In the clinical environment, this linear melody plays on a cyclic basis: "The patient has a skin tear!" This common declaration is usually punctuated by silence, a pause, and then uncertainty about how to treat this common occurrence.
What is a skin tear? Can you find this commonly used term in a medical dictionary or in the nomenclature of nursing diagnosis? In the taxonomy of wound care, it is well recognized that "the more terms there are to describe an entity, the less we know about it." And, oftentimes, there is less agreement on how to treat the given medical problem, as in this case-skin tears.
In humans, is a skin tear failure of the skin and/or its anatomical and histological components? Are skin tears a consequence of the aging process? What about the physical factors-the pathomechanical factors? In other words, the human body and the largest organ in the body (skin) are affected by interactions with the physical environment-the human machine interface-such as hospital beds, mattresses, sheets, and other components thereof; wheelchairs; and supplementary support surfaces.
As aptly described by LeBlanc and Baranoski in their continuing education article, "Prevention and Management of Skin Tears," on page 325, it is useful to classify the etiologic factors associated with skin tears as intrinsic and extrinsic. To complement their system, I will consider the etiologic factors associated with the development of skin tears through these 2 subdivisions: pathomechanical and pathophysiological.
The French term la melodie de la peau de papier ("the melody of the little piece of paper") is useful to describe both the mechanical (human machine interface) and the pathophysiological (human) mechanisms of skin tears. To make the point, try the following experiment. First, take a clean smooth piece of paper on a flat surface and run your hand and fingers over the top surface. There should be no drag or friction, and the surface tension should be minimal-a smooth ride, if you will. Now take that same paper, fold it, make a tear in it, and, finally, wrinkle and moisten it. Now repeat the experiment by the hand motion. There is a significant increase in the drag coefficient (Cd) (increasing the resistance and shear forces), decreased surface tension, and further damage to the paper surface. In this experiment, the paper was the surrogate for the skin, and I consider this a model for explaining the mechanisms of mechanical forces and how they contribute to skin tears.
When considering the human pathophysiological factors associated with skin tears, more questions than answers remain. Again, the melody of the little piece of paper plays itself out in the history of the patients. Patients with advanced age seen in the outpatient clinic will often show the practitioner a small piece of paper with their questions, anxieties, pains, diseases, and the list of drugs they are taking. Now, we all like eponyms, acronyms, and mnemonics; indulge me on this for evaluating patients at risk for skin tears using the following mnemonic, ADD:
Age-disease interactions
Disease-drug interactions
Drug-drug interactions.
To slightly expand the ADD concept to ADI, we can add:
Age-Disease Interactions.
"Aging skin undergoes a process in which it experiences dermal and subcutaneous tissue loss, epidermal thinning, and serum composition changes, which cause decreased skin surface moisture. The skin's elasticity and tensile strength decrease as these other changes occur."1,2 In addition, as part of the aging process, the skin undergoes apoptosis (preprogrammed cell death), which is accelerated in serious illness, tissue compromise, ischemia, and reperfusion. Unless one is like the cinematic character of Benjamin Button and grows younger as he ages, the skin is preprogrammed to age in the same cycle as we age.
Drug-Disease Interactions
Are skin tears a manifestation of and/or a confluence of pharmacological factors, such as the chronic use of warfarin, antiplatelet drugs, or steroids? Patients with fragile, friable, and feeble skin include those who are taking antirejection drugs such as high doses of steroids because of organ transplantation, as well as those with a multitude of other conditions, such as chronic obstructive pulmonary disease. Patients with diabetes or those who have acquired immune deficiency have a number of skin manifestations that are complex and require consideration and skill to evaluate and treat.
Drug-Drug Interactions
When considering the drug-drug interactions and their influences on the skin, we should consider the pharmacodynamics and pharmacokinetics of any medication the patient is taking or has taken in the recent past. This includes antibiotics, proton pump inhibitors, and histamine blockers, which may increase the potency of warfarin and platelet inhibitors, thus contributing to subcutaneous manifestations such as bleeding and tearing. In this month's continuing education article as mentioned previously, we will learn the practical clinical considerations in treating skin tears. In addition, when needed, consider consultation with a dermatologist, hematologist, skin care team, physical therapist, and the little piece of paper.
Richard "Sal" Salcido, MD
References