Introduction

Vulnerable skin within the skin microclimate is caused by a multitude of factors that are often aggravated by one another. Urine and feces, for example, have a negative impact on the skin as a result of the microorganisms and enzymes they contain. These factors break down the skin barrier and cause inflammation through the release of cytokines that trigger an immune response leading to symptoms of dermatitis (i.e., moisture-associated skin damage [MASD]).¹ Incontinence-associated dermatitis (IAD) is one type of MASD, and the external factors that contribute to IAD include microclimate (water, temperature, pH), mechanical forces (friction, pressure, shear), and biochemical factors (fungi, irritants, bacteria, enzymes).²

Pathophysiology of Contributing Factors

Contributors to MASD include tissue tolerance impairments, perineal environment problems, and altered daily toileting. Prolonged exposure of moisture leads to maceration, or overhydration of skin cells that pulls the cells apart and compromises the brick-and-mortar system of the skin. This process weakens the epidermis. Friction and shearing are other sources of damage to the skin.³ When skin conditions change in response to prolonged exposure to urine or feces, the pH of the skin increases, thereby putting the skin at higher risk for breakdown and impacting its ability to fight infection.⁴ Clinicians should have practical knowledge of how to remove the cause of prolonged moisture to the skin, how to cleanse skin appropriately, and how to provide barrier protection for creating the best microclimate and function of skin.

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Absorbent Briefs in MASD Pathophysiology and Prevention

Not all briefs have the same level of absorbency or features. Absorbent or high-wicking briefs have an absorbent core feature that can wick away and trap moisture, thus helping to keep the skin dry. However, wearing a brief (depending on the product breathability) changes the microclimate close to the skin, and this change in turn affects the skin. The microclimate raises the humidity, pH, and temperature. Moist skin is also affected by mechanical interaction. Following the steps to good incontinence care is necessary to avoid skin breakdown.⁵ Briefs with high breathability, however, help to maintain an ideal microclimate, which can help to prevent breakdown related to moisture, pH, and temperature.

Incontinence Management Components

Prolonged exposure to urine and feces is one of the most common causes of skin breakdown and other skin issues such as MASD, bacterial infections, and fungal infections. Incontinence management is key in preventing and treating skin breakdown related to prolonged moisture. Fluid Management Incontinence management includes containing or diverting fluids in pads or briefs with absorbent and high wicking capacity. Remember that these products are not a fix-all in incontinence management and should have a change frequency in accordance with the manufacturer’s instructions.³Skin Cleansing Cleansing the skin regularly in incontinent patients is vital. However, frequent cleansing can lead to irritation and swelling of the skin (stratum corneum) that cause epidermal stripping. Skin cleansers normally have a pH of 9. Healthy skin pH is 4.5 to 5.5. Use skin cleansers with pH ranges that mirror those of the skin’s acid mantle.^4,6Skin Barrier Creams Providing a barrier cream to the skin protects the skin from fluids and can help reduce friction. Using a skin barrier cream has been shown to prevent and/or treat IAD or MASD.⁴ There are various skin barrier products on the market, such as zinc oxide, dimethicone, and petrolatum.⁷Skin Moisturizing Moisturizing the skin after bathing or cleansing will help repair, hydrate, protect, and restore the skin. Use protective moisturizers formulated for the perineal area.

Conclusion

The stress put on skin in patients with incontinence from urine and/or feces changes the microclimate and makes skin vulnerable. Good skin care includes the general steps of managing moisture, cleansing skin, protecting, moisturizing, and utilizing high-absorbency incontinence products. Following these steps in patient care can help to prevent and manage moisture-related skin impairments.

References

1. Runeman B, Rybo G, Forsgren-Brusk U, Larkö O, Larsson P, Faergemann J. The vulvar skin microenvironment: influence of different panty liners on temperature, pH and microflora. Acta Derm Venereol. 2004;84(4):277-284.
2. Bender JK, Faergemann J, Sköld M. Skin health connected to the use of absorbent hygiene products: a review. Dermatol Ther (Heidelb). 2017;7(3):319-330. doi:10.1007/s13555-017-0189-y
3. Denat Y, Khorshid L. The effect of 2 different care products on incontinence-associated dermatitis in patients with fecal incontinence. J Wound Ostomy Continence Nurs. 2011;38(2):171-176.
4. Corcoran E, Woodward S. Incontinence-associated dermatitis in the elderly: treatment options. Br J Nurs. 2013;22(8):450-457.
5. Stamatas GN, Tierney NK. Diaper dermatitis: etiology, manifestations, prevention, and management. Pediatr Dermatol. 2014;31(1):1-7. doi:10.1111/pde.12245
6. Beeckman D, Van Lancker A, Van Hecke A, Verhaeghe S. A systematic review and meta-analysis of incontinence-associated dermatitis, incontinence, and moisture as risk factors for pressure ulcer development. Res Nurs Health. 2014;37(3):204-218.
7. Beeckman D, Schoonhoven L, Fletcher J, et al. Pressure ulcers and incontinence-associated dermatitis: effectiveness of the pressure ulcer classification education tool on classification by nurses. Qual Saf Health Care. 2010;19(5):e3-e3.