Board Secretary Part 2 in a two-part series looking at the basics of preventing and managing moisture-associated skin damage in the long-term care setting. For Part 1, click here.

Incontinence-Associated Dermatitis

Incontinence-associated dermatitis (IAD) is a prevalent complication of incontinence that compromises skin integrity, predisposes patients to cutaneous infection, and increases pressure ulcer risk. IAD is an inflammation of the skin as a result of long-term or repeated exposure to urine or feces. Reported IAD incidence rates in long-term care settings vary from 3.4% to 25% and up to 65% in the presence of double incontinence (urine and stool).¹ Clinical manifestations include erythema, edema, maceration, denudation, papular or vesicular formations, erosion of the epidermis and/or dermis, poorly demarcated borders, flaking, crust formation, weeping, development of secondary cutaneous infection, and sensations of tenderness, pain, burning and itching. Complications of IAD are bacterial infection (appearing as red, scaling areas), fungal infection (appearing as discrete satellite lesions), pressure ulcers, and severe pain.

IAD is not confined to areas over bony prominences. It is usually diffuse, found in skin folds, and often falls within the confinement area of a containment garment, if worn.² The severity of IAD is dependent on the concentration of the irritant, the degree of skin sensitization, and the specific microflora present. Skin is normally acidic, with a pH range of 5.5 to 5.9. When feces and urine are mixed together, bacteria in the feces convert urea in the urine to ammonia, which makes the skin more alkaline.

Management Considerations

• Minimize incontinence with scheduled toileting programs.
• Consider using drug therapy to control noninfectious diarrhea.
• Use skin care products that cleanse, moisturize, and protect.
• Avoid soap because it is alkaline and causes skin irritation.
• Skin should be cleansed gently, avoiding friction, and patted dry.
• Apply barrier pastes following each incontinence episode.
• If needed, mineral oil is a gentle and effective method for removing ointments or pastes.
• Consider using briefs when out of bed and disposable underpads when in bed to minimize moisture and heat trapping.
• Reduce pressure, and ensure adequate nutrition, hydration, and oxygenation.
• Treat fungal infections with topical antifungal powder or cream.
• Treat bacterial infections with an organism-specific antibiotic.
• Perform clean intermittent catheterization.

On admission, it is important to evaluate residents for incontinence and ensure that interventions are implemented immediately. Provide supplies at the bedside of each at-risk resident who is incontinent. Providing the staff with the supplies needed to immediately clean, dry, and protect the resident's skin after each episode of incontinence from day one will better ensure consistent care and prevention of system breakdown. Provide underpads that pull the moisture away from the skin, and limit the use of disposable briefs or containment garments if at all possible. Provide pre-moistened, disposable barrier wipes to help cleanse, moisturize, deodorize, and protect residents from perineal dermatitis resulting from incontinence.³ Being proactive can reduce incidents of IAD within your facility.

Periwound Moisture-Associated Dermatitis

Periwound moisture-associated dermatitis is wound exudate that has sustained contact with the skin and has caused damage; inflammation, and erythema to the skin with or without erosion. Exudate is the normal result of the inflammatory phase of wound healing. However, the key to optimal outcomes for wound healing is moisture balance. Excessive amounts of exudate can cause the periwound edges to become macerated and even break down. The presence of bacteria, specific proteins, or enzymes, as well as the volume of exudate, greatly reduces the barrier function of the skin and can lead to maceration. Periwound moisture-associated dermatitis is marked by erythema, maceration, and irregular edges. The resident may complain of pain, burning, or itching at the site or may be continually fussing with the dressing or itching . Damage may be focused on the dependent area of the wound in extremities. Infections also increase the risk of periwound maceration because they increase exudate production. Diabetic foot ulcers, venous leg ulcers, pressure ulcers, fungating tumors, and full-thickness burns are more prone to developing periwound moisture-associated dermatitis.

Management Considerations

• Manage exudate with dressings for proper absorption.
• Assess wounds and surrounding tissue routinely for changes.
• Use barrier films or skin protectants on the periwound tissue as needed.
• Consult with a wound specialist as needed.

Peristomal Moisture-Associated Dermatitis

Peristomal moisture-associated dermatitis is inflammation surrounding a stoma that is caused by sustained contact of stool or urine. The solid skin barrier applied around the stoma to protect the skin becomes compromised by too much moisture from sweat, exudate from the peristomal wound, or extended exposure to water (shower or swimming), and the adhesive fails. This creates a leak or frequent mechanical damage from pouch changes. The results are inflammation and skin erosion. Maceration is common because moisture is trapped under the solid skin barrier.

Management Considerations

• Perform gentle cleansing of the peristomal area.
• Avoid lotions and creams at the stoma site and surrounding tissues.
• Apply skin preparation to peristomal tissue before a solid skin barrier before redness or irritation occurs.
• Monitor wear time—not too long or too short—avoid occlusion of underlying skin and mechanical stripping.
• Re-evaluate the pouching system for proper fit and draining ability.
• Use barrier powders, pastes, and rings judiciously.

Intertriginous Dermatitis

Intertriginous dermatitis is inflammation in skin-to-skin or skin-to-device related to perspiration, friction, or bacterial and/or fungal bioburden. When sweat becomes trapped and unable to evaporate, the stratum corneum becomes hyperhydrated and macerated, and friction damage is facilitated and often mirrored on both sides of skin folds. Inflammation and infection are potential outcomes. Typically, this condition manifests with mild erythema that may progress to more severe inflammation, erosion, oozing, exudation, maceration, and crusting.⁴

Management Considerations

• Promote proper general hygiene—remember, for older adults, harsh soaps are not always necessary.
• Keep at-risk areas clean and dry.
• Reduce heat and moisture to skin folds.
• Shower after exercise or heated or warmer excursions.
• Apply antiperspirants to skin folds before irritation occurs.
• Reduce the use of powders and creams in skin folds—moisture makes them into pasty hard balls that create pressure, which creates ulcers.
• Silver wicking sheets or an absorptive dressing may be placed in skin folds to inhibit microbial growth and absorb moisture.
• Change clothes daily and following sweaty outings, including socks and undergarments—safe to say once you've taken them off, don't put them back on. Yes, I have seen it done!

Care Planning

Create a plan to prevent moisture-associated skin damage in your building. Start with assessments: assess thoroughly and often, and establish who is at risk. Provide the tools and knowledge to your caregivers to provide the necessary care. Explain to residents and loved ones about when, where, and why they are doing what they are doing, and make sure they are doing it!

References

1. Gray M. Incontinence-related skin damage: essential knowledge. Ostomy Wound Manage. 2007;53:28–32.

2. Wound Ostomy and Continence Nurses Society. Incontinence Associated Dermatitis (IAD): Best Practice for Clinicians. Mount Laurel, NJ: Wound Ostomy and Continence Nurses Society; 2010–2011.

3. Protecting 5 Million Lives From Harm. 2018. Institute for Healthcare Improvement. Available at: http://www.ihi.org/IHI/Programs/Campaign/. Accessed May 16, 2018.

4. Brown C. Skin deep. Adv Tissue. 2014;Nov-Dec:1–6. Available at: http://www.advancedtissue.com/wp-content/uploads/2013/12/LTC-Newsletter…. Accessed May 10. 2018.

About the Author

Susan M. Cleveland, BSN, RN, WCC, CDP, NADONA Board Secretary, is Wound Care Certified through National Association of Wound Care since 2004. Currently, she consults in LTC and alternate care settings on wounds, skin care, and various other issues. She has been employed in the long-term care setting since 1969, spending 25 years in a long-term care rehabilitation facility where the focus was wound healing therapies. NADONA/LTC has been a leading advocate and educational organization for DONs, ADONs, and nurses in long-term care since 1986. With 40 state chapters, it continues to be the largest organization representing nurses working in both post-acute and long-term care settings. NADONA/LTC offers a wide array of services to its members, including educational materials; conferences; executive fellows program, webinars, scholarships; Nurse Leader, Licensed Practical Nurse and Assisted Living certification programs; a mentoring program; and a quarterly journal, The Director. Through its publications and programs, NADONA/LTC reaches approximately 20,000 nurses who are employed in long-term care. For more information regarding NADONA/LTC, please contact their offices at 800-222-0539 or visit their website at www.nadona.org.