Introduction

The outer layer of the skin, the epidermis, is the body's physical barrier to the environment. This barrier is compromised when moisture or trauma damages the epidermis. Frequently, moisture or adhesives can damage the skin and cause painful injuries. The damaged area is then more susceptible to infection and delayed healing.¹ Overexposure to moisture can compromise the skin's integrity by disrupting the delicate molecular arrangement of intercellular lipids in the stratum corneum and the intercellular connections between epidermal cells or corneocytes. The term moisture-associated skin damage (MASD) encompasses a spectrum of injuries characterized by denudation (inflammation and erosion) of the epidermis resulting from prolonged exposure to various sources of moisture or irritants such as wound exudate, perspiration, urine, stool, or ostomy effluent.²

At-Risk Populations for MASD

The development and severity of MASD depend on various factors internal and external factors, including an individual’s metabolism and perspiration rates, abnormal skin pH, a history of atopy, the presence of deep body folds, dermal atrophy, inadequate sebum production, mechanical stress on the skin, fungal proliferation, incontinence, and general hygienic practices.²

How much do you know about skin management? Take our 10-question quiz to find out! Click here.

There are four types of MASD: incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), periwound dermatitis, and peristomal dermatitis. IAD describes skin damage associated with exposure to urine, stool, or a combination of both. In addition to fecal or urinary incontinence, risk factors for IAD include³:

• Exposure for prolonged periods of time
• Mechanical force
• Poor skin condition, particularly in older adult patients
• Interval between cleaning
• Diabetes
• Impaired mobility
• Advanced age
• Diminished cognitive awareness
• Inadequate personal hygiene
• Medication
• Malnutrition
• Smoking
• Critical illness or fever
• Low oxygen saturation

These risk factors can diminish the integrity of the skin and render it more vulnerable to MASD.³ ITD, sometimes referred to as intertrigo, is an inflammatory dermatosis of opposing skin surfaces caused by moisture and is commonly found in skin folds. It is thought to arise from skin-on-skin friction leading to mild erythema that progresses to intense inflammation with erosion, oozing, exudation, maceration, and crusting.⁴ Peristomal MASD results from fecal, urinary, or chemical irritants occurring at the stoma-skin junction.⁵ Periwound MASD occurs when wound exudate comes into contact with the periwound skin for a prolonged period of time. Exudate has high concentrations of bacteria and matrix metalloproteases, which also hasten the destruction of this tissue.⁶

Preventing MASD

It is always easier to prevent MASD than it is to heal it after a wound has developed. Any damage to the skin is painful and may lead to additional complications, such as infection.¹¹ There are several strategies that can help prevent MASD from developing and help these injuries heal when they have developed, including¹:

• Careful and regular assessment of the skin for at-risk populations
• Individualized care planning
• Staff education on early signs of MASD
• Implementation of a structured skin regimen
• Skin cleansing using appropriate cleansers rather than soap and water
• Use of barrier products, such as sprays, creams, and wipes, when appropriate, with skin protectants advised for all patients with incontinence
• Use of absorbent dressings for exudative wounds²
• Use of atraumatic tapes and adhesives²
• Appropriate treatments for skin infection and dermatitis to manage the microclimate²
• Use of moisturizers and emollients to replace intercellular lipids in the stratum corneum⁴
• Managing incontinence with collection devices, absorptive pads, and briefs to remove irritants and minimize exposure time⁴
• Adequate cleaning and drying between skin folds⁴

Conclusion

MASD is defined as the painful inflammation and erosion of the skin caused by prolonged exposure to one or more types of moisture. Certain populations, including older adults, are at greater risk for nearly all types of MASD. Preventing and treating this condition require that clinicians are diligent in monitoring for early signs of MASD and treating these signs before the wound progresses.⁴

References

1. Zulkowski K. Understanding moisture-associated skin damage, medical adhesive-related skin injuries, and skin tears. Adv Skin Wound Care. 2017;30(8):372-381.
2. Woo KY, Deeckman D, Chakravarthy D. Management of moisture-associated skin damage: a scoping review. Adv Skin Wound Care. 2017;30(11):494-501.
3. Fletcher J, Beeckman D, Boyles A, et al. International best practice recommendations: prevention and management of moisture-associated skin damage (MASD). Wounds Int. 2020. https://www.woundsinternational.com/resources/details/best-practice-rec…. Accessed March 29, 2021.
4. Black JM, Gray M, Bliss D, et al. (2011). MASD part 2: incontinence-associated dermatitis and intertriginous dermatitis. J Wound Ostomy Continence Nurs. 2011;38(4):359-370.
5. Gray M, Colwell JC, Doughty D, et al. Peristomal moisture-associated skin damage in adults with fecal ostomies: a comprehensive review. J Wound Ostomy Continence Nurs. 2013;40(4):389-399.
6. WoundSource. MASD: what are the types of moisture-associated skin damage? WoundSource.com. 2018. https://www.woundsource.com/blog/masd-what-are-types-moisture-associate…. Accessed March 29, 2021.