Fragile skin safety isn’t optional—it’s part of preventing avoidable harm. This beginner’s guide is for bedside nurses, WOC clinicians, and hospital value analysis teams who want a clear, evidence-grounded starting point. You’ll learn what counts as medical adhesive-related skin injury (MARSI), where risk is highest (older adults with skin tears and neonates), and how to apply a simple, atraumatic workflow you can validate locally. We’ll also translate common IFU patterns for silicone foams and explain the ISO 10993 biocompatibility basics procurement teams should expect from vendors.
What is medical adhesive-related skin injury (MARSI)?
MARSI typically refers to erythema or skin damage (vesicle, bulla, erosion, or tear) that persists for 30 minutes or more after removal of an adhesive or device. That operational definition, established in consensus work by McNichol, Lund, Rosen, and Gray and echoed in later summaries, frames MARSI as preventable harm when adhesives are selected, applied, or removed in ways the skin can’t tolerate. For a practical overview of prevention and removal technique, see the 2024 Wounds International summary on preventing patient harm from adhesive use, which reiterates gentle-adhesive selection and slow, supported removal as core elements of care: “Medical adhesive-related skin injury (MARSI): preventing patient harm” (Wounds International, 2024). A 2022 open-access review likewise emphasizes risk assessment, barrier protection where indicated, and atraumatic technique: De Faria et al., MARSI prevention review (2022).
A quick rule of thumb to distinguish terms:
Skin tears are traumatic separations of skin layers (common in aged skin) and are classified to guide treatment.
Pressure injuries result from sustained pressure/shear, not primarily from adhesives.
MARSI centers on damage linked to adhesives/devices and the way we apply and remove them.
A proven 5-step atraumatic workflow
Assess Screen for MARSI risk: advanced age or neonatal skin, history of skin tears or dermatitis, chronic steroid use, edema/moisture, frequent device manipulation (ICU/post-op). Document baseline skin condition and the plan for wear time.
Prepare skin Cleanse gently and dry thoroughly. Where local policy allows, consider alcohol-free barrier film on at-risk periwound skin. Reduce adhesive footprint (smaller borders, protect bony edges) and plan fixation to avoid tension.
Select the least traumatic adhesive that still meets the goal For fragile skin, soft silicone adhesives are commonly preferred because they maintain gentle adhesion and can be removed with lower peel forces compared with many traditional acrylics in lab and clinical contexts. When coverage is needed over a delicate wound bed, consider a non-adherent silicone contact layer under a secondary dressing to protect the skin–dressing interface. For education on when a contact interface is useful, see a neutral explainer on a silicone wound contact layer.
Apply without stretch Anchor without tension, smooth out wrinkles, and avoid sealing excess moisture. Record start time/date and the intended wear window so staff can avoid unnecessary early changes.
Remove “low and slow,” supporting the skin Support the periwound skin at the edge with one hand. With the other, gently peel the dressing back at a low angle (about 15–20 degrees) in the direction of hair growth, staying close to the skin surface. Advance slowly, re-adhering the edge to reduce shear. If policy allows, use a silicone-based adhesive remover—especially for long-in-place dressings.
Practical example (elderly skin tear, neutral brand reference) An 83-year-old with a Category 2 skin tear on the forearm has paper-thin, ecchymotic skin. After assessing risk and prepping the skin, the team selects a soft silicone foam dressing to protect the flap and manage moderate exudate. The dressing is applied without stretch and documented for a multi-day wear target. Removal is performed “low and slow,” with the skin supported. In many hospitals, options include widely available soft-silicone foams; teams may review vendor IFUs and materials science summaries (e.g., SLK Medical’s silicone foam research) alongside clinical guidance when building local SOPs—kept strictly non-promotional and evidence-aligned.
Older adults and skin tears — practical pointers aligned with ISTAP
Frailty, dry skin, and minor trauma make older adults particularly vulnerable to skin tears and MARSI. Consensus documents aligned with ISTAP emphasize early classification, gentle handling, moisturization, and atraumatic dressings. The latest prevention recommendations for aged skin can be accessed in the Wounds International/ISTAP update: Best Practice Recommendations for the prevention and management of skin tears in aged skin — 2nd edition (Wounds International/ISTAP, 2025).
What to do at the bedside, in plain language:
Classify the skin tear promptly to guide flap protection and dressing selection.
Maintain a routine of pH-balanced cleansing and moisturization; protect edges and prominences.
Choose gentle adhesives (often soft silicone) or use a protective contact layer beneath a secondary dressing when the periwound is fragile.
Educate staff and caregivers; audit incidents so the team can see trend improvements.
Short vignette During morning rounds, a nurse notes blanchable erythema extending beyond the dressing border on an elderly patient’s shin. Instead of immediate re-taping, they cleanse, allow the skin to dry, apply an alcohol-free barrier film per protocol, and re-secure using a low-tack silicone tape with no stretch. At the next change, removal is performed slowly with skin support. The erythema does not persist beyond 30 minutes, helping the team avoid a MARSI classification.
Neonates and pediatrics — minimize adhesive trauma from the start
Infant skin—especially in preterm neonates—has a thin stratum corneum, higher permeability, and lower mechanical tolerance. Institutional guidelines consistently advise minimizing adhesives, selecting gentler options when fixation is required, and avoiding harsh solvents. See the nursing guideline on neonatal and infant skin care from the Royal Children’s Hospital for practical bedside guardrails: RCH Neonatal & Infant Skin Care Guideline (updated through 2024). Alberta Health Services offers a complementary, prevention-focused approach: Neonatal Skin Assessment and Injury Prevention (AHS, 2021).
Practice themes to carry forward:
Use the smallest necessary adhesive footprint; prefer soft silicone tapes or electrodes when policy supports it.
Cleanse gently and dry completely; for device fixation, consider dedicated securement devices to avoid repeated re-taping.
Remove dressings and tapes very slowly, parallel to the skin, with continuous skin support; avoid solvent-based removers unless explicitly approved by neonatal policy.
Vignette A preterm infant requires ECG monitoring. The team chooses neonatal-appropriate electrodes and secures lines with minimal adhesive footprint. During line repositioning, removal is done gradually with the skin supported. No erythema persists past 30 minutes, reducing the risk of MARSI and preserving fragile skin integrity.
Device-related MARSI in ICU/post-op — a quick primer
In high-intensity settings where adhesives are manipulated frequently, MARSI risk rises. A Korean spinal-surgery cohort reported a substantial incidence of MARSI at surgical sites and identified patient and postoperative factors associated with risk: Kim et al., surgical dressing–associated MARSI (2021). A later comparative cohort found that acrylate adhesive dressings were associated with a higher adjusted MARSI risk than silicone adhesive dressings and earlier onset after surgery: Yang et al., acrylate vs silicone after spinal surgery (2025).
What helps here: standardize a bundle—risk screening, consider barrier films where indicated, prefer gentle adhesives for at-risk skin, minimize re-taping, and enforce slow, supported removal technique at every dressing/device check.
IFU guardrails for silicone foam dressings
Across manufacturers, Instructions for Use (IFUs) show recurring patterns for bordered silicone foams. Typical indications include management of low-to-high exudate wounds such as pressure injuries, venous/diabetic ulcers, traumatic wounds (including skin tears), and post-operative wounds. Common cautions include known hypersensitivity to components, single-use sterility, and avoiding oxidizing agents (e.g., hydrogen peroxide or hypochlorite). Wear-time windows are often “up to 7 days,” but vary with exudate level, wound condition, and patient factors. Always defer to the exact IFU in hand for indications, contraindications, and wear guidance specific to the product variant in use.
Biocompatibility basics: what ISO 10993 means for dressings
Procurement and value analysis teams should expect vendors to provide a current biocompatibility rationale aligned to FDA-recognized ISO 10993-1. For devices contacting intact skin (e.g., adhesive borders), expect data or justification for cytotoxicity, sensitization, and irritation. For dressings contacting breached skin or used for prolonged durations, additional endpoints (such as acute systemic toxicity, pyrogenicity, subacute/subchronic toxicity, and others depending on duration and nature of contact) are typically addressed via testing and/or chemical characterization with toxicological risk assessment. FDA’s guidance outlines endpoint selection and documentation expectations: FDA Guidance on the use of ISO 10993-1 (current page).
From a supplier qualification standpoint, procurement teams also commonly record quality-system credentials (separate from biocompatibility), such as ISO 13485 certification; SLK Medical notes ISO 13485 on its company profile page.
From evidence to action
Source type and year | Key finding (plain language) | How to apply safely |
|---|---|---|
Guideline/consensus (Wounds International, 2024; De Faria et al., 2022) | MARSI is preventable with risk screening, gentle adhesives, barrier protection where indicated, and slow, supported removal. | Build a standard 5-step workflow and audit adherence; document skin condition and removal technique in rounds. |
Aged-skin guidance (Wounds International/ISTAP, 2025) | Prioritize moisturization, safe handling, early classification, and atraumatic dressings for skin tears. | Add moisturization and skin-tear classification to admission checklists; train on flap protection. |
Surgical cohorts (Kim 2021; Yang 2025) | High MARSI incidence at surgical sites; acrylate adhesives associated with higher MARSI risk vs silicone in one cohort. | For at-risk patients, prefer gentle adhesives and minimize re-taping; monitor for early erythema that persists ≥30 minutes. |
Manufacturer IFU patterns (Mölnlycke catalog, 2024) | Silicone foams often indicate up to 7-day wear; contraindications and cautions recur across brands. | Set wear-time targets but individualize; always follow the exact IFU on hand; avoid oxidizing agents if listed. |
FDA/ISO 10993 (FDA guidance page) | Intact vs breached skin contact drives different endpoint expectations. | Request current ISO 10993 summaries and FDA recognition status during vendor evaluations. |
Implementation checklist for teams
Adopt the 5-step atraumatic workflow and include “low-and-slow” removal in skills validation.
Standardize risk screening for MARSI (adults and neonates) at admission and shift handover.
Stock gentle options (e.g., soft silicone foams, tapes, and contact layers) and reduce high-tack defaults for fragile skin areas.
Add IFU verification to bedside setup: indication confirmed, intended wear window noted, removal plan documented.
Capture KPIs: MARSI incidence per 1,000 dressing-days, average wear time achieved, nursing time per change, and maceration/skin-stripping events.
Include biocompatibility documentation (ISO 10993 summaries) in supplier files and review annually.
Closing Fragile-skin safety improves when teams agree on definitions, standardize an atraumatic workflow, and align products and policies to IFUs and biocompatibility expectations. As you build or refresh local SOPs, review vendor IFUs and technical specs—SLK Medical’s public product literature can be one of several neutral sources—so your choices match policy, patient mix, and training plans. If your clinicians need fixation options for fragile skin, an educational starting point is medical silicone tape, which can reduce the adhesive footprint when used appropriately and per local protocols.
