Although clinical practice is hampered by a lack of rigorous studies, standardized terminology, or definitions of incontinence-associated skin damage, it is well known among health care providers that this damage places patients at increased risk for pressure ulcer/injury development. The worldwide challenge represented by incontinence-associated skin damage prompted the development of a global expert panel on the topic in 2014. The group, chaired by Professor Dimitri Beeckman, a leading authority on the topic, collaborated to develop international best practice guidelines for prevention and treatment of incontinence-associated dermatitis (IAD) that were published in 2015.¹

Definitions and Clinical Features of Incontinence-Associated Dermatitis

IAD is defined by Beeckman and colleagues¹ as a type of moisture-associated skin damage, which describes skin damage associated with exposure to urine or stool. It causes considerable discomfort and can be difficult, time consuming, and expensive to treat. It is called by many names including diaper dermatitis, maceration, diaper rash, perineal dermatitis, and moisture lesions. IAD is a form of irritant dermatitis resulting from prolonged or chronic exposure to urine and/or stool, particularly liquid stool. These lesions are also often mistakenly labeled as stage 1 or stage 2 pressure injury.² IAD occurs in the perianal area. In women this includes the perineum, labial folds, and vulva to the anus. In men the area involved is from the scrotum to the anus. In both men and women this can extend to the groin, buttocks, gluteal cleft, and even extend down to the inner and posterior thighs.³ Kottner and colleagues also found a statistically significant higher rate of IAD in men with diabetes mellitus, a higher body mass index, and mobility issues. However, the IAD was more often associated with fecal rather than urinary incontinence.²

Prevention and Treatment of Incontinence-Associated Dermatitis

Prevention begins with assessing an individual’s risk, and numerous risk assessments have been developed over the years. The Perirectal Skin Assessment Tool was developed in the early 1990s. However, it lacked validity but was a start to IAD data collection. ⁴ Next was work by Brown and Sears, who identified tissue tolerance, perineal environment, and toileting ability as factors in perineal dermatitis.⁵ Validity and reliability were not established, however, because the instrument required the patient’s being alert enough to report symptoms. In 2002, Denise Nix⁶ developed the Perineal Assessment Tool, or PAT, that looked at type and intensity of irritant, amount of time the skin is exposed to the irritant, perineal skin condition, and contributing factors that can lead to loose or watery diarrhea stools. After testing validity, it was believed that this instrument measured risk versus actual dermatitis.

The Incontinence-Associated Dermatitis and Its Severity Instrument, or IADS, was developed in 2010 by Borchert and colleagues and evaluated four components.⁷ First is location of the IAD, and each area of the entire perineal, perianal, perirectal, and perivaginal area is numbered so that the location can be specific and consistent. When measuring for redness there are computer-generated red tones to assist with accuracy. For the measurement of skin loss there is a reminder that a pressure injury is not IAD and should not be assessed here. Finally, the caregiver is reminded that a fungal infection must be addressed and treated appropriately.

Prevention entails a thorough nursing assessment of urinary and fecal incontinence that leads to implementation of protocols aimed at preventing IAD and promoting healing of already damaged skin, as well as being linked to pressure ulcer/injury prevention. This is a two-pronged approach: 1) assessing and managing the incontinence to reduce skin exposure to the caustic components of urine and stool; and 2) using a targeted skin care regimen to maintain skin integrity plus protect from moisture and irritant exposure that compromise the brick and mortar structure of the skin.⁸ Using this approach also provides additional opportunities for identifying reversible causes of incontinence such as medications (for example, diuretic therapy for those with mobility issues), urinary tract infections, and constipation.

Other incontinence management approaches include nutrition and fluid management, toileting techniques, urinary sheaths for men, and the use of absorbent products that wick moisture away from the skin that also reduce overhydration without occluding the skin. If these methods are not successful or if IAD is severe, then the use of urinary catheters (only as a last resort because of the risk of infection) or fecal containment devices should be considered.³ Implementing a skin care regimen following any incontinent episode, especially when stool is present, is the most important step in preventing IAD. Soap and water are too harsh because the pH of soap is too alkaline and can lead to irritation of the skin. Instead, gentle cleansers that protect the lipid profile of the skin yet cleanse contaminants away easily should be chosen, followed by a skin protectant.

The protectant should be one that does not disintegrate easily in the presence of stool and urine and provides a barrier to moisture and caustic agents. The emergence of all-in-one-no-rinse products also has made this process easier. If the skin is compromised, then choosing a barrier that can stick to moist skin is imperative. When the assessment indicates the possibility of a fungal infection, then an antifungal agent should be incorporated into the skin care regimen.¹

Summary

The common clinical issue of IAD affects over 50% of patients with urinary or fecal incontinence despite the use of absorptive products. Although confusion still exists in differentiating IAD from pressure injury, thorough and careful assessment can help make the appropriate determination and enable the accurate choice of prevention and treatment strategies. Successful prevention and treatment of IAD include careful and accurate assessment, followed by implementation of evidence-based practice in continence and skin care protocols.¹

References

1. Beeckman D, Campbell J, Campbell K, et al. Incontinence-associated dermatitis: moving prevention forward. Wounds International. February 2015. Retrieved from http://www.woundsinternational.com/consensus-documents/view/incontinenc…. Accessed January 16, 2018.

2. Kottner J, Blume-Peytavi U, Lohrmann C, Halfens R. Associations between individual characteristics and incontinence-associated dermatitis: a secondary data analysis of a multi-centre prevalence study. Int J Nurs Stud. 2014;51(10):1373-80. doi.org/10.1016/j.ijnurstu.2014.02.012.

3. Black JM, Gray M, Bliss D, et al. MASD part 2: incontinence-associated dermatitis and intertriginous dermatitis. J Wound Ostomy Continence Nurs. 2011;38(4):359-70. doi:10.1097/WON.0b013e31822272d9

4. Yeoman A, Davit M, Peters C, Pasture C, Cob S. Efficacy of chlorhexidine gluconate use in the prevention of perirectal infections in patients with acute leukemia. Oncol Nurs Forum. 1991;18(7):1207-13.

5. Brown DS, Sears M. Perineal dermatitis: a conceptual framework. Ostomy Wound Manage. 1993;39(7):20-4.

6. Nix D. Validity and reliability of the perineal assessment tool. Ostomy Wound Manage. 2002;48(2):43-9.

7. Borchert K, Bliss DZ, Savik K, Radosevich DM. The incontinence-associated dermatitis and its severity instrument: development and validation. J Wound Ostomy Continence Nurs. 2010;37(5):527-35. doi: 10.1097/WON.0b013e3181edac3e.

8. Voegeli D. Prevention and management of incontinence-associated dermatitis. Br J Nurs. 2017;26(20):1128-32.