Meet MARSI and understand why medical adhesive selection, application and removal are critical
Experience is etched on the skin. It becomes a canvas for our identities and displays the messages we want to tell the world. But what the skin should never show is damage caused by medical adhesives.
Medical adhesive-related skin injury, or MARSI, can be a prevalent and serious complication that occurs across all care settings and age groups, yet such injuries are generally accepted as an inevitable part of patient care. However, with the array of products available today, MARSI can often be prevented, greatly improving the patient experience.
Skin injury from medical adhesives can be a significant problem for elderly patients, young children, or patients with various dermatological conditions.1 However, this problem can also affect the general population when improper application and removal techniques are used.
A panel of key opinion leaders convened to establish consensus statements serving as guidelines for proper assessment, prevention, product selection and usage, and treatment of skin injuries caused by medical adhesive devices such as tape, dressings, drapes, or electrodes. The term MARSI emerged from this conference, and guidelines were published in 2013.2
Some preventable causes of medical adhesive-related skin injury are:2
- using adhesive products with excessive adhesion for the purpose;
- wrong choice of products, such as not using a tape with stretch to accommodate swelling or movement;
- improper application technique;
- leaving occlusive products on for too long;
- improper removal technique; and
- repeated taping or dressing changes
MARSI includes mechanical effects (e.g., skin stripping, tension injury or blisters, skin tears), dermatitis (irritant contact dermatitis and allergic dermatitis), and complications such as maceration and folliculitis.
The actual prevalence of MARSI is largely unknown. Only a few studies have been published so far in specific populations, reporting 8%3 and 14.8%4 in hospitalized pediatric patients in the U.S., and 15.5%5 in elderly patients in a long-term care environment in Japan. It is thought that this condition is underreported because it is often considered the cost of providing care by many clinicians.
Various studies have now shown the proper choice of tape can make a big difference in complication rates, as demonstrated in a study on the prevalence of tape blisters after hip surgery.6 This study showed the prevalence of tape blisters in this surgical application was significantly lower (10% versus 41%) when a perforated cloth tape was used compared to a nonstretchable silk tape. A different study showed a nonwoven porous adhesive bandage caused fewer skin problems than a transparent film bandage as a fixation product after hip surgery.7
Product Selection Matters
Several different types of adhesives are employed in wound care products, depending on the intended application (e.g., securing a device, covering a chronic wound, protecting skin at risk). Acrylic adhesives are commonly used in wound dressings and tapes because they provide secure attachment. However, because acrylic adhesion generally builds over the 24-48 hours following application, they can be difficult to remove. Ideally, acrylic adhesives should be limited to the border in dressing products, so as to adhere to the peri-wound skin but not to the wound bed itself. When selecting a tape with acrylic adhesive, the backing material (e.g., elastic foam, paper, plastic, silk, soft cloth) should drive the choice as it impacts the gentleness, stretch, strength, and moisture tolerance.2
Hydrocolloid adhesive dressings form a soft gel in the presence of wound exudate, facilitating their removal. However, they can elicit contact allergic reactions and possibly lead to peri-wound maceration.8 Hydrocolloid adhesive products can also be used as a taping platform to provide a protective layer under tape that is frequently changed.2
Silicone adhesives provide a safe level of adhesion that, unlike acrylic adhesives, does not increase over time. Silicone adhesives are also associated with less damage to the top layer of the skin, the stratum corneum, upon removal and are favored for fragile skin applications. Lund has reviewed this topic, with special considerations for skin injury in the neonatal intensive care unit.9 Various silicone dressings are available for wounds. Silicone tape is a good choice for securement of lightweight dressings and tubing, and on at-risk skin or when frequent retaping is required. It is not recommended for primary securement of critical tubing and appliances.2
Medical Adhesive Application & Removal
Proper adhesive product application and removal can help minimize the risks of MARSI.2 Consider the following steps:
- Prepare the skin
- Clip/trim hair
- Clean and dry skin to remove soil and residue
- If using a skin prep or a skin barrier film, allow it to dry completely
- Select the best adhesive for the clinical needs
- Apply and remove adhesive carefully
- Avoid the routine use of tackifiers (e.g., benzoin tincture and mastic) to increase adhesion
- Apply tape/dressing without tension or stretching
- Apply firm pressure to activate the adhesive and gain full contact with the skin
- Remove tape/dressing slowly in the direction of hair growth, keeping it close to the skin and supporting skin at the peel line
Barrier films may mitigate adhesive stripping by forming a protective interface between the epidermis and the adhesive.10 Adhesive removers can also be used in conjunction with the medical adhesives to reduce pain and the risk of MARSI.11
Expert opinion suggests appropriate selection of adhesive products and proper application and removal techniques can help minimize MARSI.