Clinical Guideline: Catheter-Associated Skin Injury

Prevention, Assessment, and Management in Vascular Access Care

1. Introduction and Scope

This clinical guideline provides evidence-based recommendations for the prevention, identification, and management of catheter-associated skin injury (CASI) in patients with peripheral and central vascular access devices. The guidance applies across clinical settings including acute care, critical care, oncology, neonatology, and ambulatory infusion services.

Catheter-associated skin injury represents a significant clinical concern that increases patient discomfort, elevates healthcare costs, delays treatment, and may necessitate premature device removal and replacement. Implementing standardized prevention and management protocols is essential for optimizing patient outcomes and preserving vascular access.

2. Definitions and Classification

2.1 Catheter-Associated Skin Injury (CASI)

Catheter-associated skin injury encompasses any abnormality of the skin occurring at a peripheral or central vascular access device site. This includes erythema, vesicles, bullae, erosion, or skin tears observed in the area of the device dressing or securement device that remains visible for 30 minutes or more following dressing or securement removal. CASI excludes skin conditions arising from unrelated sources such as eczema, autoimmune disorders, or systemic medication adverse events.

2.2 Medical Adhesive-Related Skin Injury (MARSI)

Medical adhesive-related skin injury specifically refers to erythema or cutaneous abnormalities—including vesicles, bullae, erosion, or skin tears—that persist for 30 minutes or more after adhesive removal. This subcategory of CASI addresses injuries directly attributable to adhesive products used in vascular access management.

2.3 Classification of Skin Injury Types

Erythema presents as red discoloration of the skin that may be painful or pruritic. Clinical recognition can be challenging in patients with darker skin pigmentation, requiring enhanced assessment techniques and attention to changes in skin texture or temperature.

Allergic Contact Dermatitis (ACD) represents a cell-mediated immune response occurring in the area of catheter or product contact. The affected area corresponds precisely to the zone of exposure. Clinical presentation includes erythema, vesicles, and pruritic dermatitis, with symptoms typically persisting up to one week.

Irritant Contact Dermatitis (ICD) involves non-immunological skin injury confined to the area of exposure. Presentation includes erythema, edema, and vesicles. Unlike allergic contact dermatitis, symptoms typically resolve quickly once the irritating exposure is eliminated.

Tension Injury or Blister results from separation of the epidermis from the dermis caused by tension or shear forces. Severe edema significantly potentiates the risk of this injury type.

Skin Stripping involves removal of one or more layers of the stratum corneum, commonly resulting from adhesive removal or excessive friction during site cleansing.

Maceration develops from prolonged moisture exposure and presents as pale, white, grey, or wrinkled skin. Macerated skin demonstrates increased permeability and heightened susceptibility to further injury.

Skin Tear describes separation of the epidermis from the dermis due to shear or friction forces and may be partial or full thickness in nature.

Pressure Injury involves damage to superficial and potentially deeper tissue structures resulting from prolonged pressure at the device site.

Folliculitis appears as small, inflamed, elevated pustules at hair follicles, frequently caused by trapped microorganisms or damage from shaving.

3. Risk Assessment and Patient Factors

3.1 Comprehensive Risk Evaluation

Effective prevention of catheter-associated skin injury begins with thorough assessment of individual patient risk factors. Risk evaluation should inform decisions regarding device selection, insertion site, product choices, and monitoring frequency.

3.2 Patient Population Risk Factors

Clinical evidence identifies several patient populations at elevated risk for CASI. Neonates and premature infants demonstrate particular vulnerability due to immature skin barrier function, with extremely low-birthweight and low-birthweight infants requiring specialized protocols (August et al., 2021; Mishra et al., 2021). Elderly patients face increased risk due to age-related changes in skin integrity and fragility.

Patients receiving oncology treatment, particularly those undergoing chemotherapy, experience heightened risk due to treatment-related skin toxicity and immunocompromise (Zhao et al., 2022; Tian et al., 2021). Additional high-risk populations include critically ill patients in intensive care settings, patients with compromised immune function, and those with pre-existing dermatological conditions (Frota et al., 2023; Kim et al., 2019).

Patients with peripheral edema or anasarca face elevated risk of tension injuries and dressing complications. Those with coagulopathies or receiving anticoagulation therapy may develop hematomas that promote subsequent skin injury. Patients with documented allergies or sensitivities to adhesives, antiseptics, or catheter materials require alternative product selection to prevent injury.

Nutritional status and hydration significantly influence skin integrity. Malnourished or dehydrated patients demonstrate compromised wound healing capacity and reduced skin resilience (McNichol et al., 2013; Broadhurst et al., 2017).

3.3 Device and Treatment-Related Factors

The type of vascular access device, anticipated dwell time, and characteristics of prescribed infusates contribute to CASI risk. Patients requiring vesicant or irritant infusions, multiple infusion therapies, or extended treatment courses warrant enhanced monitoring protocols.

4. Prevention Strategies

4.1 Site Selection and Device Planning

Prevention of catheter-associated skin injury begins with thoughtful device and site selection. Clinicians should avoid inserting vascular access devices into areas of pre-existing skin injury, scarring, or dermatological conditions (Rabelo et al., 2022; Pires-Júnior et al., 2021).

Utilization of vascular visualization technology during insertion reduces vascular trauma, minimizing bruising and hematoma formation that may promote subsequent skin injury (Ullman et al., 2019). For patients receiving chemotherapy with high skin toxicity risk, implanted ports may offer advantages over peripherally inserted devices (Yang et al., 2021).

Prior to device placement, clinicians should obtain a thorough patient history regarding previous CASI episodes and documented allergies to adhesives, antiseptics, or catheter materials. This information guides individualized product selection and preventive strategies (McNichol et al., 2013; Thayer, 2021; Ullman et al., 2019).

4.2 Hair Removal

When hair removal at the insertion site is necessary, clipping or trimming is recommended rather than shaving. Shaving creates micro-abrasions that increase risk of folliculitis and infection (McNichol et al., 2013).

4.3 Skin Antisepsis

The preferred skin antiseptic agent for vascular access procedures is alcohol-based chlorhexidine solution. Selection of antiseptic products should balance effective antimicrobial action with minimization of skin irritation and damage.

Clinical teams should carefully review product information, particularly for high-risk patients, as some antiseptic products are supplied in non-sterile form and may contain contaminants (Wiemken, 2019). When skin irritation is a concern, lower concentrations of antiseptic or aqueous solutions may be substituted. In cases of severe skin conditions, sterile saline may be used as an alternative.

Complete drying of antiseptic solution prior to dressing application is essential to reduce risk of maceration and skin irritation. Premature dressing application over wet antiseptic promotes moisture-related injury and may compromise adhesive integrity.

Chlorhexidine Considerations: True allergy to chlorhexidine is uncommon but has been documented, including reports of anaphylaxis (Devinck et al., 2021). Clinicians should note that patient histories may record skin irritation as an allergy, potentially limiting antiseptic options unnecessarily. Patch testing can help differentiate true allergy from irritant reactions (McNichol et al., 2013; Broadhurst et al., 2017).

Neonatal Populations: The neonatal population, particularly premature and low-birthweight infants, faces well-documented risk of skin injury from chlorhexidine use (Neri et al., 2017). Many neonatal intensive care units employ weight and gestational age criteria to guide antiseptic selection. Tincture of iodine is contraindicated in neonates due to absorption risk and potential thyroid toxicity.

Evidence remains insufficient to identify optimal skin antisepsis protocols for neonates, especially extremely low-birthweight infants. Current recommendations favor using the lowest effective chlorhexidine concentration (less than 1%), avoiding alcohol-based preparations in high-risk infants, and preferring aqueous chlorhexidine formulations (Mishra et al., 2021; Beekman & Steward, 2020; Bagheri et al., 2020; Sharma et al., 2021). Sodium hypochlorite has demonstrated minimal skin irritation in neonatal populations and represents an alternative option (Neri et al., 2017; Ciccia et al., 2018).

4.4 Skin Barrier Application

Application of an alcohol-free skin barrier product enhances protection for the skin surrounding the vascular access device insertion site. Skin barriers provide a physical protective layer for the epidermis against irritants and reduce adhesive-related trauma during dressing changes. A variety of products are available with variable effectiveness; clinicians should follow manufacturer instructions and ensure compatibility with the antiseptic solution being used (Woo et al., 2019; Bodkhe et al., 2021; Ryder & Duley, 2017). Complete drying of the barrier product is required before proceeding with dressing application.

4.5 Dressing Selection and Application

Vascular access device dressings are typically composed of polyurethane film with pressure-sensitive acrylate adhesive backing. Selection should consider breathability, stretch, conformity, adhesive characteristics, and compatibility with other products in use (Zhao et al., 2022; Thayer, 2021; McNichol et al., 2013).

Application Technique: Proper dressing application involves applying firm, gentle pressure while eliminating tension or stretch on the dressing material. Clinicians should limit or avoid substances that increase dressing adhesion such as tackifiers or bonding agents. Circumferential dressing coverage should be avoided as it may contribute to pressure injury (Rabelo et al., 2022; Thayer, 2021; McNichol et al., 2013).

Chlorhexidine-Impregnated Dressings: Chlorhexidine gluconate-containing dressings should be used to prevent central line-associated bloodstream infections in patients greater than 2 months of age with short-term central vascular access devices, including oncology patients, unless contraindicated by sensitivity or allergy to chlorhexidine (Zhao et al., 2022; Rabelo et al., 2022; Hawes, 2021).

The risks and benefits of chlorhexidine-impregnated dressings require careful evaluation in patients with complicated skin disorders such as Stevens-Johnson syndrome, graft-versus-host disease, burns, or anasarca, as well as in immunocompromised patients and infants (Canadian Vascular Access Association, 2019; Short, 2019; Jitrungruengnij et al., 2020).

Alternative Dressing Options: For challenging clinical situations, alternative dressing approaches may be warranted, including dressings that do not contain patient-specific allergens, gauze-only coverage for severe exfoliative dermatitis, silicone-based dressings, silver ion alginate antibacterial dressings to reduce folliculitis risk, hydrocolloid dressings for increased absorption, absorbent clear acrylic dressings, or hemostatic dressings for sites with bleeding (Zhao et al., 2022; Bernatchez & Bichel, 2023; Ye et al., 2019; Melhorn & Burkett, 2022).

When non-transparent dressings such as gauze are clinically indicated, expert consultation with wound care specialists, vascular access teams, or infectious disease specialists may inform optimal assessment frequency and dressing change intervals.

4.6 Dressing Change Intervals

Dressings should be changed promptly when soiled, when integrity is compromised, or upon initial signs or symptoms of skin impairment, following manufacturer guidelines. The risks and benefits of extended dressing change intervals for central vascular access devices must be weighed against increased infection risk in certain populations (Short, 2019; de Campos Pereira Silveira et al., 2020).

4.7 Securement Methods

Selection of dressing and securement methods should aim to reduce the frequency of dressing changes while incorporating patient characteristics, application area, anticipated dwell time, and prescribed therapy considerations (Thayer, 2021; McNichol et al., 2013; Hawes, 2021; Ryder & Duley, 2017).

Liquid Adhesives: Gum mastic liquid adhesive compatible with antiseptic and dressing products may be used when enhanced dressing adherence is required (Ullman et al., 2019; Ryder & Duley, 2017; DeVries et al., 2021). Cyanoacrylate tissue adhesive has demonstrated improved hemostasis, reducing localized bleeding at insertion sites and decreasing the need for early dressing changes (Gilardi et al., 2021; Zhang et al., 2022). When liquid adhesives are used, application of skin barrier film prior to adhesive application and correct removal technique are essential to prevent skin injury from enhanced bonding (Thayer, 2021; McNichol et al., 2013; Bernatchez & Bichel, 2023).

Securement Alternatives: Various securement options may reduce CASI risk, including subcutaneous anchor securement systems, integrated securement dressings, silicone splinting for infants, and central line vests (Kleidon et al., 2020; Harris et al., 2022; McParlan et al., 2020).

Medical Adhesive Tape: When evaluating medical adhesive tape for additional securement or tubing anchoring, clinicians should consider skin stripping risk. Rubber-backed tapes are associated with increased skin stripping compared to other formulations (Frota et al., 2023). Ongoing research into temperature-sensitive and photo-thermal release adhesive prototypes shows promise for developing high-adhesion tapes with safer removal properties (Swanson et al., 2022; Lim et al., 2020).

4.8 Dressing and Securement Removal

Proper removal technique is critical for preventing skin injury. The product should be kept horizontal to the skin surface during removal, as vertical pulling significantly increases peel force. The skin should be supported at the peel line throughout the removal process (Mishra et al., 2021; Thayer, 2021; McNichol et al., 2013; Hitchcock et al., 2021).

Medical adhesive remover should be used according to manufacturer instructions while maintaining aseptic non-touch technique. Additional precautions are warranted for patients at high risk for skin injury. Sterile saline may assist with removal in high-risk patients (Zhao et al., 2022; Mishra et al., 2021; Thayer, 2021; McNichol et al., 2013; Barton, 2020; Ryder & Duley, 2017; DeVries et al., 2021).

4.9 Product Integrity and Single-Patient Use

The integrity of all products should be verified prior to use. Single-patient use should be maintained for all vascular access supplies (McNichol et al., 2013; Bernatchez & Bichel, 2023).

4.10 Supportive Measures

Optimal skin health is supported by adequate hydration and nutrition. Patients with compromised nutritional status or dehydration may benefit from nutritional consultation and optimization as part of a comprehensive CASI prevention strategy (McNichol et al., 2013; Li et al., 2022; Broadhurst et al., 2017).

4.11 Education

Staff education on vascular access site care, early recognition of skin injury, and prompt management of CASI is essential. Education should address proper antiseptic application, atraumatic dressing application, and safe removal techniques. Patients and caregivers, particularly parents of pediatric patients, should also receive education appropriate to their level of involvement in care (Zhao et al., 2022; Rabelo et al., 2022; Thayer, 2021; McNichol et al., 2013; Beekman & Steward, 2020; Broadhurst et al., 2017; Hawes, 2021).

4.12 Multidisciplinary Collaboration

For high-risk patients, multidisciplinary collaboration involving dermatology and wound care specialists should be considered (Zhao et al., 2022; McNichol et al., 2013; Li et al., 2022; Ullman et al., 2019; Ye et al., 2019; DeVries et al., 2021).

4.13 Timely Device Removal

Vascular access devices should be removed as soon as they are no longer clinically indicated to prevent skin injury associated with prolonged dwell time (Barton, 2020; Jacobs et al., 2022).

5. Assessment and Monitoring

5.1 Routine Assessment

The vascular access device site, dressing, and securement status should be routinely assessed for signs and symptoms of skin injury. Assessment should include evaluation of skin texture, color, uniformity of appearance, and integrity using adequate lighting. Documented abnormalities should include specific findings such as vesicles, exudate, erythema, warmth, edema, or pressure-related injury (Zhao et al., 2022; McNichol et al., 2013; Liu et al., 2022; Pires-Júnior et al., 2021; Frota et al., 2023; Broadhurst et al., 2017; Saleh & Ibrahim, 2023).

5.2 Severity Assessment

When skin injury is identified, severity assessment determines the impact on the vascular access device, the treatment regimen, and required management interventions (McNichol et al., 2013).

For premature infants exhibiting signs of chemical burn or irritation, immediate action is required to remove the potential source of irritation. Prompt treatment and specialist consultation with dermatology and surgery should be initiated as indicated (Neri et al., 2017).

5.3 Pain Assessment

Pain related to skin injury should be assessed and treated as indicated. Management options include analgesics, anti-inflammatory agents, or cool compresses (Liu et al., 2022; Li et al., 2022; Broadhurst et al., 2017; Canadian Vascular Access Association, 2019).

5.4 Pruritus Evaluation

Pruritus associated with vascular access devices should be assessed. Treatment with antihistamines or steroids may be indicated. Clinicians should be aware that pruritus is common in certain populations, particularly patients with end-stage renal disease, which may mask CASI or other serious conditions (Broadhurst et al., 2017; Jacobs et al., 2022).

5.5 Differential Diagnosis

Assessment should rule out other conditions that may mimic or accompany CASI, including infiltration, extravasation, thrombophlebitis, and skin conditions related to other body regions such as eczema, impetigo, cellulitis, erysipelas, or drug eruptions. Wound care or dermatology consultation should be obtained as indicated (Broadhurst et al., 2017).

Signs of localized or systemic infection, including fungal infection such as candidiasis presenting as whitish or raised red areas unresponsive to other treatment, should be assessed. Adhesives and resultant skin injury may promote bacterial overgrowth (Thayer, 2021; McNichol et al., 2013; Li et al., 2022; Barton, 2021; Pivkina et al., 2018; DeVries et al., 2021).

5.6 Product-Related Factors

When abnormalities are noted, dressing, antiseptic, and securement-related factors should be ruled out. Common contributing factors include failure to allow products to fully dry, excessively frequent dressing changes, and improper removal technique (McNichol et al., 2013; Bernatchez & Bichel, 2023; Broadhurst et al., 2017).

5.7 Allergy and Sensitivity Monitoring

Early monitoring and intervention are essential when allergy or sensitivity to a product is suspected. Alternative products for cleansing, dressing, and securement should be identified promptly (Thayer, 2021; Ullman et al., 2019; Devinck et al., 2021).

5.8 Assessment Tool Development

Further validation of CASI assessment resources is needed to establish comprehensive, standardized skin assessment tools for vascular access care (Liu et al., 2022; Broadhurst et al., 2017).

6. Management of Catheter-Associated Skin Injury

6.1 General Principles

Practice variation in CASI management remains significant, and further research is needed to establish evidence-based protocols. The following interventions are recommended based on current evidence (Zhao et al., 2022; McNichol et al., 2013; Li et al., 2022; Ullman et al., 2019; Bernatchez & Bichel, 2023; Milanesi et al., 2018; Barton, 2021; Broadhurst et al., 2017; Marcant et al., 2021).

6.2 Recommended Interventions

Exposure Elimination: Subsequent exposure to products suspected of causing CASI should be avoided.

Antiseptic Modification: Consider changing to a different antiseptic product or reducing the concentration when antiseptic-related injury is suspected.

Dressing Alternatives: Dressing alternatives should be considered, balancing the need for adequate adhesion and securement against prevention of further skin damage during removal. The risks of insufficient adhesion leading to device loss must be weighed against skin protection needs.

Securement Modifications: Securement alternatives that reduce adhesive use should be considered. When using dressing systems with limited securement properties, additional attention to catheter securement and site protection is required, and monitoring frequency should be increased.

Allergy Evaluation: When new allergy is suspected, patch testing should be performed. Referral for formal allergy testing may be indicated (Marcant et al., 2021).

Adhesive Remover: If not already in use, medical adhesive remover should be incorporated into the dressing change protocol.

6.3 Skin Tear Management

When skin tears with viable skin flaps are present, the skin flap edges should be realigned prior to dressing application (Broadhurst et al., 2017; Hitchcock et al., 2021).

Transparent semi-permeable membrane dressings, adhesive strips, and hydrocolloid dressings should be avoided for skin tear management due to risk of epidermal stripping if not removed properly.

When skin damage or drainage is not in the immediate area of the vascular access device insertion site, the wound and exudate should be isolated from the exit site. An absorbent dressing should be applied over the injury, with the transparent dressing then applied over the insertion site. Published protocols indicate that silicone mesh with transparent semi-permeable membrane dressing may be used when the dressing is applied over a healthy skin border (Hitchcock et al., 2021).

6.4 Corticosteroid Therapy

When inflammation and pruritus at the site do not improve with initial interventions, short-term use of topical low-to-moderate potency corticosteroid may be considered. The corticosteroid should not be applied directly on the vascular access device insertion site, as these agents are non-sterile. Culture of the insertion site should be considered if infection is suspected (Broadhurst et al., 2017).

6.5 Escalation of Care

If skin condition does not improve within 3 to 7 days or deteriorates despite the above measures, expert consultation should be obtained from wound care specialists or dermatology (McNichol et al., 2013; Broadhurst et al., 2017; Canadian Vascular Access Association, 2019).

6.6 Device Removal Consideration

Vascular access device removal should be considered when skin injury is severe or unresponsive to treatment. The plan for ongoing vascular access needs should be reassessed prior to removal (Canadian Vascular Access Association, 2019).

6.7 Patient and Caregiver Education

Patients and caregivers should understand the strategies in place to mitigate further skin injury and the specific products that should be avoided to prevent future recurrence (Thayer, 2021; Broadhurst et al., 2017).

7. Quality Improvement

Quality improvement measures should be employed to monitor and address the incidence of catheter-associated skin injury. Ongoing monitoring of current evidence should inform exploration of new prevention and management options (McNichol et al., 2013; DeVries et al., 2021).

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Ullman AJ, Kleidon TM, Turner K, et al. Skin complications associated with pediatric central venous access devices: prevalence, incidence, and risk. J Pediatr Oncol Nurs. 2019;36(5):343-351. doi:10.1177/1043454219849572

Ullman AJ, Long D, Williams T, et al. Innovation in central venous access device security: a pilot randomized controlled trial in pediatric critical care. Pediatr Crit Care Med. 2019;20(10):E480-E488. doi:10.1097/PCC.0000000000002059

Ullman AJ, Mihala G, O’Leary K, et al. Skin complications associated with vascular access devices: a secondary analysis of 13 studies involving 10,859 devices. Int J Nurs Stud. 2019;91:6-13. doi:10.1016/j.ijnurstu.2018.10.006

Wiemken T. Skin antiseptics in healthcare facilities: is a targeted approach necessary? BMC Public Health. 2019;19(1):1158. doi:10.1186/s12889-019-7507-5

Woo K, Hill R, LeBlanc K, et al. Technological features of advanced skin protectants and an examination of the evidence base. J Wound Care. 2019;28(2):110-125. doi:10.12968/jowc.2019.28.2.110

Yang H, Rui Y, Wang G. A case of unexpected peripherally inserted central catheter removal from a colorectal cancer patient with cetuximab-induced skin toxicity and contact dermatitis at the peripherally inserted central catheter insertion site: should we recommend the patient to choose subcutaneous port preferentially? J Vasc Access. 2021;22(2):310-313. doi:10.1177/1129729820910880

Ye GJ, Wang CY, Chen Y, Xu J. Case report: a multidisciplinary approach to maintenance of a peripherally inserted central catheter in a patient with extensive exfoliative dermatitis. Int J Clin Exp Med. 2019;12(2):2004-2009.

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Zhao H, He Y, Huang H, et al. Prevalence of medical adhesive-related skin injury at peripherally inserted central catheter insertion site in oncology patients. J Vasc Access. 2018;19(1):23-27. doi:10.5301/jva.5000805

Zhao H, He Y, Wei Q, Ying Y. Medical adhesive-related skin injury prevalence at the peripherally inserted central catheter insertion site: a cross-sectional, multiple-center study. J Wound Ostomy Continence Nurs. 2018;45(1):22-25. doi:10.1097/WON.0000000000000394

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This clinical guideline synthesizes current evidence-based practice recommendations. Clinical judgment should be applied when implementing these recommendations in individual patient care. Regular review and updates are recommended as new evidence emerges.

Document Version: 1.0 Last Updated: January 2026 Review Date: January 2027