Skin tears are not a sexy complaint to write about. We see them all the time. They aren’t particularly dangerous. They are usually small, often easily fixed with steri-strips, coated with bacitracin, and covered in gauze never to be thought about again. But recently, in a shift where we treated a patient with exertional syncope and an abnormal EKG, an unstable acute GI bleed, and multiple patients with suspected covid, the large complex skin tear (while not life threatening) may have still been the most difficult problem I faced. These can be quite challenging to fix and they are certainly common in the ED. So perhaps it’s time we talk about it.

Skin tears are wounds caused by shearing, friction, or blunt trauma causing separation of skin layers.  Usually in the elderly and chronically ill due to thin, frail skin.

Is there a classification system? Yes. Do you need to know it? Probably not. But there are some important aspects of the wound to note, as these will be clues as to viability of the skin flap.

- Whether the skin flap can be easily re-aligned to normal anatomic position

- Tension on wound edges when you pull it together

- Presence of a hematoma

- Discoloration of skin (pale, dusky, darkened)

Repair:

- Irrigate!

- Update tetanus vaccine

- The simple/best repair: re-approximate edges, use steri strips as needed to hold edges together, and cover with a nonadherent dressing. It may not look pretty but it’ll get the job done without causing further damage to the thin skin. Most skin tears can be repaired this way.

- Skin adhesive can be used if the edges approximate completely, but this can be difficult to achieve

- Sutures: often more damaging than helpful. With thin skin, the suture often tears through the edge and cause more skin tearing/shredding, especially if the edges are under tension. Try to avoid this! However, if you do need to suture (ie if parts of the laceration are deeper or the steri-strips won’t hold) consider strategies to minimize further tearing - consider using steri-strips first to anchor and reduce tension.  

- Remember – if the wound is under too much tension, if your meticulous repair just leads to further tearing, or if you skin flap was never viable in the first place, it won’t heal well regardless - don’t push for perfect appearance.  Less is more!

**Caveat: there isn’t great data on this…

References:

eBlanc, Kimberly MN, RN, CETN(C), KDS; Baranoski, Sharon MSN, RN, CWCN, APN-CCNS, FAAN Skin Tears: State of the Science: Consensus Statements for the Prevention, Prediction, Assessment, and Treatment of Skin Tears©, Advances in Skin & Wound Care: September 2011 - Volume 24 - Issue 9 - p 2-15 doi: 10.1097/01.ASW.0000405316.99011.95