Cath Lab Digest

Literature Review

Skin tears are traumatic wounds resulting from the separation of the epidermis from the dermis.¹ They occur principally on the extremities of older adults as a result of friction alone or shearing and friction forces. Skin tears may be partial-thickness, separating the epidermis from the dermis ranging from a linear skin tear or flap-type tear (Category 1) to scant to moderate tissue loss (Category 2). They also may present as full-thickness wounds that separate both the epidermis and dermis from the underlying structures with complete tissue loss.^2,3 Malone and colleagues¹ estimate at least 1.5 million skin tears occur each year in institutionalized elderly. Individual facilities have reported skin tear prevalence rates ranging from 14% to 24%.^2,4,5 Skin tears are painful and may lead to infection. Each skin tear increases caregiver time and facility costs.^2,6

The Role of Skin Care in Skin Tear Prevention

In several studies involving elderly persons,^2,4,7 dry skin (xerosis) has been associated with skin tears. Aging skin is vulnerable to skin tears because the dermal-epidermal junction is impaired. Healthy rete ridges interdigitate with dermal papilla from the dermis to help nourish and bond with the epidermis, preventing shearing and separating the skin layers (see Figure 1).

As rete ridges flatten with age, they become less effective in anchoring the epidermis to the dermis. Rete ridge flattening and other changes that occur with aging impair the ability of the skin to retain moisture, resulting in dry skin that is vulnerable to trauma. Skin cleansers can further alter the stratum corneum (the skin’s protective barrier layer) by reducing the thickness and number of cell layers and removing lipids and resident bacteria (normal flora). Harsh soap (especially one with a high pH) can dry the skin by interfering with its water-holding capacity.⁸

White and colleagues² conducted a 6-month retrospective review of incident reports involving skin tears in a 120-bed long-term care facility. They found that, on average, 14% of the population sustained a skin tear each month. In a 12-month follow-up study, 85% of residents whose care plans included specific interventions to reduce skin tears (including moisturizing arms and legs twice a day) showed a decrease in skin tear incidence. No statistical analysis was performed and the type of lotion used was not disclosed.

A 4-month prospective study⁵ was conducted in a 173-bed long-term care facility to evaluate the effectiveness of an emollient soap compared to a non-emollient soap in reducing skin tears. The rate of skin tears decreased after residents switched from a non-emollient skin cleanser in the first and third month of the study to an emollient cleanser during the second and fourth months by 37% and 33%, respectively. This difference was not statistically significant but the author considered the rate decrease clinically significant and the emollient soap worth using to reduce the effects of skin breakdown.