Background

The literature suggests that patients with a high degree of adiposity are more at risk for inflammatory conditions, and the numbers of these patients continue to rise. Increased adipose tissue may impact activities of daily living, continence, and overall quality of life (QoL), among other complications. Abdominal (central) obesity may be associated with incontinence, mechanical and neurogenic changes (chronic strain or weakening of nerves in the pelvic area), and skinfold inflammation or irritation.¹

Skin Health

When it comes to skinfold management, basic hygiene should be the initial step while keeping in mind that, often, less is more. An individualized plan of care is important because some patients may tolerate creams or lotions, and others may not (complaints of feeling wet, increased moisture, etc.). Additionally, powders may accumulate in skinfolds and become abrasive or difficult to clean from deeper folds. It is important to use a pH-balanced cleanser and pat skin dry (dry well, but gently), versus rubbing or aggressively drying with towels, to avoid friction injuries. Lifting or repositioning equipment may be helpful here, if accessible, or having another set of hands to assist with hygiene. As with many skin and wound care concepts, an interdisciplinary approach will likely best serve the patient.¹

Moisture-Associated Skin Damage

Moisture-associated skin damage (MASD) is a general term for inflammation or denuded skin related to prolonged exposure to moisture (urine, stool, diaphoresis, wound drainage, mucus, etc.). Intertriginous dermatitis (ITD) and incontinence-associated dermatitis (IAD) are two types of MASD, and they require a different approach and management.

Intertriginous Dermatitis

ITD is often seen in deeper skin folds, beneath the pannus, or in the perineal area. The posterior upper legs may also trap moisture, leading to ITD. If skin is not diligently cleaned and dried, maceration and skin irritation may develop, which could lead to viral, bacterial, or fungal growth. There is often a resultant odor from this combination, which may contribute to a decreased QoL, social isolation, and even feelings of hopelessness. Developing an evidence-based, individualized plan of care for each patient is critical not only for skin health but also for overall QoL. Absorbent cloths or wicking textiles are helpful for skinfold management, after cleansing and drying, with regular skin assessments conducted at least daily.

Extra care should be taken to be sure that the layers of cloth between skinfolds do not create additional pressure, which could result in a device-related pressure injury. A polyurethane-coated silver-impregnated fabric is helpful with skinfold management because it is designed to fit within the skinfold, thus not causing extra pressure. The textile should extend out approximately two to three inches to wick away moisture, and it should be changed at regular intervals, according to the manufacturer’s recommendations. Without treatment or follow-up, ITD may deteriorate into cellulitis or other, more significant medical problems.¹ For more information on ITD and its treatment, please refer to my previous WoundSource blog, here.

Incontinence-Associated Dermatitis

IAD, as the name “incontinence-associated” suggests, is a moisture-associated skin condition that results from fecal or urinary incontinence. IAD typically requires treatment and prevention measures beyond basic skin care or hygiene. Moisture barrier ointments and/or cleansing cloths designed for management or cleansing during incontinence care are often recommended. Moisture barrier ointments are typically applied initially and then after each incontinent episode to maintain or preserve skin integrity.

It is recommended not to remove all of the ointment from the skin, but instead simply to wipe away what is soiled by using a cleansing cloth and/or perineal cleansing spray and then reapply the ointment.¹ In addition to protecting the skin, we must also offload, look at additional risk factors, complete a thorough head-to-toe assessment, and take into account any additional comorbid conditions that may delay healing. Containment is another option for managing incontinence, and there are multiple options for body-worn absorptive products to provide odor control, contain effluent, and preserve the patient’s dignity.¹

Conclusion

Skinfold management is a critical element of care for all patients, but especially those with increased adipose tissue. Irritation to skinfolds is commonly caused by moisture, which may be related to ITD or IAD. It is important to start with a strict hygiene routine, keeping skin clean and dry. Determining the etiology of skinfold irritation is key to an effective treatment plan and preventing complications.

There are several options for skinfold management to maintain the patient’s dignity and promote QoL. Evidence-based practices and an interdisciplinary team approach are essential components of a holistic approach to patient care that will provide the best outcomes. As mentioned in my previous blogs, as skilled wound care clinicians, we need to manage the whole patient, not just the hole in the patient!

Reference

1. Gallagher S. Incontinence and the individual who is obese. In: Wound, Ostomy, and Continence Nurses Society Core Curriculum Continence Management. Wolters Kluwer; 2022:315-327.

About the Author

Holly is a board certified gerontological nurse and advanced practice wound, ostomy, and continence nurse coordinator at The Department of Veterans Affairs Medical Center in Cleveland, Ohio. She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately six years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention. She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation. She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible. She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes.