London: Springer
25. Paul, C. N. (2008). Skin Substitutes in Burn Care. Wounds Research, 20 (4).
26. Proksch, E., Brandner, J. M. and Jensen, J-M. (2008). The skin: an indispensable barrier. Experimental Dermatology, 17; 1063-1072.
27. Raschke, C. and Elsner, P. (2010). Chapter 5: Skin Aging: A Brief Summary of Characteristic Changes. In M. A. Farage, K. W. Miller and H. I. Maibach (Eds.), Textbook of Aging Skin (pp. 37-43). Berlin: Springer Berlin Heidelberg.
28. Rawlings, A. W., Harding, C. R., Watkinson, A. Scott, I. R. (2002). Chapter 6: Dry and Xerotic Skin Conditions. In Leyden, J. J. (editor), Rawlings, A. V. (editor), Skin Moisturization (pp. 119-144). Boca Raton: CRC Press.
29. Rosser, M., Couldridge G., Rosser, S. (2012). Body Massage. 3rd ed. Ocon: Bookpoint. 
30. Saffle, J. R., Banister, M., Cahalane, M., Lee, J. O., Palmieri, T. L. (2013). Chapter 10: Burns. In Lawrence, P. F. Essentials of General Surgery (pp. 188). 5th ed. Philadelphia: Lippincott Williams & Wilkins.
31. Schmid-Wendtner, M-H., Korting, H. C. (2006). The pH of the Skin Surface and Its Impact on the Barrier Function. Skin Pharmacology and Physiology, 19; 296-302
32. Sherwood, L. (2012). Chapter 11: The Blood and Body Defenses. In Sherwood, L. Fundamentals of Human Physiology (pp. 383). 4th ed. Belmont: Brooks/Cole.
33. Shimizu, H. (2017). Chapter 1: Structure and function of the skin. In Shimizu, H. Shimizu’s Dermatology (pp 1- 42). 2nd ed. West Sussex: John Wiley & Sons, Ltd.
34. Shimizu, H. (2017). Chapter 15: Disorders of keratinization. In Shimizu, H. Shimizu’s Dermatology (pp 1- 42). 2nd ed. West Sussex: John Wiley & Sons, Ltd.
35. Sibbald, R. G., Kelley, J., Kennedy-Evans, K. L., Labrecque, C., Waters, N. (2013). A Practical approach to the Prevention and Management of Intertrigo, or Moisture-associated Skin Damage, due to Perspiration: Expert Consensus on Best Practice. Wound Care Canada, 11 (2); 1-21.
36. Voegeli, D. (2012). Moisture-associated skin damage: aetiology, prevention and treatment. British Journal of Nursing, 21(9), 517-521.
37. White, R. J. and Cutting, K. F. (2003). Interventions to avoid maceration of the skin and wound bed. British Journal of Nursing, 12(20), 1186-1201.
38. Wickett, R. R., Visscher, M. O. (2006). Structure and function of the epidermal barrier. American Journal of Infection Control, 34, 98-110.