While skin tears are a common GP presentation, doctors don’t get much training in how to manage them, and delayed or failed healing and progression to a chronic ulcer can occur.

Skin is about “the most forgiving organ we have,” and following a step-by-step approach can help you get a successful outcome, says emergency physician Dr Iestyn Lewis, medical lead for Royal Hobart Hospital’s wound clinic.

Acute skin tears

Most new skin tears can be managed successfully with fairly minimal resources, Dr Lewis says.

Step 1: Apply analgesic

“Lignocaine catheter gel works quite well. It adds a little bit of analgesia, as well as making everything a bit slippery.”

Step 2: Fold the skin tear back and scrape off clotted blood

It can help to think of skin tears as a “split skin graft that is still attached to you,” Dr Lewis says.

“If that clot remains, it actually is going to devitalise the skin from sitting down on the wound bed, which hopefully is going to revascularise.”

To lift away a clot, you can gently rub the back of metal forceps across the flap, he suggests.

Step 3: Unfurl the skin

“You don’t want the edges to roll out,” he says. “And you want to do that fairly gently. A little cotton bud or swab stick works quite well.”

Step 4: Secure the flap in place

Wounds managed by pulling everything tight and covering them with Steri-Strips often fail to heal because Steri-Strips trap moisture and are very difficult to remove, frequently lifting the skin flap with them, Dr Lewis says.

Instead, he recommends using a silicone mesh dressing, ideally one that is tacky (but not adhesive) on only one side—such as Mepitel 1 by Mölnlycke.

“You place that tacky side down and just drape it over the skin tear. And that’s transparent, moisture comes through it, it doesn’t adhere to the skin tear, and it holds it nicely in place. And that then can be left for a week or potentially two weeks.”

“I like the Mepitel because it means the absorbent dressing can be removed and you can see what’s going on. Then you can just leave it alone, essentially.”

This type of dressing will lift off easily if you soak it in water, Dr Lewis explains. “But in the meantime, it actually holds the wound quite firmly.”

“For smaller skin tears, you can use the little border silicone dressings, but they’re not transparent. And you actually want to put an arrow on to show the direction of removal,” he adds.

Importantly, the flap doesn’t have to fit perfectly. “It’s not a jigsaw puzzle,” Dr Lewis says. “You’re allowed some missing bits. And a lot of that skin flap is going to devitalise, but it’s probably donated a whole bunch of epithelial tissue that can grow from there.”

Step 5: Put an absorbent pad on top

“You need something that locks the fluid away,” he says. “So certainly not a combine.”

Zetuvit or Mesorb are suitable options.

Step 6: Fixate with a bandage or Hypafix

“You can place Hypafix on even the most delicate skin if you’re prepared to remove it gently or with appropriate adhesive removers.”

Chronic skin tears

Step 1: Remove devitalised tissue

Until you get down to base tissue.

Step 2: Apply a non-adherent, absorbent dressing

“I’ll often use Mepitel again, which is quite expensive, but it can just be left alone. And that allows granulation tissue to appear and then the epithelial tissue to migrate in. And then I dress over that. And then I just keep an eye on it a couple of times a week.

Plain foam or silicone border dressings also work, he adds. “It just needs to not adhere and be absorbent.”

If the dressing will be left on for any length of time, he recommends steering away from products like Jelonet or Bactigras because they tend to dry out. “And after a couple of days, you may well find that the epithelial and granulation tissue has grown through them.”

Step 3: Fixate as above

Infected skin tears

Step 1: Clean the wound

“Solutions containing PHMB (polyhexamethylene biguanide) such as Prontosan® are very good for cleaning infected or chronic wounds,” Dr Lewis says. He explains that PHMB breaks down bacteria (including MRSA and pseudomonas) without promoting resistance and accelerates healing.

Saline can be used, he adds, but it doesn’t cleanse the wound or affect bacterial load.

Step 2: Antibiotics

You can prescribe oral antibiotics if there is cellulitis around the wound.

However, they won’t help with the biofilms (bacterial films) that can form on the surface of wounds like plaque on teeth, which can lead to local infection.

“This is where your topical antimicrobial dressings are helpful,” Dr Lewis says, noting they vary in cost and characteristics.

“Very simple antimicrobial dressings like Inadine––an iodine-soaked gauze—may well help,” he says. “The more expensive dressings include things like silver.”

“Antimicrobials like honey tend to make things very wet. And salt-based dressings need to be changed quite often, but are quite cheap.”