Prevention of medical adhesive-related skin injury during patient care: A scoping review

Abstract

Background

: Medical adhesive-related skin injury can occur during health care. Professionals must adopt preventive measures to maintain the integrity of the skin and patient comfort and safety.

Objective

: To map the existing scientific evidence on preventing medical adhesive-related skin injury in adults.

Design

: Scoping Review.

Methods

: Searches were conducted in PubMed/Medline, Cochrane Library, Embase®, Latin American and Caribbean Literature in Health Sciences, Cumulative Index for Nursing and Allied Health Literature, and Google Scholar, without period delimitation. Duplicate studies and those that didn´t answer the research question were excluded.

Results

: Of the 209 studies identified in the search process, 30 made up the final sample. The prevention of injury by adhesives mainly involves identifying risk factors, proper adhesive selection, and correct application and removal. Health education and medical records about injuries related to medical adhesives are essential.

Conclusions

: The prevention of medical adhesive-related skin injury should be done by adopting multifactorial measures, which range from identifying risk factors and correct handling of adhesives to the process of educating professionals, patients and communities about these injuries.

Registration

: The research was registered on the Open Science Framework DOI 10.17605/OSF.IO/NSWP8.

What is already known

• •Medical adhesive-related skin injuries can occur in any health service.
• •It is necessary to invest in preventive measures and good clinical nursing practices based on evidence to reduce the incidence of medical adhesive-related skin injuries.

What this paper adds

• •The prevention of medical adhesive-related skin injuries involves knowledge and awareness of professionals and patients about these lesions; daily skin care; choice and proper use of adhesives; identification of risk factors for these injuries; application of barriers between the skin and adhesives; and recording of lesions in medical records to monitor the condition.
• •This review identified the need to create and validate a measurement instrument capable of assisting health professionals in preventing, identifying, and treating medical adhesive-related skin injuries.

1. Background

Medical adhesive-related skin injuries are lesions that remain for 30 min or more after removing adhesives. They can be of mechanical origin (skin stripping; tension injuries or blisters; skin tears), dermatitis (irritant contact dermatitis; allergic contact dermatitis), and others (maceration; folliculitis).

Skin stripping occurs when the stratum corneum layers are removed with the adhesive. Tension injuries include blisters and skin tears (McNichol et al., 2013).

Irritant contact dermatitis occurs when chemicals or other physical irritants contact the skin. The initial reaction is restricted to the area of tissue directly exposed to the product, and subjective symptoms such as burning and stinging may be present. Well-delimited erythema, superficial edema, and in more severe cases, vesicles, blisters, erosions and necrosis are visible (Klaus Wolff et al., 2017).

Allergic contact dermatitis is an inflammatory process triggered by immune system cells after skin contact with the allergen to which the individual has been sensitized. Skin rashes may occur 48 h, or even days, after contact with the allergen, and reactions worsen the greater the exposure. There is intense itching, and in more severe cases, there is a sensation of stinging and pain. The skin may present changes such as erythema, edema, papules or vesicles. Blisters, erosions, serum exudate, and crusting appear in the most severe reactions. Initially, the lesions are well delimited to the area of contact with the allergen; then, they may affect adjacent areas. Lesions tend to disappear in one to two weeks (Klaus Wolff et al., 2017).

Macerations result from the accumulation of moisture under the adhesives and make the skin softer, white or gray, and with wrinkles. In this state, the skin is susceptible to other injuries, and its permeability increases making it more susceptible to skin irritants. Folliculitis results from the trapping of bacteria and hair, with small areas of inflammation surrounding the hair follicle, and papules and pustules may be present (McNichol et al., 2013).

Skin injury due to adhesives is underestimated and underreported. Hospitalized patients are at high risk of developing them due to daily exposure to adhesives in fixation of dressings, drains, probes, and catheters, or by the use of electrodes. In addition, they are also subject to situations that increase the skin's vulnerability, such as fasting, loss of fluid volume, and topical use of products that are aggressive to the skin (Ferreira et al., 2017).

Extremes of age and skin diseases are important risk factors for these lesions. Aging causes changes in skin structure, such as increased water loss and decreased elasticity, thickness, resistance and collagen synthesis, especially after 75 years of age (Vieira et al., 2020). As an aggravating factor, women after menopause have weakened skin due to decreased estrogen levels, because this hormone is related to intercellular connections, thickness, and skin elasticity (Quan et al., 2018).

Skin disorders associated with increased fragility for example epidermolysis bullosa, atopic dermatitis, and psoriasis (Klaus Wolff et al.,2017) make the skin more vulnerable to adhesive injury.

Medical adhesive-related skin injury prevalence varies according to the population and risk factors. In patients in an intensive care unit, the prevalence ranged from 3.4% to 25%, with a daily mean of 13% (Farris et al., 2015). In older people who were in long-term care, the prevalence was 15.4% (Konya et al., 2010). In ostomized patients, the incidence of skin lesions exceeded 77% (Malik et al., 2018).

Preventing medical adhesive-related skin injury can avoid pain and discomfort generated in patients, reduce additional costs to the health system, and minimize the length of hospitalizations (Jones et al., 2018). It is necessary to seek literature on the prevention of medical adhesive-related skin injury to support clinical protocols and guide professionals in clinical practice based on scientific evidence. Thus, the present scoping review aimed to map existing scientific evidence on preventing skin lesions related to medical adhesives in adults.

2. Methods

This scoping review was conducted according to the Manual for Evidence Synthesis (Peters et al., 2020), prepared by the Joanna Briggs Institute. Initially, the research was filed on the Open Science Framework platform with the title "Prevention of medical adhesive-related skin injuries in adults: a scoping review." Research information can be accessed at DOI 10.17605/OSF.IO/NSWP8.

The PCC strategy (population, concept, context) was used to elaborate the research question, defining P - adults; C - prevention of medical adhesive-related skin injury; C - use of medical adhesives. Thus, the research question was: "What evidence is available about the forms of prevention of medical adhesive-related skin injury in adults who use medical adhesives?"

The searches were carried out in March 2021 in the databases PubMed/Medline, Cochrane Library, Embase®, Latin American and Caribbean Literature in Health Sciences, Cumulative Index for Nursing and Allied Health Literature, in addition to the Google Scholar search tool. All were accessed through the Portal CAPES, Federated Academic Community, to access the most significant number of publications using the University login.

All study types and methods, including gray (unpublished) literature, published in all languages, without time delimitation, were considered. Duplicate studies in the databases and those that did not present forms of prevention of medical adhesive-related skin injury in adults were excluded.

To perform the searches, the descriptors indexed in the Medical Subject Headings (MeSH) were identified and converted to the standard descriptor used in each database. The search strategy performed was:

- PubMed/Medline (MeSH terms): (“Tissue Adhesives”[Mesh] OR “Surgical Tape”[Mesh]) AND “adverse effects” [Subheading] AND “Skin”[Mesh];

- Embase (Emtree): ('tissue adhesive'/exp OR 'surgical tape'/exp) AND 'adverse event'/exp AND 'skin'/exp;

- Cochrane Library (Medical terms): (“Tissue Adhesives” OR “Surgical Tape”) AND “adverse effects” AND “Skin”;

- Lilacs (DeCS): (“Adesivos Teciduais” OR “Fita Cirúrgica”) AND “Pele”;

- CINAHL (Subject Headings): (“Tissue Adhesives” OR “Surgical Tape”) AND “Adverse Health Care Event” AND Skin;

- Google Scholar (MeSH terms): “Tissue Adhesives” “Surgical Tape” “adverse effects” “Skin”.

All searches were carried out in a single day by two researchers, one with a master's degree and one with a PhD, independently. The studies found were exported to EndNote Web, an online version of the reference manager, to identify and exclude duplicate studies.

The other studies were exported to the Rayyan QCRIA application, which allowed the second identification and exclusion of duplicate reports, followed by an independent evaluation by two reviewers of all titles and abstracts of the references found in the different databases to select the articles that met the eligibility criteria. After a consensus meeting, two independent reviewers read all the eligible studies. The reference list of selected studies was hand-searched to include additional studies that met the inclusion criteria and were not identified in previous searches.

Data extraction was performed according to the template proposed by the Joanna Briggs Institute, composed of the following information: authorship, year of publication, the country where the study was carried out, objectives, population and sample size, method, type and duration of the intervention, results, and main findings related to the prevention of medical adhesive-related skin injury.

The classification of the level of evidence was performed as proposed by Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009) — center for Evidence-Based Medicine, University of Oxford, n.d.). In this system, studies on therapy / prevention, etiology / harm, receive the following classification:

• •1A- Systematic review (with homogeneity) of randomized clinical trials
• •1B- Individual randomized clinical trial (with narrow confidence interval)
• •1C- All or none
• •2A- Systematic review (with homogeneity) of cohort studies
• •2B- Individual cohort study (including low quality randomized clinical trials; e.g., <80% follow-up)
• •2C- “Outcomes” research; ecological studies
• •3A- Systematic review (with homogeneity) of case-control studies
• •3B- Individual case-control study
• •4- Case-series (and poor quality cohort and case-control studies)
• •5- Expert opinion without explicit critical appraisal, or based on physiology, bench research or “first principles”

According to the classifications, the studies receive different degrees of recommendation, with "A" being the most recommended and “D” being the lowest degree of recommendation.

• •consistent level 1 studies
• •B- consistent level 2 or 3 studies or extrapolations from level 1 studies
• •C- level 4 studies or extrapolations from level 2 or 3 studies
• •D- level 5 evidence or troublingly inconsistent or inconclusive studies of any level

It is emphasized that "Extrapolations" are where the data are used in a situation that has potentially clinically important differences from the original situation of the study.

To present the results, included studies were characterized descriptively with the main information (year, authorship, method, objectives, and forms of prevention of medical adhesive-related skin injury). The evidence was grouped and described in categories.

3. Results

Of the 209 results identified in the initial searches, a final sample of 30 was obtained, as described in Fig. 1.

Fig. 1.

PRISMA -ScR flow diagram.

There has been an increase in publications on adhesives and medical adhesive-related skin injury prevention in recent years. Among the publications identified, up to 2007, there was one or no publication on the subject. In 2016 and 2019, the highest rates were recorded, with four studies published each year, as shown in Graph 1.

Graph 1.

Publications on prevention of medical adhesive-related skin injury over the years.

The included studies are described in Table 1.

Table 1.

- Characterization of the studies.

Authorship	Year	Country	Language	Level of Evidence†
Santos, A.S. et al.	2019	Brazil	English/ Portuguese	1A
Landsperger, J. S. et al.	2019	USA	English	1B
Chan, R. J. et al.	2017	Australia	English	1B
Waring, M. et al.	2012	United Kingdom and Germany	English	1B
Salem, M. A.	2010	Egypt	English	1B
Shannon, R. J. & Chakravarthy, D.	2009	USA	English	1B
Murahata, R. I. et al.	2008	USA	English	1B
Zillmer, R. et al.	2006	Denmark	English	1B
Cosker, T. et al.	2005	United Kingdom	English	1B
Marks, R., Evans, E. & Clarke, T. K.	1978	Wales	English	1B
Liu, L.	2016	Canada	English	2B
Barton, A.	2020	United Kingdom	English	4
Collier, M.	2019	United Kingdom	English	4
Hitchcock, J. & Savine, L.	2017	England	English	4
Liu, Y. et al.	2012	USA	English	4
Fumarola, S. et al.	2020	United Kingdom	English	5
Tielemans, C. & Voegeli, D.	2019	–	English	5
Hill, S. & Moureau, N. L.	2019	Switzerland	English	5
Jones, M. l.	2017	–	English	5
McNichol, L. & Bianchi, J.	2016	–	English	5
Hunt, S.	2016	–	English	5
3M	2016	United Kingdom	English	5
McNichol, L. et al.	2013	USA	English	5
Dobby, N. & Martin, R.	2011	United Kingdom	English	5
LeBlanc, K. & Baranoski, S.	2011	–	English	5
Morgan, J. E.	1981	USA	English	5
Bryant, R. A.	1988	–	English	5
Stephen-Haynes, J.	2008	United Kingdom	English	–
Cutting K. F.	2008	United Kingdom	English	–
Roberts, M. J.	2007	USA	English	–

^†Oxford center for Evidence-Based Medicine: Levels of Evidence (March 2009) — center for Evidence-Based Medicine, University of Oxford, n.d.).

The forms of prevention of medical adhesive-related skin injury are summarized in Table 2.

Table 2.

– Prevention of medical adhesive-related skin injury.

Authorship/ year	Objective	Method	MARSI† prevention
Santos, A.S. et al./ 2019	Compare the effectiveness and safety of silicone tape and microporous tape in patients with fragile skin.	Systematic review and meta-analysis	Silicone tape can be softer for the skin than microporous tape. However, studies with greater methodological rigor are needed to prove the advantage of silicone tape over microporous in preventing MARSI.
Landsperger, J. S et al./ 2019	Compare the effect of adhesive tape and endotracheal tube fixator in the occurrence of adverse events: lip ulcers, facial skin lesions; endotracheal tube dislodgement; and ventilator-associated pneumonia in adults.	Randomized clinical trial	Endotracheal tube fixators reduced the incidence of lip ulcers, facial skin lesions and endotracheal tube dislodgement compared to the use of adhesive tape.
Chan, R. J. et al./ 2017	Compare standard treatment with three dressings and fixation methods for peripherally inserted central catheters in adult patients.	Randomized clinical trial	The use of polyurethane with absorbent lattice pad dressings and non-woven adhesive tape resulted in less frequency of MARSI (skin rashes, blisters, itching, lacerations and bruising) after removing the dressing, when compared to the following dressings: combination securement-dressings; standard polyurethane dressings; sutureless securement devices; and tissue adhesives.
Waring et al., 2012	Compare skin damage caused by dressings with different types of adhesives after repeated application and removal.	Randomized clinical trial	The adhesives that caused the most damage to the skin were Biatain and Comfeel Plus, followed by Versiva XC, Adhesive Allevyn, and trio Urgotul. The Mepilex Border adhesive did the least damage to the skin.
Salem, M. A./ 2010	Investigate role and effectiveness of hypoallergenic tape in preventing injury to peri-wound skin after hip surgery.	Randomized clinical trial	Hypoallergenic tape associated with appropriate techniques for applying and removing the adhesive significantly decreased the occurrence of MARSI in postoperative dressings after hip surgery.
Shannon, R. J. & Chakravarthy, D/ 2009	Compare a solvent-free barrier film formulation with a solvent-containing formulation to protect the skin from MARSI.	Randomized clinical trial	Solvent-free barrier film was more efficient and more economical to prevent loss of skin barrier function and erythema caused by adhesive tape removal, when compared to the solvent barrier.
Murahata, R. I. et al./ 2008	Determine discomfort and damage to the skin by using adhesive barriers.	Randomized clinical trial	Amorphous gel adhesive caused less discomfort and damage to the skin's barrier function when compared to commercial hydrocolloid adhesives based on polyisobutylene.
Zillmer, R. et al./ 2006	To evaluate the effect of repetitive removal of four adhesive dressings on peri-ulcer skin and intact skin in patients with healed or open venous leg ulcers.	Randomized clinical trial	Hydrocolloid adhesives promoted functional changes in the stratum corneum, making it more hydrated and vital and, consequently, reducing the risk of occurrence of MARSI.
Cosker, T. et al./ 2005	To investigate the effect of three postoperative dressings on the healing of orthopedic wounds	Randomized clinical trial	There was a drop in the incidence of blisters with the application of OpSite Post-Op. Incorrect dressing selection led to increased blistering and wound secretion rates.
Marks, R., Evans, E. & Clarke, T. K./ 1978	Compare the irritating effect of seven adhesive plasters for ostomies on normal skin when removed daily and weekly.	Randomized clinical trial	The results confirmed the low degree of irritation produced by ‘Stomahesive’ and showed that daily removal of this adhesive did not produce greater irritation than weekly removal. The most irritating adhesives were the Transle Ring and Hollister Adhesive Stoma Bag.
Liu,L./ 2016	Develop a colorimetric resistant hydrogel with pH indication for smart dressings and perform quantitative analysis on the performance of the adhesive, including peeling resistance, reuse, and durability.	Thesis/ Randomized clinical trial	The commercial adhesives that showed the greatest adhesion strength, were: Acrylic Pad®, Band-Aid®, Clear Surgical Tape®, Nexcare Sensitive Skin Tape®.
Barton, A./ 2020	Describe the use of a sterile adhesive remover to remove vascular access dressings in four patients.	Case study	With the use of the adhesive remover, the four patients did not develop MARSI.
Collier, M./ 2019	Describe the effects of an adhesive remover on decreasing pain and MARSI in vulnerable patients.	Case study	The use of the adhesive remover prevented pain and MARSI and, consequently, reduced the risk of infection.
Hitchcock, J. & Savine, L./ 2017	Address the integrity of the ideal skin through case studies, and describe the implementation of an algorithm as a tool to manage cases of impaired skin integrity and protection of vascular access devices.	Case study	Changing practice is the key to the prevention of MARSI, through the education of professionals and patients, time for changing, and choosing the appropriate dressing and skin care before applying the dressing.
Liu, Y. et al./ 2012	Report two cases of skin avulsion injury after use of Iodophor-impregnated adhesive drapes during total knee arthroplasty.	Case study	The identification of patients at potential risk for MARSI is essential to prevent complications after the use of adhesive surgical drapes. The Adson forceps can be used to gently remove the adhesive drapes, avoiding skin damage.
Fumarola, S. et al./ 2020	Define MARSI, its implications for health, risk factors, and preventive measures.	Specialist consensus	To prevent MARSI, it is necessary to evaluate the skin; identify risk factors; use adhesives only when necessary; use barrier protectors and adhesive removers; use correct application and removal techniques; and maintain skin care and effective communication with health teams.
Tielemans, C. & Voegeli, D./ 2019	To present the advantages of using a silicone-based adhesive remover to prevent peristomal skin lesions.	Specialist opinion	Adhesive removers reduce trauma to the skin when removing stoma devices. Silicone-based removers should be the first choice.
Hill, S. & Moureau, N. L/ 2019	Describe the role of protection in vascular access, risk factors for complications related to inadequate protection of devices, and practices that prevent risks and improve safety.	Book chapter	To prevent MARSI at catheter insertion sites, it is necessary to evaluate the skin with each dressing change; identify potential risks; apply barrier protections; avoid moisture; use correct adhesive application and removal techniques; and maintain adequate nutrition and hydration.
Jones, M.l./ 2017	Present the risk factors and how to prevent skin tears.	Editorial	The prevention of MARSI begins at admission through the identification of patients at risk and is maintained in the institutional routine through skin assessment and care, as well as adequate fluid and nutritional intake, and use of barrier protectors, tubular dressings and adhesive removers.
McNichol, L. & Bianchi, J./ 2016	Describe MARSI, risk factors, and forms of prevention.	Specialist opinion	The identification of risks helps to choose the appropriate adhesive for each patient. Education on skin preparation, and selection, application and removal of adhesives, also prevents MARSI.
Hunt, S./ 2016	Describe intrinsic and extrinsic factors that compromise skin integrity and measures that promote skin safety.	Specialist opinion	Measures to prevent MARSI are: holistic and individualized assessment of patients; identification of risk factors; following manufacturers' recommendations regarding the use of adhesives; use of appropriate barrier and cleaning products; and patient involvement in care; and promotion of educational actions on MARSI for professionals.
3 M/ 2016	Characterize MARSI and address the forms of prevention through the presentation of products.	Information pamphlet	The four basic steps for the prevention of MARSI are: selection of the appropriate adhesive; proper skin preparation; and correctly applying and removing the adhesive.
McNichol, Liu et al., 2013	To determine a consensus on the assessment, prevention, and treatment of medical adhesive–related skin injury.	Specialist consensus	To prevent MARSI, it is necessary to adapt the choice of adhesive to the patient's conditions and needs; evaluate the skin daily; investigate allergy history; obtain additional information from manufacturers; identify patients at risk for MARSI; use soft adhesives, barriers and adhesive removers; maintain skin care, good nutrition and hydration; consider Langer Lines when applying adhesives; avoid the use of adhesion agents or binders; properly apply and remove adhesives; and store products properly.
Dobby, N. &
Martin, R./ 2011	To report methods for using electrocardiogram electrodes in patients with epidermolysis bullosa without damaging the skin.	Answer letter	Fixing electrodes with bandages or gauze moistened with conductive gel and the use of adhesive removers are methods that can prevent MARSI in patients with epidermolysis bullosa.
LeBlanc, K. & Baranoski, S./ 2011	Initiate a global discussion and develop statements on the prevention, prediction, assessment and treatment of skin lesions.	Specialist consensus	Skin tears can be prevented by maintaining skin care; standardization of care; care for the environment; identification of risk factors; and education of professional caregivers and patients. It is necessary to develop and validate instruments capable of identifying risks and classifying these injuries accurately.
Morgan, J.E./ 1981	Present the history of medical tapes, their adhesive properties, and their effects on the skin.	Specialist opinion	Acrylate surgical adhesives are less sticky than rubber-based ones, but promote less skin irritation.
Bryant, R. A./ 1988	Describe adhesive injuries and prevention.	Specialist opinion	Specific preventive measures for dermatitis, blisters, maceration, folliculitis and skin stripping related to the use of adhesives must be adopted.
Stephen-Haynes, J./ 2008	Address general aspects of the skin and the importance of maintaining the integrity of the skin during wound care and stomas.	Narrative review	Ostomy bags with hydrocolloid base and the use of silicone-based adhesive remover reduces MARSI peristome.
Cutting K.F/ 2008	Describe risk factors, forms of prevention, and the impact of MARSI on patients.	Narrative review	The identification of risk groups, adequate choice of adhesives, and monitoring of skin condition are essential to avoid MARSI.
Roberts, M. J./ 2007	Present the definitions and classification of skin tears and the clinical evidence related to the prevention and management of these injuries.	Narrative review	To prevent skin tears by adhesives, groups at risk for these injuries must be identified. Adhesive removers should be used, followed by gentle skin cleansing. If the injury has already occurred, the use of film dressings should be avoided so as not to aggravate the injury.

^†Medical adhesive-related skin injury.

The literature shows different approaches to preventing medical adhesive-related skin injury, grouped into the categories described in Table 3.

Table 3.

– Categories and subcategories for prevention of medical adhesive-related skin injury.

Medical adhesive-related skin injury prevention categories	Subcategories
Prediction of MARSI† occurrence	Identification of risk factors (Bryant, 1988; Cutting, 2008; Fumarola et al., 2020; Hill and Moureau,2019; Hunt, 2016; Jones, 2017; LeBlanc and Baranoski, 2011; (Liu et al., 2013); McNichol et al., 2013; McNichol and Bianchi, 2016; Morgan, 1981; Roberts, 2007)
	Evaluation of skin condition (3 M, 2016; Cutting, 2008; Fumarola et al., 2020; Hill and Moureau, 2019; Hunt, 2016; Jones, 2017; McNichol et al., 2013; McNichol and Bianchi, 2016)
	Need to create validated instruments (Hunt, 2016; LeBlanc and Baranoski, 2011; McNichol et al., 2013)
Skin care	Skin care routines (Fumarola et al., 2020; Hunt, 2016; Jones, 2017; LeBlanc and Baranoski, 2011; McNichol et al., 2013)
	Suitable cleaning products&(Fumarola et al., 2020; Hunt, 2016; Jones, 2017,LeBlanc and Baranoski, 2011, 2011; Roberts, 2007)
	Adequate nutrition and hydration (Hill and Moureau, 2019; Hunt, 2016; Jones, 2017; LeBlanc and Baranoski, 2011; McNichol et al., 2013)
	Rotation of application areas/fixation of adhesives (Bryant, 1988)
Adhesives	More aggressive skin adhesives (3 M, 2016; Bryant, 1988; Chan et al., 2017; Cosker et al., 2005; Cutting, 2008; Fumarola et al., 2020; Hill and Moureau, 2019; Hunt, 2016; Landsperger et al., 2019; Liu,2016; Marks et al., 1978; McNichol et al., 2013; Morgan, 1981; Murahata et al., 2008; Santos et al., 2019; Waring et al., 2013)
	Less aggressive skin adhesives (3 M, 2016; Chan et al., 2017; Cosker et al., 2005; Cutting, 2008; Fumarola et al., 2020; Hill and Moureau, 2019; Hunt, 2016; Marks et al., 1978; McNichol et al., 2013; Morgan, 1981; Murahata et al., 2008; Salem et al., 2010; Santos et al., 2019; Stephen-Haynes, 2008; Waring et al., 2013; Zillmer et al., 2006)
	Following manufacturers' recommendations (3 M, 2016; Collier, 2019; Fumarola et al., 2020; Hunt, 2016; McNichol et al., 2013)
	Proper choice of adhesive (3 M, 2016; Bryant, 1988; Cosker et al., 2005; Cutting, 2008; Fumarola et al., 2020; Hill and Moureau, 2019; Hitchcock and Savine, 2017; Hunt, 2016; LeBlanc and Baranoski, 2011; Marks et al., 1978; McNichol et al., 2013; McNichol and Bianchi, 2016; Roberts, 2007; Tielemans and Voegeli, 2019)
	Change frequency (Barton, 2020; Bryant, 1988; Hill and Moureau, 2019; Hitchcock and Savine, 2017; Hunt, 2016; Tielemans and Voegeli, 2019)
Barrier use	Physical barriers (Bryant, 1988; Dobby and Martin, 2011)
	Barrier films (3 M, 2016; Barton, 2020, 2020; Bryant, 1988; Hill and Moureau, 2019; Hitchcock and Savine, 2017; Hunt, 2016; Jones, 2017; McNichol et al., 2013; McNichol and Bianchi, 2016; Shannon and Chakravarthy, 2009)
Adhesive application	Proper skin preparation (3 M, 2016; Bryant, 1988; Hill and Moureau, 2019; Hitchcock and Savine, 2017; Liu et al., 2012)
	Correct technique of applying the adhesive (3 M, 2016; Bryant, 1988; Fumarola et al., 2020; Hill and Moureau, 2019; McNichol et al., 2013; McNichol and Bianchi, 2016; Salem et al., 2010)
Adhesive removal	Correct technique of removing the adhesive (3 M, 2016; Bryant, 1988; Fumarola et al., 2020; Hill and Moureau, 2019; Liu et al., 2012; McNichol et al., 2013; McNichol and Bianchi, 2016; Salem et al., 2010)
	Use of adhesive remover (Barton, 2020; Collier, 2019; Dobby and Martin, 2011; Fumarola et al., 2020; Jones, 2017; McNichol et al., 2013; Roberts, 2007; Stephen-Haynes, 2008; Tielemans and Vgoeeli, 2019)
Health education	Health teams (Fumarola et al., 2020; Hitchcock and Savine, 2017; Hunt, 2016; LeBlanc and Baranoski, 2011; McNichol and Bianchi, 2016)
	Patients (Fumarola et al., 2020; Hitchcock and Savine, 2017; Hunt, 2016; LeBlanc and Baranoski, 2011)
	Caregivers (Hitchcock and Savine, 2017; LeBlanc and Baranoski, 2011)
Assistance management	Effective communication in health teams (Fumarola et al., 2020)
	MARSI reporting in medical records (3 M, 2016; Fumarola et al., 2020; Hunt, 2016; Jones, 2017; LeBlanc and Baranoski, 2011; McNichol et al., 2013)

^†Medical adhesive-related skin injury.

4. Discussion

4.1. Prediction of medical adhesive-related skin injury occurrence

Identifying risk factors is the starting point for the prevention of medical adhesive-related skin injury. Upon admission and throughout the care period, it should be noted if the patient has any intrinsic or extrinsic risk factors that result in the fragility of the skin and greater probability of adhesive lesions. Intrinsic risk factors are: age extremes, comorbidities (for example atopic dermatitis, epidermolysis bullosa, ectodermal dysplasia, psoriasis, diabetes, vascular diseases, infection, kidney failure, immunosuppression, rheumatoid arthritis, venous hypertension, peristomal varicose veins), dehydration, nutritional deficit, edema, exposure to free radicals, mental disorders (for example stress and anxiety), less pigmentation skin, reduced mobility, and female sex. Extrinsic risk factors are: extremes of humidity, prolonged use of medications (for example corticosteroids, chemotherapy, anti-inflammatories, anticoagulants), radiotherapy, exposure to ultraviolet radiation, repeated removal of adhesives, inappropriate use of adhesives, creams and devices, obesity, cachexia, smoking, excessive cold or heat, friction and pressure on the skin, use of products that increase the adhesion of adhesives, excessive bathing, use of inappropriate cleaning products, and history of injury (Bryant, 1988; Cutting, 2008; Fumarola et al., 2020; Hill and Moureau, 2019; Hunt, 2016; Jones, 2017; LeBlanc and Baranoski, 2011; (Liu et al., 2013); McNichol et al., 2013; McNichol and Bianchi, 2016; Morgan, 1981; Roberts, 2007).

The population of elderly and neonates that receive care in health systems only grows, a fact that should increase the number of medical adhesive-related skin injuries in the coming year (Fumarola et al., 2020). A study showed that devices used to treat pressure ulcers, vascular access dressings, stoma equipment, nasogastric tube fixation, and adhesives applied to abrasion sites were responsible for causing skin injuries in 24 (15.4%) of the 155 elderly evaluated (Konya et al., 2010).

Aging alters the structure of the skin layers, making them more fragile and, consequently, more subject to adhesive injuries. The use of various medications by the elderly further compromises the general condition of the skin and the potential for injuries (Levine, 2017).

The application of risk assessment instruments for the development of medical adhesive-related skin injury can guide the clinical practice of health professionals. Although there are instruments for assessing skin tears (LeBlanc et al., 2013; Silva et al., 2018), there are no validated instruments for the other medical adhesive-related skin injury types. For this reason, it is essential to carry out research aimed at developing instruments that can support safe and effective assistance in predicting, preventing, and treating medical adhesive-related skin injury.

4.2. Intrinsic skin disease

Several skin diseases can alter the structure and function of skin layers, increasing the risk of adhesive injuries. Some intrinsic skin diseases are associated with adhesive lesions, for example atopic dermatitis, psoriasis and epidermolysis bullosa (Cutting, 2008; Fumarola et al., 2020; Hunt, 2016; McNichol et al., 2013; McNichol and Bianchi, 2016).

Atopic dermatitis is caused by a hypersensitivity reaction in response to environmental factors, microbial agents, food, and autoallergens, resulting in transepidermal water loss and skin dryness, and compromising barrier function. The presence of intense itching is common, making it susceptible to abrasions and secondary infections (Klaus Wolff et al., 2017).

Psoriasis is a chronic inflammatory disease that causes skin changes represented by inflamed and pruriginous lesions and pain. Psoriasis presents diversity in clinical condition and disease duration (Ljubenovic et al., 2018).

Epidermolysis bullosa is a rare disease of genetic origin; there is trauma between the different layers of the skin, forming blisters spontaneously or after slight pressure and friction. It can be classified at different levels according to the skin layer where the splitting skin is (Weisman et al., 2021).

4.3. Skin care

Skin care should be performed routinely to maintain its integrity and barrier function (Fumarola et al., 2020; Hunt, 2016; Jones, 2017; LeBlanc and Baranoski, 2011; McNichol et al., 2013). The care includes use of non-aggressive cleaning products and topical products without alcohol in their composition, and daily hydration with emollients (Fumarola et al., 2020; Hunt, 2016; Jones, 2017; LeBlanc and Baranoski, 2011; Roberts, 2007). Adequate water intake and nutrition are also part of skin care, since the nutrients and fluids ingested are metabolized into the micronutrients that make up the skin layers (Hill and Moureau, 2019; Hunt, 2016; Jones, 2017; LeBlanc and Baranoski, 2011; McNichol et al., 2013).

Maintaining skin integrity involves general care consisting of cleansing followed by skin care. Cleaning consists of applying a product, followed by rinsing to remove dirt, microorganisms, sweat, and debris. Skin care includes using non-rinse products such as moisturizers and emollients, intended to protect, increase, or restore the skin's barrier function (Lichterfeld et al., 2015).

In the cleaning process, low-irritation cleansers and humectant-containing leave-ons should be prioritized. In this way, it is possible to keep the skin more hydrated and improve the skin barrier. The use of products without rinse, composed of basic ingredients, paraffin, petroleum jelly, or glycerin, also favors the maintenance of skin integrity (Lichterfeld-Kottner et al., 2020).

4.4. Barrier use

Protectors and adhesive removers are recommended for patients who have risk factors for medical adhesive-related skin injury but need to use adhesives with high adhesion or higher frequency of change. One of the forms of protection is bandages, and barrier films can be used as physical barriers (Bryant, 1988; Dobby and Martin, 2011). When applied to the skin, the films create a flexible and breathable protective pellicle. During adhesive removal, the protective film will be removed instead of layers of cells of the epidermis (3 M, 2016; Barton et al., 2020; Barton, 2020; Bryant, 1988; Hill and Moureau, 2019; Hitchcock and Savine, 2017; Hunt, 2016; Jones, 2017; McNichol et al., 2013; McNichol and Bianchi, 2016; Shannon and Chakravarthy, 2009). Bandages are a barrier option when electrodes are necessary for people with extremely fragile skin, like those with epidermolysis bullosa. It is possible to apply the electrodes safely and effectively by wrapping the skin with thin layers of bandage soaked in a conductive gel (Dobby and Martin, 2011).

Barrier films are also allies in preventing medical adhesive-related skin injury. They protect the skin against excess moisture and mechanical damage and ease the adhesive removal force on the skin. Bodkhe et al. (2021) found that barrier film significantly reduces adhesive removal force and mechanical trauma. Barrier films are also recommended in locations requiring frequent application and adhesive removal, such as central venous catheter dressings. The incidence of skin lesions related to central catheter dressing change was 22% in patients who used barrier films and 47.9% in patients who did not, demonstrating the product's efficiency in preventing medical adhesive-related skin injury (Chen et al., 2020).

4.5. Health education

To reduce medical adhesive-related skin injury incidence during health care, the education of professionals, patients, and all who provide care to patients using adhesives is necessary. Education aims to identify risk factors, forms of medical adhesive-related skin injury, prevention, and treatment. In this way, these lesions will be prevented and, if they occur, can be managed appropriately (Fumarola et al., 2020; Hitchcock and Savine, 2017; Hunt, 2016; LeBlanc and Baranoski, 2011; McNichol and Bianchi, 2016).

To achieve long-term maintenance of skin integrity, health education for professionals and communities is essential. Didactic strategies such as workshops and case studies taught by specialists can be used, favoring greater adherence to skin care. Health education favors the practice of professionals in identifying specific needs and making referrals when necessary (Casas, 2021).

The development of educational materials also assists in continuity of care outside hospital environments. Patients regain confidence in self-care and adopt measures consistent with their needs and realities through these materials. Also, it is possible to clear doubts whenever necessary by accessing the material, a significant factor in preventing complications and adverse events (Carvalho et al., 2019).

4.6. Care management

Keeping records of medical adhesive-related skin injuries, and effective communication in health teams, should be encouraged; this makes it possible to monitor clinical evolution and implement appropriate preventive and therapeutic measures (3 M, 2016; Fumarola et al., 2020; Hunt, 2016; Jones, 2017; LeBlanc and Baranoski, 2011; McNichol et al., 2013).

Medical adhesive-related skin injuries are frequent in health care, but they are underreported in health systems. In a study in the United Kingdom, 70.5% of the 918 nurses interviewed declared that they did not record these injuries in medical records (Ousey and Wasek, 2016). Although apparently simple, they should not be underestimated. Medical adhesive-related skin injuries can contribute to the occurrence of infections at catheter insertion sites, and they can remain localized or reach the bloodstream and worsen patients’ health status (Inagaki et al., 2019). For this reason, the importance of entering medical adhesive-related skin injuries in medical records is emphasized.

4.7. Limitations

It is evident in the literature that publications on medical adhesive-related skin injuries are recent. As described in the present review, these injuries can be underreported, reinforcing the need to record them, identify risk factors, and prevent them. Among the studies included, there was a diversity of designs. However, this made it possible to broaden the view on the theme, mapping the scope of medical adhesive-related skin injuries and contributing to the development of future research.

5. Conclusions

In the present scoping review, the researchers mapped medical adhesive-related skin injury prevention research. Most articles reported on specialist opinions, randomized clinical trials, and case studies. Future research must be directed to preventing medical adhesive-related skin injuries in different healthcare settings.

The prevention of medical adhesive-related skin injuries should be done by adopting multifactorial measures, ranging from identifying risk factors and correct handling of adhesives to educating professionals, patients, and communities.

Investments in research and health education are necessary for to support professionals in the prevention of medical adhesive-related skin injuries and strengthen the quality of care and patient safety in health services.

Funding sources

This study was partially funded by the Brazilian National Council for Scientific and Technological Development [grant numbers: PQ-2021–307,468 (Research Productivity).

Declaration of Competing Interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.