Wounds uk VOL 12 ISSUE 4 NOV 2016

MARSI made
easy
Hydrotherapy
Medical adhesive-related skin injuries

Figure 1: Types of MARSI

Introduction
Medical adhesive-related skin injury (MARSI) is
prevalent, under-recognised and preventable, Mechanical
and can occur in any patient group or setting.
Skin Removal of one or more
When superficial layers of skin are removed by (epidermal) layers of the stratum corneum
stripping following removal of adhesive
medical adhesive, it not only affects skin integrity, tape or dressing
but causes pain, increases risk of infection, and
potentially increases wound size and delays Tension Injury caused by shear force
injury or as a result of distension of skin
healing, all of which reduce patient quality of life. blister under an unyielding adhesive
The presence of one or more intrinsic or extrinsic tape or dressing

factors increases the risk that MARSI will occur

when medical adhesives are used. It is important Skin tear Wound caused by shear, friction
to assess the patient and skin in order to devise and/or blunt force resulting in
separation of skin layers; can be
the most appropriate care plan. Prevention can partial- or full-thickness
be implemented through steps in four broad
categories: skin preparation, selecting appropriate
medical adhesives, adhesive product application Dermatitis
and adhesive product removal.
Irritant Non-allergic contact dermatitis
contact occurring as a result of a
Authors: McNichol L, Bianchi J dermatitis chemical irritant; a well-defined
affected area correlates with the
area of exposure
PREVALENCE OF MEDICAL ADHESIVE-RELATED
SKIN INJURIES (MARSI)
Allergic Cell-mediated immunologic
Medical adhesive-related skin injury (MARSI) is a prevalent, dermatitis response to a component
under-recognised and preventable complication that occurs of tape adhesive or backing;
across all care settings, age groups and patient types, from typically appears as an area of
healthy patients in ambulatory care, to patients with multiple erythematous vesicular, pruritic
dermatitis corresponding to the
comorbidities in critical care (McNichol et al, 2013). MARSI has area of exposure and/or beyond
been defined as “an occurrence in which erythema and/or other
manifestation of cutaneous abnormality (including, but not
limited to, vesicle, bulla, erosion, or tear) persists 30 minutes or
more after removal of the adhesive” (McNichol et al, 2013). Other
There are three main categories of MARSI, and a variety of
subtypes (Figure 1). Maceration Changes in the skin resulting
from moisture being trapped
There is evidence to show incidence of adhesive-related injuries. against the skin for a prolonged
period; skin appears wrinkled
For example, these injuries have been reported as the most and white/grey in colour
common source of skin breakdown in neonatal intensive care
units (Kuller-McManus, 2001).

In elderly patients, the incidence of these injuries is higher. In a Folliculitis Inflammatory reaction in hair
follicle caused by shaving
nursing home-based study, an overwhelming 98.6% of registered or entrapment of bacteria;
nurses surveyed indicated that skin tears were “common” to appears as small inflamed
elevations of skin surrounding
“extremely common” among their elderly patients (White, 2001). the hair follicle
A survey of hospital-based nurses found that nearly all (n=41)
respondents had treated MARSI in the 12 months leading up to the
survey, with a MARSI incidence rate of 7.1% and an average of 2.8

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Figure 2: Two-part MARSI risk assessment

Assess intrinsic patient risk factors Assess extrinsic patient risk factors

Risk factors Risk factors

Extremes of age Drying of the skin due to harsh skin

(neonate/premature infant cleansers, excessive bathing, low
and the elderly) humidity, etc

Race/ethnicity Prolonged exposure to moisture

Dermatologic conditions Certain medications (e.g. anti-

(i.e. eczema, dermatitis, chronic inflammatory agents, anticoagulants,
exudative ulcers, epidermolysis chemotherapeutic agents, long-term
bullosa) corticosteroid use)

Underlying medical Radiation therapy

conditions (i.e. diabetes,
infection, renal insufficiency,
immunosuppression, Photodamage
venous insufficiency, venous
hypertension, peristomal varices)
Tape/dressing/device removal
Malnutrition
Repeated taping
Dehydration

injuries per patient who suffered skin damage (Maene, 2013). Skin treatment application at ~€1.23—€8.86 (~£1.10—£7.90) per
stripping and skin tears were the most common MARSI, followed by patient over the course of treatment (Maene, 2013).
tension blisters and dermatitis (Maene, 2013). A study in an elderly
patient population found that the incidence rate of MARSI was
15.5%, with the most common injuries being contact dermatitis, CAUSES OF MARSI AND CHALLENGES
trauma and infection (Konya et al, 2010). IN ITS PREVENTION
Perhaps because MARSI is so common, current thinking is that it
When considering the research, it is important to note that skin is just part of life with medical adhesive use — a necessary evil.
tears can be caused by factors other than MARSI, and that much of In addition, difficulties arise because MARSI may seem to occur
the existing research on skin injuries in general focuses on the use despite best efforts at gentle removal, and clinicians may come to
of medical tapes (LeBlanc and Baranoski, 2011). Clinicians are in the believe that nothing can be done.
early stages of reporting and understanding MARSI and its causes.
In truth, although it is intuitive that MARSI occurs when the bond
between adhesive and skin layers is stronger than that between
IMPORTANCE OF MARSI PREVENTION the various skin layers — resulting in separation of skin cells upon
When superficial layers of skin are removed by medical adhesive, adhesive removal — the pathophysiology is not fully understood
it not only affects skin integrity, but causes pain, increases risk (McNichol et al, 2013).
of infection, and potentially increases wound size and delays
healing, all of which reduce patient quality of life (Cutting, 2008). However, there are several causal factors that result in MARSI.
In some cases, adhesives can also cause deeper tissue injuries Firstly, varying compositions of medical adhesives warrant careful
beyond the loss of superficial skin layers (Denyer, 2011). consideration before selection: adhesives warm when pressed
against the skin, filling in the gaps between the adhesive and
Although the injuries caused by medical adhesives may appear irregularities in the skin surface (Zeng et al, 2016).
minor, care and management of MARSI can be costly in terms
of nursing time and money: nurses report treating MARSI The traditional adhesives (acrylates, in particular) increase in
approximately five times a week, an average of 7.8 times per strength over time, whereas silicone adhesives mould into the
patient, and costs calculations put the average cost per MARSI skin’s irregularities more quickly, and maintain a constant level

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of adhesion over time (Zeng et al, elevated, and that steps for prevention Box 1: Recommendations for use of
2016). However, caution should should be initiated. barrier films (McNichol et al, 2013)
be exercised when using silicone
adhesives to secure some devices, n Skin barrier products provide
as they may result in sub-optimal CONCLUSION protection between the skin and
adhesion and dressing failure For many patients, MARSI is a adhesives, as well as providing
(McNichol et al, 2013). preventable injury (Figure 3, p4). protection against body fluids,
Adopting a focused, structured approach wound exudate, urine and faeces
Techniques used both to apply and to risk assessment will help clinicians n Typically available as a liquid
remove medical adhesives should to choose the right product for each (wipes, foam applicators
be examined as potential ways to patient. Education incorporating skin or spray), barrier films may
decrease the incidence of injury. preparation, adhesive selection and contain silicones, acrylates,
application and removal of adhesive organic polymers or inorganic
Secondly, intrinsic patient factors products will also reduce the risk compounds in a solvent
(e.g. very young or very old age, of MARSI. that evaporates to create a
underlying medical conditions) transparent, flexible, breathable,
increase the risk of MARSI protective coating on the skin
(McNichol et al, 2013), and extrinsic REFERENCES n Some barrier films also include
and/or treatment factors (e.g. Cutting KF (2008). Impact of adhesive surgical tape an added component (plasticiser)
certain medications, repeated use of and wound dressings on the skin, with reference to that allows flexibility in the
skin stripping. J Wound Care 17(4):157-8, 160-2.
adhesives over a prolonged period) applied product
can influence the likelihood of injury Davis JM (2016). Patient safety – the role of medical n Barrier films reduce erythema
adhesives. Presented 21 April 2016 at: Birmingham
(McNichol et al, 2013). Area WOC Nurses Association; UAB Hospital, and incidence of MARSI and are
Birmingham, USA. therefore recommended for use
The condition and environment Denyer J (2011). Reducing pain during the removal of in conjunction with medical
of the skin itself must be accounted adhesive and adherent products. Br J Nurs 20 (suppl adhesives, particularly in high-
15): S28-S35.
for, to understand the level of risk patients
skin integrity. Holloway S, Jones V (2005). The importance of skin n Use of barrier products in
care and assessment. Br J Nurs 14(22):1172-6.
neonates and in the periwound
Furthermore, components of the Konya C, Sanada H, Sugama J, et al (2010). Skin and ostomy setting is particularly
injuries caused by medical adhesive tape in older
adhesive may cause inflammation of important, given the propensity
people and associated factors. J Clin Nurs19(9-
the skin, resulting in irritant contact 10):1236-42. for compromised skin integrity
or allergic dermatitis-type MARSI. Kuller-McManus J (2001). Skin breakdown: Risk
n Do not use barrier films that
These factors must be considered factors, prevention and treatment. Newborn and contain alcohol in neonates,
together when determining MARSI Infant Reviews 1: 35-42. due to the potential for drying
risk and, subsequently, a prevention LeBlanc K, Baranoski S (2011). Skin tears: State of of the skin
regimen. science: Consensus statement of the prevention, n Silicone-based barrier films are
prediction, assessment and treatment of skin tears.
Adv Skin Wound Care 24(9): 2-15
often used in neonates outside
of manufacturers’ indications for
Maene B (2013). Hidden costs of medical tape-
IDENTIFYING PATIENTS induced skin injuries. Wounds UK 9(1):46-50. use. Use of these barrier films has
AT RISK OF MARSI been described in neonates and
McNichol L, Lund C, Rosen T, Gray M (2013).
The presence of one or more of these Medical Adhesives and Patient Safety: State of the premature infants but further
factors increases the risk that MARSI Science: Consensus statements for the assessment, research is needed.
will occur when medical adhesives prevention, and treatment of adhesive-related skin
injuries. J Wound Ostomy Continence Nurs 40(4):
are used. All should be assessed for 365-80.
and documented before choosing an
White R (2001). Skin tears: a descriptive study of the
appropriate medical adhesive opinions, clinical practice and knowledge base of RNs
(Figure 2, p2). caring for the aged in high care residence facilities. AUTHOR DETAILS
Primary Intention 9(4):138-49.

Underlying illness, extremes of age, Wounds UK expert panel (2014). Best practice McNichol L1, Bianchi J2
immunosuppression, skin changes statement: Principles of wound management in 1. WOC Nurse, Cone Health, Wesley Long
paediatric patients. London: Wounds UK. Available
and/or existing skin injuries, and Hospital, Greensboro, USA
from: www.wounds-uk.com.
treatments for other medical 2. Medical Education Specialist, Honorary
Zeng LA, Lie SA, Chong SY (2016). Comparison of Lecturer at University of Glasgow, UK
conditions are the most significant medical adhesive tapes in patients at risk of facial
indicators that MARSI risk will be skin trauma under anesthesia. Anesthesiol Res
Pract 2016.

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Figure 3: Practical steps for minimising MARSI

There are four broad categories for preventing and minimising incidence and identification of at-risk patients, appropriate skin preparation,
of MARSI (Holloway and Jones, 2005; McNichol et al, 2013; Wounds UK appropriate selection of medical adhesives, best practice application and
Expert Panel, 2014; Davis, 2016). It is important to implement a multi- removal of adhesives — to reduce incidence of MARSI.
factorial MARSI-prevention regimen — including thorough assessment

Skin preparation Adhesive product application

n Remove excess hair by trimming or using clippers — no shaving n Provide standardised staff training in adhesive product application
n Determine and address any causes of excess moisture — e.g. sweating, n Do not routinely use tackifiers
urine or leakage from a wound or drain n Use sufficient, appropriate pressure to gain adhesion
n Assess skin maceration and oedema and initiate management n Cover adequate surface area to evenly distribute adhesion tension
for the underlying conditions n Obtain full contact — ironically, gaps will cause more tension in the adhesive
n Be sure skin is clean and dry area that has contact with the skin, increasing risk of MARSI
n Apply protective alcohol-free barrier film (Box 1, p3) n Tape or dressing should be long enough to extend to 1.25cm (2.5cm is preferred)
beyond the dressing or device
Choosing appropriate medical adhesives n Orient tape/dressing to allow stretch (i.e. in the direction of expected
n Consider the results of the two-part assessment (Figure 2, p2) swelling or movement)
n Consider the anatomy over which the adhesive will be placed. For example, n Apply tape/dressing without stretch or tension: replace arylate tape or
is the area contoured (e.g. sacrum) or flat (e.g. arm), and is there potential for reposition silicone tape if swelling/distention occurs
the skin to stretch due to factors such as oedema, distention and movement? n Apply gentle, firm pressure after application, stroking the tape in place
n Consider length of wear time, as many adhesives bond more strongly to
skin the longer they are in contact Adhesive product removal
n Match these factors against both the risk-level of the skin and the requirements n Provide standardised staff training in adhesive product removal
for medical adhesive use (Table 1, below) n Remove at a low profile to the skin; gently, slowly and evenly
n Use the lowest level of adhesion required to secure the device or dressing, n Consider the use of a specialised medical adhesive remover
and use tape with stretch where possible or needed n Removing dressings too frequently can cause unnecessary trauma to the skin
n Consider newer adhesive products such as silicone adhesive where adhesion is and potentially delay wound healing, therefore remove dressings only when
needed but skin is at risk there is an indication to do so (e.g. due to exudate levels)
n A note on silicone adhesives: although they are softer and have a lower surface n Remove tape/dressing slowly, keeping tape horizontal and close to the skin
tension, letting them fill gaps in skin irregularities quickly and gently, these n Remove in the direction of hair growth
products may be less moisture-resistant than traditional adhesives, and more n Support exposed skin at the peel line as tape/dressing is removed.
research is needed into their use, efficacy and prevention of skin injuries

Table 1: Level of adhesion consideration

Critical securement Multipurpose Gentle to skin

Securing medical devices Securing medical devices (e.g. ostomy bag) Anchoring dressings
Heavy tubing (e.g. endotracheal tube, chest Immobilising body parts Lightweight tubes/devices (e.g. IV)
tube nasogastric tube)

Higher level of adhesion Moderate level of adhesion Lower level of adhesion

To cite this document: McNichol L, Bianchi J (2016) Medical adhesive-related skin injuries (MARSI) made easy. London: Wounds UK.
Available from: www.wounds-uk.com

Supported by 3M | www.3m.co.uk
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