6.4 Prevention of Skin Tears & Medical Adhesive-Related Skin Injuries (MARSI)

Prevention of Skin Tears & Medical Adhesive-Related Skin Injuries (MARSI)

Mechanical skin injuries—specifically Skin Tears and Medical Adhesive-Related Skin Injuries (MARSI)—represent significant, highly preventable sources of acute wound formation, chronic pain, and secondary infection in geriatric, pediatric, and critically ill patient populations. Aging dermis, chronic systemic corticosteroid therapy, malnutrition, and photoaging severely compromise skin structural integrity. Clinicians must master risk identification, standardized classification frameworks, emergency skin flap preservation protocols, and low-trauma adhesive management techniques.

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Skin Aging & Pathophysiology of Cutaneous Fragility

Healthy skin possesses a resilient dermo-epidermal junction secured by interlocking microscopic projections known as rete ridges. Aging skin (dermatoporosis) and chronic disease induce physiological changes that elevate mechanical fragility:

1. Flattening of the Dermo-Epidermal Junction: Rete ridges flatten, significantly reducing the surface area of attachment between the epidermis and dermis. Minor horizontal shear or friction forces easily shear the epidermis completely off the underlying dermis.
2. Dermal Atrophy: Collagen and elastin fiber synthesis decreases by $20%\text{--}50%$, leading to thin, papery, unyielding dermal tissue. Dermal microvascular capillary fragility increases, manifesting as senile purpura (extravasated blood patches following minor trauma).
3. Decreased Subcutaneous Fat & Hydration: Subcutaneous fat cushions atrophy, sebum/sweat production declines, resulting in xerosis (extreme skin dryness) and fissuring.
4. Systemic Corticosteroids: Long-term administration of systemic corticosteroids (e.g., prednisone $\ge 10\text{ mg/day}$) inhibits fibroblast proliferation, halts collagen synthesis, and induces severe epidermal and dermal thinning.

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Skin Tear Classification: ISTAP Framework

A skin tear is defined as a traumatic wound resulting from mechanical force (shear, friction, or blunt trauma), including removal of adhesives, resulting in separation of the skin layers.

The International Skin Tear Advisory Panel (ISTAP) established a simplified, globally validated 3-type classification system based on skin flap presence and viability:

• ISTAP Type 1: No Tissue Loss. The epidermal flap is torn but remains attached. The flap can be repositioned and aligned to completely cover the underlying wound bed (linear or flap type).
• ISTAP Type 2: Partial Tissue Loss. The epidermal flap is damaged, necrotic, or rolled. The flap cannot be repositioned to cover the entire wound bed, leaving a portion of open wound bed exposed.
• ISTAP Type 3: Total Tissue Loss. The epidermal flap is completely absent, torn away, or destroyed, leaving the entire wound bed exposed.

ISTAP Type 1 = Flap present, covers 100% of wound bed (No tissue loss)
ISTAP Type 2 = Flap damaged, covers <100% of wound bed (Partial tissue loss)
ISTAP Type 3 = Flap missing/destroyed, covers 0% of wound bed (Total tissue loss)

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Comprehensive Skin Tear Prevention & Emergency Protocols

Prevention Protocols

• Twice-Daily Emollient Application: Apply pH-balanced, fragrance-free moisturizing lotions or emollients twice daily over arms, legs, and fragile skin. Apply gently smoothing in the direction of hair growth; never rub vigorously.
• Protective Apparel: Equip high-risk individuals with soft padded armguards, tubular compression bandages (Tubigrip), or long sleeves and pants to shield extremities from mechanical trauma.
• Environmental Hazards: Pad wheelchair armrests, footrests, and bed side rails. Ensure adequate lighting and remove sharp furniture corners.
• Safe Handling Techniques: Manual transfers must avoid gripping fragile extremities tightly. Utilize transfer sheets and ceiling lifts.

Emergency Management Protocol for Acute Skin Tears

1. Cleanse: Gently irrigate wound and flap with warm sterile saline or clean water; pat surrounding skin dry.
2. Flap Preservation: Do not cut or remove a viable skin flap. Gently tease, unroll, and realign the epidermal flap back over the wound bed using a moistened sterile cotton-tipped applicator or gloved finger.
3. Primary Dressing: Apply a non-adherent primary contact layer or soft silicone foam dressing. Never apply adhesive Steri-Strips or surgical tape directly over a fragile skin flap, as future removal will strip the flap.
4. Directional Arrow Marking: Draw a clear arrow on the outer secondary dressing indicating the direction for future dressing removal (removing from unattached edge toward the flap hinge to prevent flap detachment).

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Medical Adhesive-Related Skin Injuries (MARSI): Definition & Types

MARSI is defined as an occurrence in which erythema and/or other manifestation of skin trauma (blister, vesicle, erosion, tear) persists 30 minutes or more after removal of a medical adhesive product.

Five Primary Clinical Subtypes of MARSI

1. Epidermal Stripping: Detachment of one or more layers of the stratum corneum upon adhesive removal. Appears as shiny, red, shallow epidermal erosion.
2. Tension Blister (Shear Injury): Fluid-filled blister developing beneath or at the edges of tape that was applied under stretch or tension, or over tissue that subsequently swelled. Mechanical shear detaches epidermis from dermis.
3. Skin Tear (Adhesive-Induced): Mechanical detachment of skin layers caused by adhesive pull force exceeding intercellular skin layer strength.
4. Maceration: Softened, white, wrinkled skin beneath occlusive adhesive dressings caused by trapped sweat or wound exudate.
5. Folliculitis: Inflammatory papules or pustules surrounding hair follicles trapped under adhesive tape.

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Safe Adhesive Selection & Removal Techniques

Preventing MARSI requires careful product selection, barrier preparation, tension-free application, and correct removal technique:

Product Selection & Preparation

• Adhesive Selection: Prefer soft silicone adhesives or low-tack paper/acrylic tapes for fragile, elderly, or corticosteroid-treated skin. Soft silicone conforms to skin micro-contours without stripping epidermal cells upon removal.
• Liquid Barrier Films: Apply a non-stinging, solvent-free liquid skin protectant barrier film to intact skin prior to adhesive application. Allow film to dry completely (30 to 60 seconds) to create a protective polymer coat.
• Hair Clipping: Clip excessive hair with electric clippers; never shave with a razor, which creates micro-abrasions.

Tension-Free Application

• Apply tape from the center outward without stretching or pulling. Stretching tape creates continuous mechanical shear stress on epidermal cells, resulting in tension blisters.

Low-and-Slow Removal Technique

• Horizontal Peel-Back (180 Degrees): Slowly peel the adhesive product back on itself at a 180-degree angle, keeping it parallel to the skin surface. Never pull tape straight up at a 90-degree angle.
• Counter-Traction: Support the unpeeled skin immediately adjacent to the peeling line with the fingers of the opposite hand, exerting gentle counter-pressure.
• Adhesive Removers: Utilize silicone-based medical adhesive removers (wipes or sprays) to dissolve chemical adhesive bonds cleanly, eliminating mechanical drag.