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Heal Better Together�Education Series #2��Noncomplex Wounds

December 1 – 12, 2025

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Skin Tears�Types

Type 1: No skin loss. Linear or flap tear where the skin flap can be repositioned to cover the wound bed.

https://richardsonhealthcare.com/istap-classification-skin-tears/

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Skin Tears�Types

Type 2: Partial flap loss. The skin flap cannot be repositioned to cover the whole wound bed

https://richardsonhealthcare.com/istap-classification-skin-tears/

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Skin Tears�Types

Type 3: Total flap loss. Total skin flap loss that exposes the entire wound bed

https://richardsonhealthcare.com/istap-classification-skin-tears/

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Skin Tears�Prevention

Avoid use of strong adhesives on skin; use silicones when appropriate or paper tape
Hydrate skin with moisturizers especially after bathing
Avoid friction and shearing forces during repositioning and transfers
Ensure a safe environment: adequate lighting, remove obstacles
Falls risk assessment and interventions
Encourage nutrition and hydration
Consider possible effects of medications on patient's skin

Best Practice Recommendations for the Prevention and Management of Skin Tears in Aged Skin (2nd Edition) – Wounds International. https://woundsinternational.com/consensus-documents/best-practice-recommendations-for-the-prevention-and-management-of-skin-tears-in-aged-skin-2nd-edition

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Skin Tears�Intervention and Management

Control Bleeding
Cleanse with normal saline and remove any debris carefully
Re-approximate skin flap if viable:
Gently ease the flap back into place using a gloved fingertip or dampened cotton-tipped applicator

The flap will act as a biological dressing

Avoid staples, sutures or skin closure strips to approximate edges - it is no longer best practice
Manage infection/ inflammation

Best Practice Recommendations for the Prevention and Management of Skin Tears in Aged Skin (2nd Edition) – Wounds International. https://woundsinternational.com/consensus-documents/best-practice-recommendations-for-the-prevention-and-management-of-skin-tears-in-aged-skin-2nd-edition

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Skin Tears�Dressing Selection

Product Category	Indication	Skin Tear Type	Considerations	Product Example
Non-adhering mesh	Dry/weeping wounds	1,2,3	Maintains moisture balance for multiple amounts of exudate Atraumatic removal	Mepitel Adaptic
Foam dressing	Moderate exudate Longer wear time (depending on exudate)	2, 3	Caution with removal to prevent periwound trauma	Mepilex
Hydrogel/Hydrocolloid	Gives moisture back to wounds	2, 3	May cause maceration around exudative wounds
Skin glue	To approximate wound edges	1	Use within 24 hours of wound
Calcium Alginate	Moderate to heavy exudate	1,2,3	May dry out wound
Hydrofiber	Moderate to heavy exudate	2,3	May dry out wound	Aquacell
Acrylic dressing	Mild to moderate exudate w/o bleeding	1,2,3	Caution w/ removal to prevent periwound trauma	Tegaderm Absorbent Clear Acrylic

International Skin Tear Advisory Panel: Evidence Based Prediction, Prevention, Assessment, and Management of Skin Tears https://www.skintears.org/resources?lightbox=dataItem-kv8k1s9h__item1

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Skin Tears�Products that are NOT Recommended

Iodine-

Causes drying of the wound and peri-wound skin and dry skin is a major risk factor for skin tear development

Transparent film/hydrocolloid dressings with strong adhesives -

Films/hydrocolloid dressings with an acrylic- or rubber-based adhesive have a strong adhesive component that can contribute to skin tears

Note that these considerations do not apply to silicone films which are generally less aggressive or non-adherent

Gauze-

Plain gauze without a silicone contact layer does not adequately secure the skin flap, and it increases the risk of flap displacement because it may stick to the wound

Best Practice Recommendations for the Prevention and Management of Skin Tears in Aged Skin (2nd Edition) – Wounds International. https://woundsinternational.com/consensus-documents/best-practice-recommendations-for-the-prevention-and-management-of-skin-tears-in-aged-skin-2nd-edition

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Abrasions�Types

Linear (scratch): Damage to your skin in a line-like pattern. Result of a sharp, pointed object

Grazed: Skin making contact w/dragging across a rough surface. This type of abrasion can cover a large area of your skin.

Ex. Skinned knee, road rash

Patterned: An object forcefully making direct contact with your skin and rubbing against it. The wound on your skin matches the size and shape of the object that your skin touched

Ex. Markings caused by a cat scratch

Shrestha R, Krishan K, Ishaq H, Kanchan T. Abrasion. 2023 Aug 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 32119352.

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Abrasions�Intervention

Primary Dressing

Nonadherent dressings

Ex. PolyMem (for mod-high exudate)

Mepilex lite (for scant-moderate exudate)

Silver impregnated dressings if not contraindicated and infection is likely

Secondary Dressing

ABD pad

Stabilization

Kerlix

ACE Wrap

Medipore tape

https://www.woundsource.com/product/polymem-non-adhesive-dressings

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Abrasions�Considerations

Xeroform gauze will dry out and may adhere to the wound bed if not changed frequently

If a dressing is adhered to the wound, use normal saline or sterile water to wet the dressing before attempting to remove

Do not leave a large abrasion uncovered

Be careful to not apply tape over exposed wound bed

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Medical Adhesive Related Skin Injuries (MARSI)�Assessment

Signs of irritation or damage where the dressing is being applied and assess the skin based on temperature, color, moisture, turgor, integrity and fragility
Ensure proper documentation
Consider the patient’s skin tone, age, and nutritional status
Changes in skin color and texture, touch, temperature, swelling/inflammation, and the overall condition/integrity of the skin

https://www.cpd-launchpad.co.uk/summary/5662

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Medical Adhesive Related Skin Injuries (MARSI)�Prevention

Use anchor/pull technique when removing dressings

Utilize adhesive remover swabs/sticks stocked in Omnicell

Utilize appropriate skin prep

ex. cavilon

Anchor skin as close to the adhesive as possible
gently pull adhesive parallel to the skin
work your way slowly down the dressing, maintaining your anchor hand and pulling hand in close proximity

https://richardsonhealthcare.com/istap-classification-skin-tears/

https://www.woundsource.com/product/3m-cavilon-advanced-skin-protectant

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Medical Adhesive Related Skin Injuries (MARSI)�Management

Dressing selection:

use of silicone adhesive (ex. mepilex foam) in place of acrylic adhesive (mepitel) in at-risk or fragile skin
Avoid tape when possible. Use elastic netting to stabilize dressings

https://www.eboshealthcare.co.nz/catalogue-products/wound-management/dressings/film/mlycke-mepitel-film-10cmx25cm/

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Blisters�Prevention and Intervention

Prevention:

Avoid friction, clothing/devices that do not fit (TLSO braces, immobilizers, etc.)
Risk: Diabetes, peripheral neuropathy, peripheral artery disease, venous insufficiency, Infection, deformity, orthopedic devices

Intervention/Dressing Selection

Cover and protect with semi-permeable film
Foam dressings may prevent further skin irritation
Take care to not wrap a dressing too tightly

https://globemashwire.com/understanding-and-treating-blisters-a-comprehensive-guide/

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Laceration�Considerations

Contamination by dirt or foreign bodies
Associated injuries

Head/cervical spine in falls, eye in facial trauma, teeth with mouth injuries

Injury to deeper structures (e.g., tendons, joints or nerves)
Causes (e.g., animal or human bites)

Consider for tetanus prophylaxis and/or antibiotics

Impairment of blood supply

distal to the laceration/skin flap appears dusky or poorly perfused/areas with end-arteriolar supply (tip of the nose, earlobe, fingertips)

https://www.uptodate.com/contents/minor-wound-evaluation-and-preparation-for-closure?search=laceration&source=search_result&selectedTitle=2~44&usage_type=default&display_rank=2

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Laceration�Intervention

Adhesive strips (Ex. Steri-Strips)

Do not remain in place for long periods and should not be used if there is movement or tension across wound
Place strips with sufficient space between each to allow drainage of fluid from the wound to avoid infection
Keep dry for 72 hours

Tissue adhesive (Ex. Dermabond )

Can be used on wounds which have clean edges, do not require deep sutures, and are not under tension
Best for wounds <3 cm in length with edges easily held together
Do not use on mucosal surfaces
Does not require removal; comes off in 1-2 weeks

Note: Lacerations frequently require staples, sutures and/or irrigation.. Consult with primary team for necessary interventions

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Burns�Assessment

Superficial/1st Degree Burn:

Only involves the epidermis

Dry, blanchable erythema, painful, does NOT blister

Pain usually subsides in 2-3 days

Injured epithelium peels away in around 4 days

https://www.verywellhealth.com/first-degree-burn-8668084

https://www.uptodate.com/contents/assessment-and-classification-of-burn-injury#H4077291918

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Burns�Assessment

Partial thickness/2nd Degree burn:

Involves epidermis and some parts of the dermis

Superficial partial thickness:

Painful, red, weep, blanchable, blisters

These burns generally heal in 7 to 21 days

Note: Burns over joints, hands, face, or groin require consults from plastic surgery

https://www.uptodate.com/contents/assessment-and-classification-of-burn-injury#H4077291918

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Burns�Assessment

Deep partial thickness:

Dermal involvement extends to sweat glands and hair follicules

Painful, red, weeping, and sluggish blanching, painful, blisters, may be waxy or cheesy appearing

Full thickness/3rd degree burn:

Extends past the dermis to subcutaneous tissue, fascia, bone, etc.

Skin may be waxy white, leathery and grey, or black, skin is dry, insensate, and does not blanch

Note: These are considered complex wounds. If suspected notify primary team immediately

https://www.uptodate.com/contents/assessment-and-classification-of-burn-injury#H4077291918

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Burns�Considerations

There is no universal standard of practice for burns

Burns over specific anatomic sites require consultation with plastics and/or treatment at a burn specialized facility

Face
Perineum
Ears
Eyes
Hands
Feet
Joints (circumferential)

Pain control is a necessity during initial assessment, debridement, and dressing changes. Ensure patients are pre-medicated prior to any interventions

https://www.uptodate.com/contents/treatment-of-epidermal-superficial-partial-thickness-burn-injury-requiring-hospital-admission?search=burn%20dressing&topicRef=13509&source=see_link

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Burns�Intervention

Intervention:

Superficial burns do not require a dressing
Partial thickness burns may be dressed and require debridement

Dressings usually consist of 4 layers:

topical antibiotics
nonadherent gauze (ex. xeroform, adaptic, mepitel)
dry/fluffed gauze
kerlix

Foams, hydrogels, and hydrocolloids can also be used depending on exudate levels, and dressing availability

Dry gauze by itself should be avoided

https://www.uptodate.com/contents/treatment-of-epidermal-superficial-partial-thickness-burn-injury-requiring-hospital-admission?search=burn%20dressing&topicRef=13509&source=see_link