Author: Rachel Taylor, National Clinical Nurse Educator, Access Group
Following our previous article on skin tear assessment and treatment, this article discusses the role of full vascular assessment in determining whether compression should be considered as part of lower limb skin tear management.
Early assessment and differential diagnosis are essential to ensure treatment is clinically effective, cost-effective, and safe. Ankle Brachial Pressure Index (ABPI) assessment should be considered an important component of holistic lower limb assessment.
To recap ‘A skin tear is a traumatic wound caused by mechanical forces, including removal of adhesives and patient handling, the depth of which may vary (not extending through the subcutaneous layer’ (IWII, 2025).
Skin tears can be further defined as ‘uncomplicated’ or ‘complicated.’
An uncomplicated skin tear is expected to achieve full epithelialisation or heal within approximately 4 weeks.
A complicated skin tear is one that does not heal within 4 weeks. Contributing factors may include multiple comorbidities, such as peripheral arterial disease or diabetes, which can affect the normal healing trajectory; older patients may also be at greater risk of infection (LeBlanc et al., 2018; IWII, 2025).
The Wounds UK 2020 Best Practice Statement on the Management of lower limb skin tears in adults recommends incorporating compression therapy for lower limb skin tears to control oedema and aid healing, provided severe arterial disease is absent.
Doppler ultrasound assessment and ABPI form only one part of the assessment process and should not be relied on in isolation to determine diagnosis.
Doppler is a tool for assessing arterial disease in the lower leg, and any deviation from the recommended process can affect the reliability of results (Worboys, 2006).
A full leg ulcer assessment enables the clinician to identify the likely cause of the wound and any factors that may delay healing. Knowledge of lower limb circulation is essential because treatment should be guided by wound aetiology; inappropriate treatment may result in ineffective care or patient harm.
Oedema is common in patients with lower limb wounds and can delay healing. It may not always be obvious, but unmanaged oedema can negatively affect skin tear healing.
Compression therapy can reduce time to healing and improve patient outcomes in people with lower limb skin tears; however, perfusion status should be thoroughly assessed before compression is initiated (Wounds UK, 2020).
Low-level compression, such as up to 10 mmHg, may be considered where no red flag indicators are present. Higher levels of compression, up to 40 mmHg, should only be used when the patient has been assessed as suitable following full vascular assessment (Wounds UK, 2020). The New Zealand Wound Care Society (NZWCS) guidance also suggests that a liner stocking delivering 20 mmHg compression may be used for patients with a lower limb wound when no red flag indicators are identified during the first 2 weeks. If there is no evidence of healing within this timeframe, a full lower limb assessment should be completed; if clinically appropriate, full compression therapy should then be provided to reduce the risk of a complex ulcer developing.
Structured pathways for managing lower limb skin tears have been associated with improved patient outcomes and reduced costs from unhealed wounds and related complications. An early case series found that the pathway was straightforward to implement, rated highly by patients and clinicians, and associated with improved healing rates, reduced costs, improved pain levels, and no reported infections or complications in the study cohort (Vernon et al., 2019b).
Assessment
When a patient initially presents with a skin tear, a full holistic assessment of the patient, their limb and their wound should be undertaken (Wounds UK, 2015).
The patient should be assessed for:
- General health
- Skin health
- Medical history and any previous skin tears
- Individual capacity and consent
- Comorbidities and medication
- Mobility and activities of daily living
- Lifestyle and preferences.
The limb should be assessed for factors such as:
- Oedema
- Size/shape
- Adequate blood flow/signs of poor perfusion (through visible signs and ABPI testing)
- Overall skin integrity and condition.
The skin tear itself should be examined for the following factors, to inform care and prevent complications:
- Cause of the wound
- Anatomical location
- Duration of injury
- Dimensions (length, width, depth)
- Wound bed characteristics and percentage of viable/non-viable tissue
- Presence/absence of skin flap
- Type and amount of exudate
- Presence of bleeding or haematoma
- Integrity of surrounding skin
- Signs and symptoms of infection
- Associated pain (Stephen-Haynes and Carville, 2011).
Assessment findings should be fully documented, including rationale for treatment decisions and any escalation required.
Total Care Health nursing – best practice for skin tears
At Total Care Health, the nursing team has purchased MESI Doppler machines to support timely vascular assessment. When a client is admitted with a complicated lower leg skin tear, liner stockings are applied where appropriate and a full vascular assessment is completed within two weeks; once the full leg ulcer assessment is completed and compression is deemed suitable, the appropriate compression therapy is ordered for the client. The nurses are highly skilled, having been trained in both the theory and practice to complete full vascular assessments and are able to determine the results to ensure the best patient outcomes.
In summary, Doppler and ABPI assessment should be used as part of a holistic lower limb assessment to guide safe, timely decisions about compression and reduce the risk of delayed healing or progression to complex ulceration.
Total Care Health nurses can complete these assessments promptly and support best practice for complicated lower leg skin tears. Early referral to our service is therefore essential to help achieve the best possible patient outcomes.
References
Whayman, N. (2014). Doppler assessment: getting it right. Wounds Essentials, 9(2). https://wounds-uk.com/wp-content/uploads/2023/02/content_11510.pdf
Worboys, F. (2006). How to obtain the resting ABPI in leg ulcer management. Wounds Essentials, 1, 55–60.
Wounds UK. (2020). Compression therapy in skin tears. See Best Practice Statement: Management of Lower Limb Skin Tears in Adults.
Wounds UK. (2021). Tissue viability: Skin tear management, updated from Best Practice Statement: Management of Lower Limb Skin Tears in Adults.
Wounds UK. (2020). Best Practice Statement: Management of Lower Limb Skin Tears in Adults.
