This page provides clinical guidance on skin tears for health professionals.
The following information about skin tears is taken from 3D Regional HealthPathways, accessed June 2020:
About skin tears
Skin tears occur principally in the limbs of older adults as a result of friction with or without shearing.
Either the epidermis separates from the dermis (partial thickness wound), or in flap skin tears, both the epidermis and dermis separate from underlying structures (full thickness wound).
- Assess the wound using the General Wound Care pathway.
- Also assess:
• whether skin edges can be realigned.
• flap viability i.e., not pale, dusky, or darkened.
- Classify the skin tear using the International Skin Tear Advisory Panel (ISTAP) skin tear classification system:
• Type 1: No skin loss – linear or flap tear which can be repositioned to cover the wound bed
• Type 2: Partial flap loss – partial flap loss which cannot be repositioned to cover the wound bed
• Type 3: Total flap loss – total flap loss exposing entire wound bed
- Stop the bleeding and cleanse the wound:
• Apply pressure and elevate limb if appropriate.
• Irrigate with potable water or sterile saline and remove any clots.
• If bleeding is uncontrollable, arrange immediate transfer to the nearest Emergency Department.
- If the wound is deep, beyond the hypodermis layer, or muscle, bone or tendon is exposed, request acute plastic surgery assessment.
- If there are symptoms or signs of local, spreading, or systemic infection, see Wound Infections.
- Approximate the flap over the wound bed by rolling skin with moist cotton bud.
• Avoid forcing or stretching the skin edges together as tension causes ischaemia and healing is more likely if a gap of a few millimetres is left.
• If there is detached skin, it can be applied to the wound, much like a skin graft.
- Dry the surrounding skin.
- Dress the wound:
• Select appropriate dressings based on skin tear type, exudate levels and signs of infection. Skin tears tend to be dry so choosing correct products for maintenance of moisture balance is important.
• When applying, ensure the primary dressing:
◊ overlaps the wound edge by at least 2 cm.
◊ is not overstretched.
◊ is sealed around the outer edge.
• Do not apply:
◊ sutures and staples.
◊ iodine solutions or dressings – these cause drying of the wound and peri-wound.
◊ films and hydrocolloids – may cause further injury due to strong adhesive component.
◊ gauze – does not adequately secure the flap, causing increased risk of flap displacement when changing secondary dressing.
• Apply a firm supportive bandage using orthopaedic wool padding, crepe, and a tubular retention bandages to the whole affected limb. When bandaging a lower limb, apply the bandage from the base of the toes to below the knee.
- Provide tetanus‑prone wound management if indicated.
- Limit mobility for the first 24 to 48 hours and advise elevation of the leg when not walking.
- Provide preventative education and consider recommending use of protective garments to reduce risk of further skin tears.
- Manage any other factors that may affect healing.
- Review and reassess:
• Review and reassess within 48 to 72 hours unless using silicon interface sheet dressing. If using silicon interface sheet dressing, review within 5 days.
• Take down the top layer of dressings, leaving the primary dressing intact where possible.
• Reassess the wound.
• If there are symptoms or signs of local, spreading, or systemic infection, see Wound Infections.
• Change dressings as required.
• Re‑pad and bandage.
- If there is inadequate healing or failure to reduce in size within 2 weeks, manage according to wound type:
• For a leg wound, see Leg Ulcers.
• For all other wounds, consider requesting specialised wound care nursing.
- Skin tears 3D Regional HealthPathways, NZ, 2020