Skin Tears: A Review of the Evidence to Support Prevention and Treatment

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Author(s): 
Catherine R. Ratliff, PhD, APRN-BC, CWOCN; and Kathleen R. Fletcher, MSN, APRN-BC, FAAN

Index: Ostomy Wound Manage. 2007;53(3):32-42.

Introduction

  In July 2003, 35.9 million people in the US – 12% of the total population – were 65 years and older. Of these, 4.7 million were 85 and older. According to US Census Bureau projections, the number of older people is expected to grow to 72 million, comprising nearly 20% of the total US population. In 2000, 420 million people – 7% of the world’s population – were 65 and older. Projections indicate that by 2030 the number of elderly in the world will rise to more than 70%.1

  In 2004, Pennsylvania made it mandatory for healthcare facilities to report skin tears to the Pennsylvania Patient Safety Reporting System (PA-PSRS).2 Of the 2,807 reports submitted during the first year, patients over 65 years accounted for 88.2% of skin tears; the largest number of skin tears (41.3%) was reported in the 75- to 84-year-old group.2

Because a lack of consistent care in the authors’ facility was noted, a literature review was conducted to determine best evidence for practice in skin care management; specifically, the literature review assessed information available on the prevention and treatment of skin tears in this rapidly expanding segment of the population.

Method

  Medline® and Cochrane Library databases were searched for studies and systematic reviews published in English from 1990 to 2006 on skin tear prevention and treatment using the following medical subject headings (MESH): skin tears, skin lacerations, xerosis, and elderly skin. The search targeted meta-analyses, randomized controlled trials, prospective clinical trials, retrospective studies, and systematic reviews. All articles were reviewed.

Why the Elderly are at Risk

  Aging skin. With aging comes a 20% loss in dermal thickness, making the skin of many elderly adults almost transparent in appearance.3 The subcutaneous fatty layer also becomes thinner, especially on the face, neck, back of the hands, and shins. If traumatized, these areas will absorb more energy than other parts of the body because they lack cushioning fatty subcutaneous tissue; thus, they are at increased risk for an injury such as a skin tear.3-5 The skin has less resilience – sufficient force exerted against the skin will result in a tearing-type injury.4

  Also, as people age, the epidermal-dermal papillae that project into the epidermis flatten, increasing susceptibility to shearing and friction injuries. The fragile epidermal-dermal junction increases the risk of blister formation,3,4 a slowly developing phenomenon that may take some time to become clinically obvious. In the elderly, the network of blood vessels is reduced in the dermis and the vessels are altered – the slow clinical appearance of blisters is the result of the inhibited flow of vascular fluids to fill them.4

  Elderly skin is stretched more easily because the number of elastin fibers decreases with age, reducing the ability of skin to recover its shape when stretched and causing it to sag.5,6 With aging, the blood vessels also become thinner and more fragile. This condition, combined with decreased collagenous support to the blood vessels, leads to bruising beneath the skin known as senile purpura. Senile purpura affects older patients, particularly those who have had excessive sun exposure.



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