From the Guidelines
Skin tears are classified using the Payne-Martin or STAR (Skin Tear Audit Research) classification systems, with management focused on preserving the skin flap and promoting healing. However, the provided evidence does not directly address skin tear classification or management, as it focuses on the management of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) [ 1 ].
Classification and Management
Despite the lack of direct evidence, the general approach to skin tear management can be inferred from wound care principles. For treatment,
- first clean the wound gently with normal saline or water,
- then if a skin flap is present, reposition it over the wound bed using a moist cotton swab or sterile forceps.
- Apply a non-adherent, silicone-based dressing that can remain in place for several days to minimize trauma during dressing changes.
- Hydrogel, foam, or transparent film dressings are appropriate options depending on wound characteristics.
- Avoid adhesive products directly on fragile skin and use paper tape or silicone tape when necessary.
Prevention and Healing
Preventive measures include
- keeping skin well-hydrated with emollients,
- using proper lifting techniques to avoid shearing forces,
- padding furniture edges, and
- removing environmental hazards. Nutritional support with adequate protein, vitamin C, and zinc intake promotes healing [ 1 ]. Skin tears typically heal within 7-21 days with proper care, but may take longer in elderly patients or those with compromised circulation or diabetes. Documentation should include the tear's location, size, presence of skin flap, and classification to track healing progress.
Wound Care
In the context of wound care, as seen in the management of SJS/TEN,
- employing strict barrier nursing to reduce nosocomial infections [ 1 ],
- taking swabs for bacterial and candidal culture from lesional skin [ 1 ], and
- administering systemic antibiotics only if there are clinical signs of infection [ 1 ] are crucial. These principles can be applied to the management of skin tears, focusing on preventing infection and promoting a conducive environment for healing.
From the Research
Skin Tear Classification
- The Payne-Martin Classification System is a commonly used system for classifying skin tears, which categorizes them into three types: Type I, Type II, and Type III 2, 3.
- Type I skin tears are characterized by a partial-thickness wound, while Type II skin tears are full-thickness wounds, and Type III skin tears are characterized by a complete loss of skin 3.
- The International Skin Tear Advisory Panel (ISTAP) Classification System is another system that has been validated and tested for its reliability and validity in classifying skin tears 4.
- The ISTAP Classification System consists of three skin tear types and includes a definition for the concept of a 'skin flap' in the area of skin tears 4.
Management of Skin Tears
- The management of skin tears involves identification and assessment, classification and differentiation, and treatment 2.
- A Web-based educational program has been shown to be effective in improving nurses' knowledge regarding skin tear identification and assessment, classification and differentiation, and treatment 2.
- The use of a standardized classification system, such as the ISTAP Classification System, can help to standardize documentation and description of skin tears in clinical practice and research 4.
- Accurate classification and documentation of skin tears are essential for proper treatment and prevention of further complications 3, 4.