Yikes, a skin tear!

In my last post, I discussed preventative care for fragile skin. But even with extra care, skin tears happen. Healthy skin stretches when bumped or pulled. Fragile skin rips open. This is especially common on the forearms and calves. We managed many skin tears in our clinic. In fact, we had a ready to go skincare equipment tray.

There’s a right way and a wrong way to manage a skin tear. This post will cover both. We saw skin tears managed the wrong way all too often. When a skin tear isn’t managed correctly it doesn’t heal well. Pain persists and the skin grows back weaker.

Ouch! But don’t use an adhesive bandage.

It's a normal reaction to put an adhesive bandage on a skin injury. Bandages are comforting for children but problematic when used on fragile skin. Children usually have healthy skin, and the bandage comes off easily. But when skin is thin and weak, the adhesive on a bandage will pull the skin off. In some patients, just pulling the tape off after a blood draw results in a skin tear. Problems due to bandages are so common that there’s a medical term used for this: MARSI (Medical Adhesive-Related Skin Injury). MARSI doesn’t mean just skin tears however. Adhesive bandages can also cause irritation and dermatitis on unhealthy skin.

Patients often came into our clinic with bandages on skin tears. This is what we do to remove the bandage:

Apply a generous amount of bandage adhesive remover on the bandage and surrounding skin. The adhesive remover is available as a liquid, spray, or wipe. DO NOT USE ALCOHOL OR ALCOHOL WIPES TO REMOVE BANDAGES OFF SKIN TEARS.

Allow the adhesive remover to soak in thoroughly. This could take as long as 10 minutes. Hairy skin tends to stick more.

Determine the direction of the skin tear. The bandage should be peeled from the strong side first. That way, there is less likelihood of pulling the skin off. Use a two-handed approach. Push the undamaged skin down with a finger as you start peeling the edge of the bandage off using the other hand. Do not rip off or pull straight up on a bandage. Instead go “low and slow”, gently peeling the bandage off. Avoid pulling at hairs.

Management of skin tears

Skin tears should be managed promptly for good healing. Tears which are bleeding heavily, larger than one inch, or down into muscle are more serious. Get medical attention for these tears.

Supplies

A large towel to keep the area clean
Mild liquid soap and warm water (sterile water is seldom needed)
Clean wash cloth (2)
Paper towels (soft)
Q tips
Squirt bottle with warm water
Antibiotic ointment such as Bacitracin
Non adherent dressing (no tape)
Net or self-adhesive bandage
Paper or “sensitive skin” tape if needed.

Stop the bleeding first

Do not use dry dressings on bleeding skin. The blood is sticky and will pull on the fibers of the dressing. Instead, soak a washcloth in mild liquid soap and warm water. Wring out excess water but keep the cloth slightly damp. Apply the cloth to the bleeding area using your whole hand to provide even pressure. Do not press with just a finger. If blood soaks through, add another washcloth on top. Do not remove the first washcloth. Elevate the extremity if the bleeding is on the arm or leg. Remove the washcloth when the bleeding has stopped.

Clean the wound

This can be done by gently squirting slightly soapy warm water. Then rinse off with just water. A Q-tip can be used to remove any foreign material or dead skin. Do not poke at the skin tear. After you have cleaned the wound, briefly drape and pat the entire area with a soft dry paper towel. Then lift the towel off to remove excess water.

Skin flaps

Flaps of skin that are still attached have good blood flow. The flap can help tissue heal if the skin tear is recent. The flap frequently shrinks. Apply a little antibiotic ointment to the area to help the flap slide back into place. Use a Q-tip to nudge the skin flap back into approximate position. The skin flap should NOT have rolled over edges. Instead, the flap should be as flat as possible  and without creases, just like a bedsheet on a mattress.

Apply dressing.

Use more antibiotic ointment to cover the entire area for the dressing. This will keep the dressing from sticking anywhere on the skin. Then, apply the nonadherent dressing. Use stretch netting or a self-adhesive bandage to hold the dressing in place. The goal is to avoid using any adhesive on the skin. A long clean elastic sock with the foot cut off can also hold a dressing in place. Using two socks holds it tighter.

For locations such as the back or buttocks, adhesive tape is needed to hold the dressing in place. Use paper tape or “sensitive skin” tape. These tapes are not as sticky. But they will hold a dressing in place if the tape covers the entire dressing and surrounding skin.

Avoid the temptation to remove a dressing too soon. Skin tears can take more than a week to heal. Only remove a dressing if it has soaked through. Even then, be sure to use adhesive remover.

Signs of infection

An increase in pain, redness or heat around a skin tear are signs of inflammation. These findings, or an increase in drainage, may be signs of infection. Seek medical attention under these conditions.

Avoid using the following products on skin tears

Povidone-iodine should be avoided on skin tears. It dries the skin out. It is also sticky and bandages do not come off easily.

Avoid plain gauze pads. Threads from the gauze stick to the wound. Instead, look for dressings that are labeled "non-adherent" or "non-stick".

Wound closure strips are best used for straight lacerations, not skin tears. When used on skin tears the strips pull in different directions and can pull the skin off.

The following link has more information on how to manage skin tears. Just a caution, the photos show some major skin tears.

Warmest Aloha,

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PS: I say it over and over again: There's no one more important than the caregiver in the daily life of a frail person.