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Authors

  1. Strazzieri-Pulido, Kelly Cristina
  2. Peres, Giovana Ribau Picolo
  3. Campanili, Ticiane Carolina Goncalves Faustino
  4. de Gouveia Santos, Vera Lucia Conceicao

Abstract

Skin tears are traumatic wounds resulting from friction and shearing forces. Clinical practice strongly indicates that skin tears are a prevalent problem but their incidence is not well established in the literature. This systematic literature review identified and evaluated the available literature on the incidence and risk factors for skin tears in adults and the elderly. Inclusion criteria were epidemiological studies published in English, Spanish, or Portuguese languages from January 1990 through June 2014 and available in full text. Study quality was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement and the Guidelines for Critically Appraising Studies of Prevalence or Incidence of a Health Problem. Five studies reporting incidence of skin tears met the selection criteria. Reported incidence rates of skin tears ranged from 2.23% to 92% in long-term care facilities and varied from 2.1% among men to 4.6% among women living in the community. The most prevalent risk factor for skin tears was old age, followed by impaired mobility, falls and accidental injuries, previous skin tears, cognitive deficit/dementia, dependence in transfers, and upper limbs. Further epidemiological studies on skin tears are necessary to elucidate the cause of these injuries and identify the profile of people at risk for skin tears, contributing to the development and implementation of appropriate preventive interventions.

 

Article Content

INTRODUCTION

Skin tears are traumatic wounds occurring on the extremities; they are caused by friction and shearing forces that separate the dermis from the epidermis (resulting in a partial-thickness wound) or both the dermis and epidermis from underlying structures (resulting in a full-thickness wound).1-4 Skin tears are particularly prevalent among frail, malnourished, and functionally dependent elderly persons.1,2,5-17

 

Skin tears have been reported to be more prevalent than pressure injuries and burns.2,18-21 However, research concerning the prevalence, incidence, or economic impact of skin tears is sparse.13,20,22 Despite the paucity of research in this area, clinical practice strongly suggests that skin tears are a clinically relevant and prevalent occurrence, especially among older patients and individuals with chronic or critically illness.8,23 The aim of this systematic review was to identify and evaluate research on the incidence and risk factors associated with skin tears in adults and elderly persons.

 

METHODS

We followed methods recommended by the Cochrane Collaboration for this systematic review.24 Our search was guided by the following question, "What information is available in the literature on the incidence and factors associated with skin tears in adults and the elderly?" To answer this question, the Cochrane, CINAHL, EBM Reviews, EMBASE, LILACS, PubMed, Scopus, and Web of Science electronic databases were searched for articles published from January 1990 through June 2014.

 

Inclusion criteria were epidemiological studies investigating the incidence of skin tears, published in English, Spanish, or Portuguese languages. Only studies available in full text were included. Book chapters, summary of events, integrative or comprehensive review articles, case reports, consensus, editorials, guides, correspondences, clinical trials, case-control, and cohort studies were excluded.

 

Because the terminology used to describe skin tears is not standardized, the search strategy was based not only on the standardized medical vocabulary, the Medical Subject Headings (MeSH)25 and the Descriptors in Health Sciences (DeCS),26 which are indicated in bold in Table 1, but also on key words used in narrative reviews and update articles. Articles were located using the Boolean functions AND and OR, according to the database searched. The search strategy is summarized in Table 1. Search results (ie, article title, authors' name, journal title, year of publication, volume, issue and page numbers, section, abstract, and key words) were exported to the EndNote Web software for Word 2011 (Thomson Reuters, New York).27

  
Table 1 - Click to enlarge in new windowTABLE 1. Search Strategya

Initially, articles were screened for relevance by title and abstract. The documents were randomly distributed among the authors of this systematic review; every abstract was independently checked by 2 authors. If there was doubt about the relevance of an article, the abstract was evaluated by a third author. When an abstract was found to meet inclusion criteria, we retrieved the full article. Retrieved articles were then randomly distributed among the authors, and each article was independently evaluated by 2 authors. A third reviewer served as a referee in the validation of the selection process by reevaluating a random sample of 30% of the articles.

 

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)28 and the Guidelines for Critically Appraising Studies of Prevalence or Incidence of a Health Problem (Loney Guidelines)29 were used to assess study quality. The Brazilian-Portuguese version of STROBE28 contains 22 items, with recommendations on what should be included in an accurate and complete description of observational studies. Every item was rated 0 or 1. The total score was converted into percent values to better assess the quality of the articles. Articles were considered of good quality if the total score was 80% or more.

 

The Loney Guidelines developed by Loney and collaborators29 assess adequacy and accuracy of a study related to validity of methods and interpretation and applicability of results. The instrument comprises 8 items, as follows: random sample or whole population; criteria for sample selection; adequate of sample size; standardized measures/instruments; impartiality (inter and intra-rater reliability); adequate response rate and description of refusers; confidence intervals and subgroup analysis; and description of study subjects. Items present in a study are assigned a score of 1 for a maximum score of 8. There are no quality categories or cutoff score for the Loney Guidelines. We deemed articles with a total score of 7 or more of good quality.

 

RESULTS

The initial search identified 8087 documents from the 8 electronic databases identified previously; 2426 duplicate documents were removed, yielding 5661 documents with unique titles. After reading the titles, 5425 documents were excluded and 236 abstracts were reviewed to eliminate book chapters, conference abstracts, review articles, case reports, consensus statements, editorials, guidelines, letters, clinical trials, cross-sectional studies, and case-control studies. Five articles on the incidence of skin tears met selection criteria and were read in full.1,8-10,30

 

Most documents were identified via EMBASE (n = 4644; 57.4%) and PubMed (n = 2788; 34.5%). Articles were also identified through the Cochrane Database (n = 68; 0.84%), CINAHL (n = 17; 0.21%), EBM Reviews (n = 7; 0.09%), and LILACS (n = 1; 0.01%) (Table 2). Table 3 summarizes data from the 5 studies incorporated into this systematic review. This summary includes the authors' name, year of publication, country where the study was conducted, methods, results, and quality scores based on STROBE and the Loney Guidelines.

  
Table 2 - Click to enlarge in new windowTABLE 2. Number of Articles per Database
 
Table 3 - Click to enlarge in new windowTABLE 3. Summary of the 5 Selected Articles on Skin Tear Epidemiology

Three studies were conducted in the United States,1,9,10 1 was conducted in Australia,8 and 1 in New Zealand.30 Three studies were conducted in long-term care facilities (LTCFs),1,9,10 1 was conducted in an acute care facility,8 and 1 in a community setting.30 Physical examination was the main strategy for data collection and performed in all 5 studies.1,8-10,30 The Payne-Martin Classification System for Skin Tears was administered in 3 studies,1,10,30 1 study9 used its own classification system, and 1 study report8 did not identify the instrument used to classify skin tears.

 

The incidence of skin tears ranged from 2.23% among 896 residents from 10 LTCFs1 to 92% among 349 residents of an LTCF.9 A 2-year epidemiological study with older adults living in the community found an overall incidence of skin tears of 2.1% and 4.6% among men and women, respectively, and incidence rates of 1.1% and 6.1%, respectively, for those aged 70 to 74 years, increasing to 4% and 30%, respectively, for those aged 85 years or older.30 Two articles8,10 did not report on the incidence of skin tears, although it was initially stated as an objective of those studies.

 

The most frequently reported risk factors for skin tears were advanced age (n = 4),1,9,10,30 impaired mobility (n = 3),1,8,10 falls and accidental injuries (n = 3),8,9,30 history of skin tears (n = 2),1,10 cognitive impairment/dementia (n = 2),1,10 dependence in transfers (n = 2),1,9 and upper limbs (n = 2).8,9 Other risk factors mentioned in the 5 studies were presence of senile purpura, being bedridden, unable to change positions, unable to feed themselves/use of a feeding tube, reduced dermal thickness,1 wheelchairs,9 chairs and beds, fragile skin, lack of balance, lower limbs,8 frail elderly, dependence in activities of daily living, malnutrition, spasticity and stiffness, sensory loss, poor appetite, polypharmacy, use of an assistive device (orthosis), presence of ecchymosis,10 and summer season.30

 

The articles by Malone and collaborators9 and Kennedy and Kerse30 were considered of good quality, whereas the articles by Payne and Martin1 and Everett and Powell8 showed the lowest study quality, failing to report confidence intervals for incidence estimates and to describe the study sample.

 

DISCUSSION

The incidence of skin tears reported in these studies ranged from 1.1% to 92% in different facilities, varying according to gender and age group. The highest incidence was found in a retrospective study conducted in the United States, in which 321 skin tears were detected in 349 patients over 1 year, resulting in an incidence rate of 92% (ie, 0.92 skin tears per patient per year).9 However, the authors suggested that this incidence rate could be up to 3 times higher than that found because the records for this type of wound usually are not accurate.9

 

The lowest incidence of skin tears (2.1% for men and 4.6% for women) was reported by Kennedy and Kerse,30 who estimated the incidence of pretibial skin tears in patients aged 65 years or older from a rural primary health care facility in New Zealand over 2 years.

 

Payne and Martin1 conducted a 5-month study in 10 LTCFs in the United States, totaling 896 beds. Skin tears were detected in 20 patients, corresponding to a 2.23% incidence rate for the study period. The 20 patients had a total of 50 skin tears, averaging 2.5 skin tears per patient.

 

Kennedy and Kerse30 found that the mean age of patients with skin tears was 80 years. The incidence of skin tears was lower in the winter (11%) compared to summer (44%); this finding may be associated with wearing clothing that increase exposure of the extremities during the warmer summer season.30 Most of the skin tears were caused by objects that fell on the legs or were out of sight; falls were the least frequent cause.30 McGough-Csarny and Kopac10 conducted a 6-month study in a nursing home for war veterans and found 154 skin tears among the 154 residents during the study period, corresponding to an incidence of 1 skin tear per resident. Most of residents (79.2%) had a history of skin tears.10

 

Advanced age was the risk factor most frequently associated with skin tears in the reviewed studies and specialized literature.1,2,9,31-33 Nevertheless, clinical experience strongly suggests that skin tears are not restricted to the extremes of age.2,32,34-36 Although the elderly and infants are the highest-risk groups for skin tears, there are other groups subject to the weakening of the skin who should not be ignored. These groups included critically ill patients (persons receiving care in an intensive care unit or those who have suffered major trauma or surgery), patients near the end of life, and persons with intrinsic and extrinsic risk factors for skin tears, regardless of age.32,34-36

 

This systematic review found considerable variability in the incidence of skin tears among the few evidence-based studies found in the literature and lack of more recent incidence studies on this topic. Further epidemiological studies on skin tears are needed to increase our knowledge of the incidence of skin tears and modifiable and constitutional risk factors associated with these wounds. Understanding how and why skin tears occur is essential for the identification of at-risk patients and development of prevention strategies.37

 

CONCLUSION

The incidence of skin tears ranged from 1.1% in community-dwelling men to 92% in different settings in an LTCF. Skin tears were associated with advanced age, impaired/limited mobility, falls and accidental injuries, female gender, history of skin tears, cognitive impairment/dementia, dependence in transfers, and upper limbs.

 

KEY POINTS

 

* The incidence of skin tears ranged from 2% to 92% in different settings, varying according to gender and age group.

 

* Incidence rates of 1.1% for men and 4.6% for women were found in the community.

 

* Advanced age was the risk factor more frequently identified in the reviewed studies.

 

REFERENCES

 

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26. DeCS (Descritores em Ciencias da Saude). Controlled vocabulary thesaurus in three languages created by BIREME. http://decs.bvs.br/P/decsweb2012.htm. Accessed July 22, 2012. [Context Link]

 

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30. Kennedy P, Kerse N. Pretibial skin tears in older adults: a 2-year epidemiological study. J Am Geriatr Soc. 2011;59:1547-1548. [Context Link]

 

31. Baranoski S. Skin tears: staying on guard against the enemy of frail skin. Nursing. 2000;30:41-46. [Context Link]

 

32. Irving V, Bethell E, Burtin F. Neonatal wound care: minimizing trauma and pain. Wounds UK. 2006:2:33-41. [Context Link]

 

33. LeBlanc K, Christensen D, Orstead H, Keast D. Best practice recommendations for the prevention and treatment of skin tears. Wound Care Can. 2008;6:14-32. [Context Link]

 

34. McLane KM, Bookout K, McCord S, McCain J, Jefferson LS. The 2003 National Pediatric Pressure Ulcer and Skin Breakdown Prevalence Survey: a multisite study. J Wound Ostomy Continence Nurs. 2004;31:168-178. [Context Link]

 

35. Santos VLCG. SCALE: modificacoes da pele no final da vida [SCALE: Skin changes at life's end]. Rev Estima. 2009;7:42-44. [Context Link]

 

36. Sibbald RG, Krasner DL, Lutz J. SCALE: Skin Changes at Life's End: final consensus statement: October 1, 2009. Adv Skin Wound Care. 2010;23:225-236. [Context Link]

 

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For an additional continuing education article related to skin tears, go to http://NursingCenter.com\CE.

 

Skin aging; Skin tears; Epidemiology; Incidence Risk factors