Incontinence-associated dermatitis

Denise Nix

Vicki Haugen

What is incontinence-associated dermatitis (IAD)?

Perineal dermatitis, recently relabeled incontinence-associated dermatitis, is an inflammation of the skin that occurs when urine and/or stool comes into contact with the skin. IAD is painful and can range in severity from erythema with or without loss of skin integrity and infection. IAD affects as many as 41% of adults in long- term care; it is costly, painful, and for the most part, preventable.

What causes IAD?

Multiple potentially harmful variables work together to cause perineal skin breakdown. Moisture from incontinence alters the skin’s protective pH and increases the permeability of the stratum corneum. An intense irritant such as feces contains bacteria that can permeate the stratum corneum, allowing for secondary infections (e.g., candidiasis). The need for frequent cleansing can lead to further pH changes and damage from friction.

How is IAD prevented and treated?

Perhaps the most important intervention is to address the underlying cause of the incontinence itself. It should not be assumed that incontinence is expected in the elderly; in fact, there are a number of reversible factors that can lead to incontinence such as constipation or urinary tract infection. Each patient who is incontinent should be evaluated by a professional with the ability to diagnose and manage underlying and reversible causes.

Perineal skin assessment will help drive prevention and treatment choices; ongoing skin assessments will help determine if the interventions are effective. The skin assessment must differentiate between IAD and other types of skin disorders (e.g., pressure ulcers or herpes simplex), and include identification of secondary infection (e.g., Candida albicans) that will require antifungal therapy. The goal for perineal skin care will focus on keeping feces and urine off the skin with protocols that include cleansing, protection, and containment.

At a glance…

IAD can be prevented and reversed with appropriate skin care. Incontinence skin care requires timely and appropriate cleansing and protection that minimizes or prevents exposure of the perineal skin to urinary or fecal incontinence.

Which skin care products are needed for effective protocols?

A gentle cleanser should be indicated for perineal skin cleansing. Perineal cleansers may be packaged as a liquid, emulsion, foam, or towelette. Bar soap and products intended for routine skin cleansing or antibacterial handwashing should not be used because they can dry the skin, raise its pH, and contribute to the erosion of the epidermis. No-rinse perineal cleansers are safe and effective and can minimize drying if they contain humectants because they are left on the skin rather than rinsed away.

The use of skin protectants are the cornerstone in the prevention and treatment of IAD. A moisture barrier (also known as skin protectant or skin barrier) may be incorporated into skin cleansers or applied separately as a cream, ointment, or paste. Newer products on the market have the properties of a paste and are formulated to be clear or transparent for skin inspection. Liquid-barrier films or skin sealants used for IAD consist of a polymer combined with a solvent. A liquid film barrier should not be combined with a barrier cream or paste because these products are often incompatible. Some solvents may irritate compromised perineal skin; therefore, liquid-barrier films for perineal skin care should be limited to products that do not sting. Barrier selection is generally based on the intensity of irritant. For example, a barrier cream is generally adequate skin protection for a patient with urine incontinence alone. However, feces is more harmful to the skin requiring a more durable barrier product such as an ointment or paste.

Which containment products are needed for effective protocols?

Underpads or absorbent briefs may be used as long as they wick moisture away from the skin (such as with polymer-based absorptive products) rather than trap the moisture against the skin such as with plastic back or nonpolymer products. External fecal pouches (i.e., fecal incontinent collectors) and external urinary catheters (i.e., condom catheters) may be used to contain and divert urine and feces away from the skin. Rectal tubes should not be used to contain fecal incontinence because they can perforate the bowel and damage the anal sphincter. FDA-approved indwelling fecal containment devices on the market can be used safely. As with all medical devices, it is critical to follow manufacturer instructions, indications, and contraindications to ensure safety and efficacy. Due to the incidence of urinary tract infections, indwelling (i.e., Foley) catheters should not be routinely used for skin protection and should be discontinued if they are not medically necessary.

Conclusion

Incontinence care should be coordinated with treatment of the causative condition. IAD can be prevented and reversed with appropriate skin care. Caring for individuals with potential or actual IAD begins with a thorough assessment that identifies potential for or actual skin injury as well as factors that may exacerbate skin injury. Incontinence skin care requires timely and appropriate cleansing and protection that minimizes or prevents exposure of the perineal skin to urinary or fecal incontinence.

The use of skin protectants are the cornerstone in the prevention and treatment of IAD.

Denise Nix, RN, MS, CWOCN, received a Bachelor of Science in Nursing from the College of St. Catherine’s in St. Paul, Minnesota and a Master of Science in Nursing from the University of Minnesota. She has been a board certified wound, ostomy, and continence nurse specialist since 1992. Her years of experience include national and international speaking, litigation consulting, and publishing in peer reviewed journals and chapters. She most recently coedited the textbook, Acute And Chronic Wounds; Current Management Concept, 3rd Edition. Ms. Nix currently serves as clinical practice chair for the North Central Region of the Wound Ostomy and Continence Nursing Society, pressure ulcer advisory group member to the Minnesota Hospital Association. Her current clinical practice is at Park Nicollet Methodist Hospital and Clinics in Minneapolis, Minnesota.

Vicki Haugen, RN, MPH, CWOCN, OCN, FCN, received a Bachelor of Arts in Nursing degree from Gustavus Adolphus College in St. Peter, Minnesota, and a Master’s degree in Public Health from California College for Health Sciences. She has been a board-certified wound, ostomy, and continence nurse since 1989, and is certified in oncology nursing and faith communality nursing. Her years of experience include regional and national speaking, litigation consulting, research in her areas of specialty, and publishing in peer- reviewed journals. She currently practices wound, ostomy, and continence nursing at Fairview Southdale Hospital in Edina, Minnesota.

To send your comments to the editor, please e-mail mhrehocik@iadvanceseniorcare.com.

Long-Term Living 2010 March;59(3):32-33