Volume 45 Number 2

Abbreviations

ADL – Activities of Daily Living
ISTAP –  International Skin Tears Advisory Panel
MARSI – Medical Adhesive Related Skin Injury

Introduction

Skin tears are acute wounds which can affect those at the extremes of age.  Van Tiggelen and Beeckman¹ undertook a synthesis of the evidence to determine prevalence of skin tears and identified that in long term care the rate is between 4.7-26%, increasing to 41.2% for those people with  dementia. In acute care the rate has been reported to be 3.7% (in paediatrics) to 19.8%.¹ These figures highlight the relative occurrence to other types of skin injuries, for example pressure injuries, the prevalence of which are estimated to be 12.8% in hospitalised patients.²

In the older person, skin tears are commonly associated with a range of factors including blunt trauma, falls, while performing activities of daily living (ADL), wound dressing related i.e. medical adhesive related skin injury (MARSI), during patient transfer and equipment injury.^3,4 In neonates the main cause is MARSI.⁵ In both young and old age groups patient handling is a frequent cause of skin tears as the tissues are more fragile at the extremes of age.^6,7

These causes are reflected in the updated International Skin Tears Advisory Panel (ISTAP) definition of a skin tear:

“A skin tear is a traumatic wound caused by mechanical forces, including removal of adhesives and patient handling, the depth of which may vary (not extending through the subcutaneous layer)” ⁸

Prevention of skin tears needs to consider three main risk factors including skin, mobility and general health.⁹ In addition to the differences in skin at extremes of age, the presence of dry or fragile skin and history of a previous skin tear are important to note. With regards to mobility a history of falls, impaired mobility, dependence on assistance for ADLs and mechanical trauma are potential risks. In terms of general health, the presence of comorbidities, polypharmacy, impaired cognition and malnutrition are individual risk factors.¹⁰ In addition to mitigating risk factors related to mechanical skin trauma, caregivers’ knowledge, attitudes, and practices, along with the physical environment and healthcare setting, can also play a role in the development of skin tears.¹¹ Educating healthcare professionals is essential if the problem is to be easily recognised and appropriate prevention and treatment measures implemented.^4,12 Even though the dissemination of evidence for skin tear prevention, assessment and management has increased in recent years, some studies show a lack of knowledge among professionals, especially regarding these aspects. This demonstrates the need to improve the educational process in relation to these injuries, both for specialised professionals and for those who deal with patients at risk.¹³

When a skin tear does occur, they require careful management based on principles of wound cleansing, skin tear flap re-approximation, classification of the skin tear and careful dressing selection.

Skin Tear Management

Skin tears are a type of acute wound which should typically heal within 2-3 weeks, however due to factors that can delay wound healing, for example older age, skin fragility, co-morbidities and polypharmacy they may often take much longer to heal.¹¹ Traditionally acute wounds heal by primary intention where the wound edges are approximated using sutures or staples however given the fragility of tissues in those most at risk of skin tears these are not a viable option therefore other methods are needed. The ISTAP have developed a toolkit which includes a decision algorithm for skin tear management, a skin tear classification system and skin tear treatment pathway.¹¹ This resource is designed to help healthcare professionals implement a systematic approach to treating and preventing skin tears.

Immediate management of a skin tear

Control bleeding: Any injury to the skin is associated with bleeding so the first step in managing a skin tear is to facilitate haemostasis to prevent excessive blood loss (Figure 1). Elevating the affected limb, applying gentle pressure and using a dressing with haemostatic properties such as a calcium alginate can help to bring the bleeding under control within about 10 minutes. If bleeding continues despite these interventions urgent medical advice should be sought. Once the bleeding is under control the skin tear should be cleansed to allow an accurate assessment of the injury.¹¹

Figure 1 First aid measure - control bleeding

Consider risk of contamination / infection: Skin tears are an acute traumatic wound and are often associated with falls or knocking a limb on a piece of furniture or equipment, consequently they are at risk of contamination and potentially infection.¹⁴ Therefore, initial management of a skin tear should consider the principles of therapeutic wound and skin cleansing to optimise healing as discussed by the International Wound Infection Institute (IWII)¹⁵ and ideally will include the use of an antiseptic wound cleansing solution due to the risk of contamination.¹⁶ If an antiseptic is not available a solution of normal saline is acceptable but does need to be used in sufficient quantities to be effective. The patient’s tetanus status also needs to be established to ensure their immunisation is up to date.¹¹ If in doubt medical advice should be sought.

Reapproximate skin tear flap: Following wound cleansing the next step is to reapproximate the skin tear flap (if present). In relation to skin tears a ‘flap’ is defined as,

“a portion of the skin (epidermis/dermis) that is unintentionally separated (partially or fully) from its original place due to shear, friction and / or blunt force. This concept is not be confused with tissue that is intentionally detached from its place of origin for therapeutic use e.g. surgical skin grafting”. ¹⁷

Ideally reapproximating the flap should take place as soon as possible after the skin tear has occurred as it is more straightforward to reposition any remaining tissue at this time. Where a skin tear happened a few days previously it may be necessary to moisten the skin tear flap to make it easier to reposition over the wound bed. This can be achieved by applying saline soaked gauze on to the skin tear and allowing it to soak for 10-15 minutes to rehydrate the flap. It is vital to avoid any further trauma so careful application and removal of the gauze is required.

Subsequently reapproximation of the skin tear flap requires very gentle manipulation of the remaining tissue to avoid risk of further trauma. A moistened gloved finger or a moistened cotton-tipped wound swab can be used to carefully ease / roll the flap back into position so that it covers as much of the wound bed as possible.¹⁸ The use of tweezers should be avoided as this could cause damage to the skin tear flap.

Determine viability of the skin tear flap: Concomitantly it is important to determine viability of the skin tear flap which refers to the ability of the separated skin to survive and heal when repositioned over the wound (Figure 2). A viable skin flap should have an adequate blood supply, remain attached to surrounding tissue, and show signs of healthy tissue regeneration.

Figure 2. Assess the skin tear flap for viability

Assessment of flap viability should consider:

• Colour: healthy tissue will have a normal skin tone appearance, whereas a non-viable flap may look pale, dusky or darkened.
• Tissue integrity: the flap should not be excessively macerated or necrotic.

If a flap is non-viable, it may require debridement to prevent infection and promote healing. There are a range of debridement techniques available for wound management which also apply to management of skin tears, ultimately the choice of debridement technique depends on a healthcare professionals’ knowledge, skills and expertise as well as the resources available and healthcare setting.¹⁸

Classification of the skin tear: Classifying a skin tear guides choice of treatment and helps to determine the prevalence / incidence of different types of skin tears. It is only after the skin tear has been cleansed and reapproximated that classification of the injury should take place. The ISTAP skin tear classification system (Figure 3) was initially developed and validated over a decade ago³ and has subsequently undergone international validation across 44 countries.¹⁷

Figure 3. ISTAP Skin Tear Classification System

The classification system is based on the presence / absence of a skin flap and categorises skin tears into three types: Type 1, Type 2 and Type 3. Of note is that Type 1 includes a linear or flap skin tear. The classification system is supported by strong evidence¹⁷ and should be used for systematic assessment and reporting of skin tears in clinical practice and research globally and has been translated into 14 different languages (Table1).

Table 1. ISTAP Classification System Languages

Goals of Treatment: The aim of skin tears management follows the principles of management of other wound types. This includes treating the cause of the skin tear, implementing a skin tear prevention protocol. In terms of local wound management moist wound healing principles comprising debridement, avoiding infection and moisture balance are essential. Protecting the periwound skin and avoiding further trauma are also vital. Patient-centred concerns should also be addressed, this means pain control, assistance with ADLs and ongoing education. Table 2 summarises the principles of management for skin tears.

Table 2. Skin Tear Management Principles (adapted from (11, 20)

Based on the guiding principles for managing skin tears the use of traditional wound closure / sticky bandage strips are not recommended as they are a risk for further trauma. Where these have been used, and their removal is considered necessary, a sterile adhesive remover should be used to remove them. The use of iodine-based dressings is not recommended as this can dry wounds out.²⁰ The use of film, hydrocolloid dressings should also be avoided as the adhesives may contribute to a MARSI and use of gauze could lead to flap displacement.

Special considerations: For individuals with skin tears on the lower limb a vascular assessment should be undertaken (Figure 4). In the absence of significant peripheral arterial disease, the use of compression therapy to support skin tear healing should be considered.²¹

Figure 4. Skin Tear on the Lower Limb

Person-centred care and interprofessional collaboration

It is important to implement person-centred approaches to the management of an individual with a skin tear. For example, ensuring the person is involved in shared and informed decision making as well as providing education so that they feel empowered and engaged with their care. Optimising skin tear healing and prevention of further skins tears also requires good skin care as well as adequate nutrition and hydration.⁸

Creating a multi-disciplinary approach to ensure care is co-ordinated and timely onward referrals are made if needed is also essential for successful outcomes. Documenting the assessment of the patient, the skin tear and recording what management and education has been provided is vital to determine if the skin tear is healing (or not). Of equal importance is ensuring all health and social care providers are educated regarding prevention, assessment and management of skin tears to raise awareness and reduce their occurrence.

Conclusion

Skin tears are acute, traumatic wounds that cause pain and are associated with complications such as infection and delayed healing. Prevention of skin tears is key with education of all health and social care professionals being essential. When a skin tear does occur the guiding principles for managing it include stopping the bleeding, cleansing the wound, reapproximating the skin tear flap, classification using the ISTAP system and choosing a dressing that will not cause trauma to the wound or periwound area on removal. It is also important to manage the patient’s pain, reduce the risk of infection and incorporate strategies to support their activities of daily living.

Conflict of interest

No conflicts to declare

Ethics

Not applicable

Funding

No funding was received for the development of this manuscript.

Author(s)

Samantha Holloway*
RN MSc PGCE
International Skin Tear Advisory Panel (ISTAP) Past President,
Reader and Programme Director, Wound Healing and Tissue Repair
Cardiff University School of Medicine, UK
Email Hollowaysl1@cardiff.ac.uk

Cinthia Viana Bandeira da Silva
RN ETN MSc
ISTAP Regional Director for Latin America
PhD Student, Nursing and Adult Health Graduate Program
School of Nursing, University of Sao Paulo, BrazIl

Karen Ousey
PhD MA PGDE BA RN
ISTAP President
Emeritus Professor of Skin Integrity, University of Huddersfield, UK

* Corresponding author

References

1. Van Tigglelen H & Beeckman D. Skin tears anno 2022: An update on definition, epidemiology, classification, aetiology, prevention and treatment. J Wound Manag . 2022; 23(2): 38-51.
2. Li, Z, Lin, F., Thalib, L., & Chaboyer, W. Global prevalence and incidence of pressure injuries in hospitalised adult patients: a systematic review and meta-analysis. International Journal of Nursing Studies. 2020;105.
3. LeBlanc K, Baranoski S, Christensen D, Langemo D, Sammon MA, Edwards K, et al. International Skin Tear Advisory Panel: A Tool Kit to Aid in the Prevention, Assessment, and Treatment of Skin Tears Using a Simplified Classification System: ©. Advances in Skin & Wound Care. 2013;26(10):459-76.
4. Cilluffo S, Bassola B, Beeckman D & Lusignani M. Risk of skin tears associated with nursing interventions: A systematic review. J Tissue Viability. 2023;32(1):120–9.
5. Kar S, Jarain VZL, Karmakar S, Devi U, Som TK, Mohanty PK, et al. Quality improvement initiative to reduce Medical Adhesive Related Skin injury (MARSI) in very preterm babies admitted to neonatal intensive care unit. BMJ Open Qual. 2024;13(Suppl 1).
6. Oranges T, Dini V & Romanelli M. Skin Physiology of the Neonate and Infant: Clinical Implications. Adv Wound Care (New Rochelle). 2015;4(10):587–95.
7. Dyer JM & Miller RA. Chronic Skin Fragility of Aging: Current Concepts in the Pathogenesis, Recognition, and Management of Dermatoporosis. J Clin Aesthet Dermatol. 2018;11(1):13–8.
8. Nokaneng et al. Best practice recommendations for the prevention and management of skin tears in aged skin. Wounds International 2025.
9. Woo K & LeBlanc K. Prevalence of skin tears among the elderly living in Canada in long-term care facilities. Canadian Association of Wound Care. 2014; 11. Toronto: CAWC.
10. LeBlanc K. Skin tear prevalence, incidence and associated risk factors in the long-term care population. 2017. Available online at: https://qspace.library.queensu.ca/handle/1974/22678
11. LeBlanc K, Campbell KE, Wood E & Beeckman D. Best Practice Recommendations for Prevention and Management of Skin Tears in Aged Skin: An Overview. JOWCN. 2018;45(6):540–2.
12. Campos H H, da Silva C V B, Takahashi J, de Almeida Cardoso M M, Mazzachiodi L R, Woo K & de Gouveia Santos V L C. Educational Interventions to Improve Knowledge Among Nurses in the Prevention of Skin Tears in Hospitalised Adults and Older Adults: A Scoping Review. International Wound Journal, 2025; 22(5), e70240. https://doi.org/10.1111/iwj.70240
13. Silva C V B D, Beeckman D & Santos V L C G. Nurses’ knowledge of skin tears: A cross-sectional survey study across four hospitals in São Paulo, Brazil. Journal of Tissue Viability, 2025; 34(2), 100874. https://doi.org/10.1016/j.jtv.2025.100874 12.
14. LeBlanc K, et al. Prevalence of skin tears in a long-term care facility. JWOCN. 2013;40(6):580–584.
15. International Wound Infection Institute. Therapeutic wound and skin cleansing: Clinical evidence and recommendations. Wounds International. 2025.
16. Nair HK et al. International Consensus Document: Use of wound antiseptics in practice. Wounds International. 2023.
17. Van Tiggelen H, Van Damme N, Theys S, Vanheyste E, Verhaeghe S, LeBlanc K, et al. The prevalence and associated factors of skin tears in Belgian nursing homes: A cross-sectional observational study. Journal of Tissue Viability. 2019;28(2):100–6.
18. Holloway S, LeBlanc K. Reapproximating a Skin Tear Flap. Adv Skin Wound Care. 2022;35(8):462–3.
19. Mayer DO, Tettelbach WH, Ciprandi G, Downie F, Hampton J, Hodgson H, et al. Best practice for wound debridement. J Wound Care. 2024;33(Sup6b):S1–s32.
20. LeBlanc K, Baranoski S, Christensen D, Langemo D, Edwards K, Holloway S, et al. The Art of Dressing Selection: A Consensus Statement on Skin Tears and Best Practice. Adv Skin Wound Care. 2016;29(1):32–46.
21. Wounds UK  Best Practice Statement: Management of lower limb skin tears in adults. 2020.