Skin tears and risk factors assessment: a systematic review on evidence‐based medicine

Abstract

Skin tears represent a common condition of traumatic wounds, which may be encountered in some categories of individuals at the extremes of age, such as infants and the elderly. Despite the high prevalence and cost of these lesions, there has been little investigation into the risk factors that lead to this condition. The aim of this review was to systematically evaluate the main risk factors involved in development of skin tears. We planned to include all the studies dealing with risk factors related to skin tears. Only publications in English were considered. We excluded all the studies that did not properly fit our research question and those with insufficient data. Of the 166 records found, 24 matched our inclusion criteria. After reading the full‐text articles, we decided to exclude seven articles because of the following reasons: (1) not responding properly to our research questions and (2) insufficient data; the final set included 17 articles. From a literature search, we found the following main issues related to risk factors, which have been described in detail in this section: age‐related skin changes, dehydration, malnutrition, sensory changes, mobility impairment, pharmacological therapies and mechanical factors related to skin care practices. Our findings clearly show that in frail populations (especially infant and elderly), the stratification risk, as a primary prevention strategy, is an effective tool in avoiding the development of chronic wounds. The development and the implementation of prevention strategies based on appropriate knowledge of the risk factors involved and the adoption of correct techniques during skin care practices could reduce or even avoid the onset of skin tears.

Introduction

Skin tears were first defined by Payne and Martin 1, 2, and thereafter by more recent studies 3, 4, 5, as traumatic wounds occurring principally on the upper limbs as a result of friction alone or shearing and friction forces, which separate the epidermis from the dermis (partial thickness wounds) or which separate both the epidermis and the dermis from underlying structures (full thickness wounds). Skin tears are reported to be a common wound especially on fragile exposed skin, which can be often encountered among older adult, disabled populations and neonates 5. Skin tears can be found on all areas of the body and are particularly common on the extremities 3. Skin tears may be also very common in public hospital inpatients and residents of aged care facilities, with prevalence of up to 41% in these settings 6, 7.

Clinical management of skin tears can be difficult, and these wounds may also be associated with prolonged hospitalisation stays, increased health care costs and adverse impacts on patients' quality of life 7, 8.

The aim of this review is to investigate, through an updated context of evidence‐based medicine, the risk factors related to developing skin tear wounds.

Materials and methods

This review was conducted and is reported in accordance with the PRISMA guidelines 9.

Inclusion and exclusion criteria

We planned to include all the studies dealing with risk factors related to skin tears. Only publications in English were considered. We excluded all the studies that did not properly fit our research question and those with insufficient data.

Search strategy

Two members of the research team (RS and NI) performed a comprehensive literature search using terms identified and agreed on by the authors. Medline and Scopus databases were searched from January 1990 to June 2017 using the following keywords: ‘skin tears and risk factors’ We also reviewed the reference lists of retrieved studies to identify studies that had not been identified by the search strategy.

Data extraction and risk of bias assessment

Two review authors (SB and SDF) independently assessed both titles and abstracts of 49 Medline and 117 Scopus potentially eligible studies. In case of ambiguous or unclear result, the study was retrieved in full and assessed further by all review authors independently and included if pertinent. All studies were assessed by using the Downs and Black quality checklist 10; this system is a well‐validated, reliable and methodologically strong tool 11.

Results

Study selection

Of the 166 records found, 24 matched our inclusion criteria (Figure 1). After reading the full‐text articles, we decided to exclude seven articles because of the following reasons: (1) not responding properly to our research questions and (2) insufficient data; the final set included 17 articles.

Figure 1.

Flow diagram of study inclusion.

From literature searching, we found the following main issues related to risk factors, which have been described in details in this section: age‐related skin changes, dehydration, malnutrition, sensory changes, mobility impairment, pharmacological therapies and mechanical factors related to skin care practices.

Age‐related skin changes

Changes to the skin due to the ageing status make the skin more vulnerable. These changes include modifications both in infants and in elderly 8, 9, 10, 11, 12.

Preterm and newborn infants are particularly susceptible to skin tears. In fact, neonates have under‐developed skin, and their decreased epidermal‐to‐dermal cohesion, deficient stratum corneum, impaired thermoregulation, body surface/weight ratio that is nearly five times greater than an adult and immature immune system place them at an increased risk for skin tears 13.

In the elderly, physiological and pathological skin changes occur: older skin has less collagen elastin and fatty tissue with decreased skin elasticity and shrinkage of subcutaneous tissue that causes wrinkles and folds to appear; skin also has a decreased sebaceous gland, and sweat gland activity causes the skin to dry out (xerosis), becoming more fragile; arteriosclerotic changes in the small and large vessels cause thinning of vessel walls and a reduction in the blood supply to the extremities, and consequently to the skin microcirculation.

In addition, the vascular capillaries become more fragile, which can lead to vascular lesions, such as ecchymosis (bruising) and senile purpura 14, 15.

All these changes make the skin less able to withstand normal wear and tear, so a simple hit will cause the skin to tear 16, 17.

Dehydration

Adequate water content is essential to maintain cellular homeostasis. As there is a continuous turnover of body water, dehydration can be caused by losing too much fluid (output problems), such as vomiting and diarrhoea, impaired kidney function or due to certain side effects of drugs (e.g., diuretics), or by input problems, such as not drinking enough water or fluids.

Infants and children are more susceptible to dehydration than young adults because of their smaller body weights and higher turnover of water and electrolytes. The elderly and those with illnesses are also at a higher risk 18, 19.

The hydration status may directly influence the protective function of the skin, which depends on hygroscopic proteins, osmotically active elements and the integrity of the lipid water barrier. Competence of the skin barrier is pivotal in response to environmental or traumatic injuries to skin; in fact, the water flux may control the correct humidity, calcium and pH gradients, osmotic pressure and the induction of cytokines and defensive proteolytic pathways when necessary 20.

Malnutrition

The term malnutrition includes a variety of nutritional concerns, such as undernutrition, resulting from decreased or inadequate food intake; overnutrition caused by excessive food consumption; and specific nutrient deficiencies 21, 22.

Several age‐associated issues put the elderly at an increased risk of developing malnutrition, such as medical, psychological, physiological, social and economic difficulties 23, 24.

Patients with wounds often experience nutrition deficiency. In fact, energy, carbohydrate, protein, fat, vitamin and mineral metabolism can all affect skin integrity and the healing process 25.

The albumin blood level that is normally related to nutrition status has been clearly identified as an independent risk factor to developing skin breakdown in certain conditions, such as pressure ulcers 26, 27.

Sensory changes

Sensory and cognitive deficits inclusive of communication difficulties; impaired decision making; and cognitive impairments, such as dementia, decreased tactile sensation, hearing impairment and visual deficits appear to be related to the onset of skin tears, probably in a context similar to pressure ulcers 3, 5, 14, 27.

Mobility impairment

History of falls, impaired mobility and consequent inability to perform activities of daily living (ADLs) and mechanical trauma have often been encountered in the clinical history of patients with skin tears 3, 8.

Pharmacological therapies

Chronic use of corticosteroids, for their potential side effects in collagen synthesis inhibition, as well as the use of anticoagulant agents, for their potential side effects in determining ecchymosis and senile purpura, appears to be related to the onset of skin tears 5, 28, 29, 30.

Mechanical factors related to skin care practices

Shearing and friction forces associated with transfer activities of patients/residents and those associated with wound dressings, adhesive tapes or bandages used may be responsible for the onset of skin tears. 31, 32.

Discussion

Skin tears represent a condition of altered skin integrity and are a common problem in some selected categories of individuals who are at the extremes of age, such as infants and elderly. Prevalence rates for skin tears have been reported to be as high as 41%. Moreover, it is estimated that the incidence of skin tears stands at 1·5 million each year. Patients affected develop important complications, such as secondary wound infections, that can be extremely debilitating, with consequent negative impact on quality of life and increasing costs to the health system for related prolonged hospitalisation stays 6, 7, 8.

Health care professionals and caregivers should place a primary focus on risk assessment in order to improve prevention strategies to reduce the onset of skin tears, and they must also be ready and skilled to manage these wounds when they occur, establishing and implementing a tailored plan of care 3. Therefore, it is important to optimise the risk assessment, improving the knowledge of the risk factors that can be categorised into seven main areas: (1) age‐related skin changes, (2) dehydration, (3) malnutrition, (4) sensory changes, (5) mobility impairment, (6) pharmacological therapies and (7) mechanical factors related to skin care practices.

Age‐related skin changes can be induced by chronological ageing and also by photo‐ageing, manifested in subcutaneous fat reduction, increased elastotic degeneration in the upper dermis, destruction of its fibrilar structure, augmented intercellular substance and moderate inflammatory infiltrate 33. In this context, a role of some inflammatory cytokines, such as tumour necrosis factor‐α (TNF‐α), and some members of matrix metalloproteinases (MMPs), such as MMP‐2 and MMP‐9, and their tissue inhibitors (TIMPs) can be postulated, which appear to be involved in anomalous extracellular matrix (ECM) remodelling, determining dermal–epidermal junction damage with subsequent formation of skin tears 5. MMPs have been previously identified in the onset, the progression and the healing process of several wounds, and they may represent molecular targets both in the prevention and in the treatment of chronic wounds 34, 35, 36, 37, 38, 39, 40, 41, 42. Further studies are needed to quantify and better identify the impact of these proteases in the skin tears area.

Senile purpura (SP), characterised by purpuric macules and patches on photo‐aged skin of the extremities, has been related to impaired mechanical protection by the dermal extracellular matrix, leading to vessel rupture after minor traumas, and may be immediately related to skin tears. In fact, some studies consider SP even at the earliest stage of dermatoporosis, which represents the prelude to skin tears 43. Therefore, it is important to protect skin at the early onset of SP by means of sunscreen application and sun‐protective clothing, protecting the patient from the evolution towards skin tears in this way.

Regarding human skin's physiology, cutaneous water content is known to play an important role in different important skin properties, such as its biomechanical structure and defence systems (skin barrier, tolerance to traumatic injuries). Conversely, water deficiency (dehydration) is associated with several dermatological dysfunctions, such as skin tear formation 20, 44.

Infants and children are at a higher risk of dehydration as they are frailer than young adult individuals 18, 19. Therefore, it is important in these selected populations to identify and fix input and/or output water problems. In fact, a recent study clearly suggests that simple dietary water intake positively influences skin water content, improving skin properties 45, 46.

Malnutrition can result from macronutrient and micronutrient deficiency. Macronutrients include carbohydrates, fats and protein, whereas micronutrients include vitamins and minerals. In developed countries, especially in elderly patients, vitamin and nutritional deficiencies most commonly result from poverty, restrictive diets, medication, alcoholism and inadequate dietary intake. Recognition of early malnutrition status can be important for diagnosing underlying skin changes that could lead to skin tear formation 21, 22, 25. Serum albumin is a valid test of a patient's nutrition status. Serum albumin levels less than 3·5 mg/dl and total lymphocyte counts less than 1500/mm³ are associated with chronic wound issues 26, 27, 47.

Sensory changes (cognitive, hearing and visual deficits) and mobility impairment have been generally related to skin tears onset, but there are no specific studies on their pathophysiological mechanisms that are probably related to the same issues of pressure ulcers 3, 5, 14, 27. In fact, patients with these problems may not adequately and distinctly feel pain when they are injured, increasing the risk of severe wounding or the worsening of an existing wound 48. Therefore, it is important to correctly apply physiotherapy, occupational treatments and surveillance systems when sensory, cognitive or visual impairment is present in order to keep individuals at risk safe and trauma free 48.

The roles of pharmacological therapies in the onset of skin tears are not yet sufficiently documented. In fact, some weak evidence suggests that the chronic use of corticosteroids, and anticoagulants, because of their potential harmful effects on the skin components, may predispose a person to the onset of skin tears, but further studies are needed to validate these theories 5, 28, 29, 30.

Mechanical factors are a real problem in the onset of skin tears. In fact, skin tears may often occur when health care practitioners handle the patients or remove surgical tapes as these interventions apply external forces to the skin surface, especially in the elderly 5. In fact, patients and their families should be involved in developing and implementing prevention strategies, and nursing staff and caregivers should be educated to ensure that they are adopting correct techniques during skin care practices in order to avoid causing skin tears 48.

In frail populations, the stratification risk, as a primary prevention strategy, is an essential tool in avoiding the development of chronic wounds. The identification of risk assessment tools 6, 49 in the area of chronic wounds, which may predict the onset of wounds, appears to be a promising strategy and may represent an important pathway in order to reduce the prevalence and the incidence of these difficult‐to‐treat diseases.