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Skin tears - a common problem among the elderly

As we age, many changes take place to the normal structure and function of skin, both visible and invisible, that impact on its ability to protect the underlying structures. The quality and function of skin is significantly adversely affected by increasing age.
The decreased sensitivity of the immune system encourages infection and skin damage.(1) Skin may become more rigid, and fluid retention may be a problem. A reduction in sebum secretion and sweating causes dry, coarse, itchy and scaly skin in the elderly.(2) The decreased production of melanin results in paler skin and increased sensitivity to the effects of the sun. Some melanocytes produce extra melanin, resulting in "age spots" in areas exposed to the sun. A reduced inflammatory response may alter allergic reactions and impede the rate of healing. However, in spite of poor healing, the quality of scar tissue is improved in the elderly.(2)
The incidence of injuries and infections increases as the epidermis thins and sensory receptors diminish in capacity. Older people are more likely to be accidentally burned or injured without perception.(1) Water loss, bruising and infection are more common, and certain drugs and irritants are more easily absorbed, possibly causing adverse or allergic reactions.(3)
Sagging and wrinkling appears as the skin weakens, the dermis thins by about 20%, collagen is lost and elasticity decreases, particularly in those areas exposed to the sun.(4) As the hypodermis becomes thinner, people are more prone to pressure damage, bruising and small haemorrhages.1 Ageing is associated with delayed wound healing and decreased vascularity.(2) Blood vessels become thinner and more fragile, leading to the appearance of superficial haemorrhaging, known as senile purpura, that is often the site for skin tears.(3)
Age is also associated with a change (atrophy) in the subcutaneous tissue at specific sites around the body, such as the face, the dorsal aspect of the hands, the shins and the feet. These sites absorb more energy when injured, resulting in increased risk and more severe damage than anticipated. This damage may take the form of a skin tear or bruise. This can be further complicated by decreased pain perception, making the person more susceptible to skin damage.

Incidence and risk factors
Skin tears are most common in people over 65 years. In the USA, the prevalence is approximately 1.5 million per annum, with the highest incidence on the hand and arm (80%) and less frequently the lower extremities.(3) Skin tears occur mainly from what can be described as "minor trauma" associated with bumping into objects (25%), wheelchair injuries (25%), transfers (18%) and falls (12.4%).(5)
Individuals who are dependent on carers for assistance with basic daily activities are at high risk for skin tears, as are sight-impaired persons.(5) The incidence of skin tears increases with age, with a 25% incidence in people aged between 60 and 69, rising to 45% in patients aged 85 years and over.(6)

Definition
Very little has been written about skin tears, although they are commonly observed in elderly people.(7) A skin tear is defined as a traumatic wound occurring principally on the extremities of older adults as a result of friction and/or shearing forces, which separate the epidermis from the dermis, or separate both the dermis and epidermis from underlying structures.(7)
The risk factors for skin tears include dependence on carers for bathing, transferring and positioning, advanced age, fragile skin, use of assistive devices or tape, sensory impairment and a history of skin tears. Mobile patients sustain skin tear injuries mainly on the lower extremities; this group may have pre-
existing oedema, purpura or ecchymosis (the skin discoloration caused by the escape of blood into the tissues from ruptured blood vessels). Nearly half of all skin tears have no apparent cause.
Patients who have used corticosteroids for extended periods, are nutritionally compromised or dehydrated, have dry skin or are taking multiple medications for multiple disease processes are also at risk of skin tears.

Classification
Skin tears can be classified by the degree of severity and loss of epidermal tissue. The revised Payne-Martin Classification for Skin Tears ranges the damage from category I to category III.(7)

Category I
A linear category I skin tear is an incision-like lesion with separation between the epidermis and dermis; the flap-type category I skin tear has an epidermal flap skin tear that almost covers the dermis.

Category II
The category II skin tear has partial loss of the overlying tissue (see Figure 1). The subtypes of category II are scant tissue loss (25% of the epidermal skin flap).

Category III
The most severe category III skin tear has complete loss of overlying tissue, with no epidermal flap remaining.(7) The authors suggest that a common taxonomy and definition for each type of skin tear helps to organise teaching, practice and research.

Treatment
Skin tears will happen sometimes for no obvious reason and in spite of the carer's best efforts. Treatment will comprise supporting healing without inducing more treatment-related trauma. There are no recognised guidelines, but basic, moist wound healing principles should direct care.
Following wound assessment, careful irrigation and patting dry with sterile normal saline, and approximation of the skin flap, a range of products can be applied, including hydrocolloid, foam, hydrogel and film dressings.
Steri-Strips (3M Healthcare) may be needed to hold the flap in place, covered with a low-adherent dressing, such as N-A Ultra (Johnson & Johnson), Urgotul (Parema Medical), or Mepitel and Mepilex (Mölnlycke Health Care), held in place with a tubular bandage, avoiding any adherence of tape to the skin. Above all, extreme care must be taken when removing any dressing or bandage to avoid skin trauma.

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References

  1. Herlihy B, Maebius NK. The human body in health and illness. London: WB Saunders; 2000.
  2. Tanj LF, Phillips TJ. Skin problems in the elderly. Wounds 2001;13:93-7.
  3. Baranoski S. Skin tears: staying on guard against the enemy of frail skin. Nurs Manage 2001;32:25-32.
  4. Wysocki AB. Anatomy and physiology of skin and soft tissue. In: Bryant R, editor. Acute and chronic wounds. Nursing management. London: Mosby; 2000.
  5. Baranoski S. How to prevent and manage skin tears. Adv Skin Wound Care 2003;16:268-70.
  6. Groeneveld A, et al. The prevalence of pressure ulcers in a tertiary care pediatric and adult hospital. J Wound Ostomy Continence Nurs 2004;31:108-20.
  7. Payne RL, Martin ML. Defining and classifying skin tears: need for a common language. Ostomy Wound Manage 1993;39:16-20, 22-4,26.