Best practice in skin care focuses on the prevention of skin breakdown and the treatment of persons with altered skin integrity. When we ask what causes skin damage we should consider the conditions that can harm the skin, including excessive moisture and overhydration, altered pH of the skin, the presence of fecal enzymes and pathogens, and characteristics of incontinence such as the volume and frequency of the output and whether the output is urine, feces, or both.

If left untreated or not treated appropriately, moisture-associated skin damage or MASD can lead to further complications such as Candida infections, bacterial overgrowth, pressure injuries, and medical adhesive-related skin injury (MARSI). These can occur individually or overlap, which can make them even more difficult to manage. Today our focus is to discuss each of these complications of MASD in more detail and address some of the most common issues leading to their development.

Candida Infection in Incontinence-Associated Dermatitis

According to a study by Campbell and colleagues,¹Candida albicans, which is the most prevalent human fungal commensal organism, is also the most frequent organism responsible for infection related to incontinence-associated dermatitis or IAD. Forty-three percent of the incontinent patients in the study developed a perianal Candida infection. Candida infection clinically manifests as a bright red maculopapular rash spreading out from the central contact area, with associated distant satellite lesions. These lesions are typically pruritic, and painful. The development of Candida infection often results in increased morbidity and extended length of stay.²

Understanding the epidemiology of Candida colonization in these situations may guide assessment and prevention strategies for these patients. Steps should include continuing to assess the skin care regimen for the proper use of skin cleansers, using moisturizers, avoiding occlusive products, managing moisture with absorptive products that will wick the fluid away from the skin, and using antifungal products. Treatment of this condition begins with interventions that address the moisture and fungus, such as 2% miconazole nitrate. Use of appropriate products to cleanse, protect, and treat the skin will help diminish pain as well.

Risk Factors for Incontinence-Associated Dermatitis

Factors that increase the risk of IAD in addition to incontinence include fragile skin, decreased mobility, decreased cognitive ability, poor personal hygiene or decreased capacity to perform personal hygiene, pain, poor nutritional status, and critical illness.³ Combined with moisture, the chemical onslaught of incontinence, obesity, skin folds, and friction with skin-to-skin contact increase the susceptibility of the skin to bacterial overgrowth. In individuals with diabetes mellitus the increased glucose levels combined with these other factors lead to an imbalance in the normal flora. This in turn creates the perfect storm leading to bacterial overgrowth and possible infection. Once again, the best approach to prevention includes continuing accurate skin assessments and maintaining an effective skin care regimen.

Loss of Skin Protective Barrier in Moisture-Associated Skin Damage

When moisture or trauma damages the epidermis or outer layer of the skin, the body's protective barrier is compromised. This can result in infection, pain, and delayed healing. The compromised condition of MASD-affected skin can also result in an increased susceptibility of the skin to MARSI. When the skin is overhydrated, the brick and mortar structure of the skin puffs up and gaps between skin cells and the lipid profile, thereby causing a loss of skin surface stability.

Medical Adhesive-Related Skin Injury

MARSI is trauma related to use of medical adhesive products or devices. Common adhesive products include tapes, dressings, ostomy appliances, electrodes, medication patches, or any products used to approximate wound edges or attach a device to the skin. A lack of proper placement or removal can result in trauma and removal of the superficial layers of the skin with the adhesive product. Sometimes initially there is no visible sign of injury, but with repeated application and removal, the skin barrier is compromised and an inflammatory response is initiated. When redness or irritation persists for 30 minutes or longer after removal, then MARSI has occurred.⁴ The trauma may range from skin stripping to blistering or skin tears. Additionally, irritant or allergic dermatitis may occur under the adhesive product, and/or maceration from trapped moisture or folliculitis may also occur. Proactive approaches to protecting the skin from the impact of moisture, or the use of cyanoacrylates, should be considered to protect the skin before, during, or after exposure to moisture and caustic substances such as wound drainage, gastric enzymes, urine, stool, or ostomy effluent.

Incontinence-Associated Dermatitis and Pressure Injuries

IAD can also predispose patients to pressure injuries. IAD and superficial stage 1 and stage 2 pressure injuries often coexist, and they are also often confused because patients at risk of skin injury secondary to pressure and shearing are also likely to be at risk of injury from moisture, friction, and the caustic components in urine and stool. Even though IAD is a top-down phenomenon and pressure injuries occur from the bottom up or from deeper tissue levels and evolve to the surface, they are often confused with one another. This confusion may reflect the lack of critical thinking and improved clinical decision making when using existing classification systems, as well as the similarities in presentation of stage 1 and 2 pressure injuries and IAD.⁵

Prevention of Complications

To prevent MASD and its complications we must take a proactive approach to assessment of the whole patient and the development of a preventive skin care regimen. This begins with an understanding of the factors putting skin at risk for MASD and should include a proactive approach to cleansing, moisturizing, and protecting the skin. Cleansing with gentle pH-balanced cleansers is performed to remove urine, stool, other body fluids, debris, and microorganisms. Moisturization of the skin should be done to aid the skin in repair or to augment the skin's barrier profile, retain or increase its moisture content, and reduce transepidermal water loss and improve the lipid profile of the skin. Finally, a barrier should be applied to provide an impermeable or semi-impermeable barrier for the skin to aid in preventing skin breakdown.⁶

References

1. Campbell JL, Coyer FM, Mudges AM, Robertson IM, Osborne SR. Candida albicans colonization, continence status, and incontinence-associated dermatitis in the acute care setting: a pilot study. Int Wound J. 2017;14(3):488-95. doi: 10.1111/iwj.12630.

2. Bliss D, Powers J. Faecal incontinence and its associated problems in hospitalised patients: the need for nursing management. J World Council Enterostomal Therapist. 2011;31:35-9.

3. Young T. Back to basics: understanding moisture-associated skin damage. Wounds UK. 2017;13(4):56-65.

4. Zulkowski K. Understanding moisture-associated skin damage, medical adhesive-related skin injuries, and skin tears. Adv Skin Wound Care. 2017;30(8):372-81.

5. Campbell JL, Gosley S, Coleman K, Coyer FM. Combining pressure injury and incontinence-associated dermatitis prevalence surveys: an effective tool? Wound Pract Res. 2016;24(3):170-7.

6. Beeckman D. A decade of research on incontinence-associated dermatitis (IAD): evidence, knowledge gaps and next steps. J Tissue Viability. 2017;26:47-56.