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Incontinence-Associated Dermatitis

Understanding and treating this painful skin condition

By Laura Kuhn

Incontinence-associated dermatitis, or IAD, is painful skin condition common among residents with urinary or fecal incontinence. Like many other conditions, however, it can be both treated and prevented with proper skin care.

IAD is characterized by irritation and inflammation that develops as a result of prolonged exposure of the skin to urine or stool.1 Approximately 20 percent of long-term care residents have IAD, and 73 percent of them are incontinent.2

IAD is part of a larger set of conditions referred to as "moisture-associated skin damage," or MASD. In general, the term "MASD" is used to describe irritation, inflammation and erosion that is associated with extensive exposure of the skin to perspiration, urine, stool or wound exudate.1 Other conditions included in the MASD group include intertrigo (inflamed skin folds caused by exposure to perspiration, friction and bacterial or fungal bioburden) and periwound maceration (skin breakdown resulting from exposure to wound exudate).

What causes IAD?

IAD is sometimes also referred to as "perineal dermatitis." The perineum is the area between the thighs. In females, this extends from the vulva to the anus. In men, it is the area between the scrotum and the anus.1

Prolonged exposure to surface irritants, such as urine and feces, can create an inflammatory response in the skin and increase transepidermal water loss (TEWL). Perineal skin and the skin on the scrotum already have the highest rates of TEWL on the body, and when TEWL is increased, delicate skin is even more susceptible to breakdown.

Urine can affect skin in multiple ways. The water in urine decreases skin hardness, which makes it more susceptible to friction and erosion. The ammonia in urine can raise the skin's pH, promote the growth of pathogens, disrupt the skin's acid mantle, activate fecal enzymes and alter the skin's normal flora (the microorganisms that reside on the skin).2 Moisture can also make skin more susceptible to damage from friction and shear during repositioning.3

Some studies point to fecal incontinence being a greater threat to skin integrity than urinary incontinence, most likely because of the bile acids and enzymes in feces.3

Risk factors for IAD 4

As people age, the barrier function of their perineal skin gradually declines. The skin itself becomes thinner and there is a decrease in collagen and elastin, which provide skin with strength and elasticity. Elderly skin is also prone to increased TEWL.2
  • Fecal incontinence
  • Frequency of incontinence
  • Poor skin condition
  • Pain
  • Poor skin oxygenation
  • Fever
  • Compromised mobility
  • Double (urinary and fecal) incontinence
  • Tissue tolerance impairments

IAD vs. pressure ulcers

The Centers for Medicare and Medicaid Services (CMS) notes that it can be difficult to differentiate incontinence-related dermatitis from partial-thickness skin loss (pressure ulcers) and advises that "the differentiation should be based on the clinical evidence and review of presenting risk factors."3 A good rule of thumb to keep in mind is that Stage I pressure ulcers typically present as a localized area of erythema or skin discoloration while IAD usually presents as a more diffuse area of erythema and discoloration where urine or stool has come into contact with the skin. IAD can present as intense erythema, scaling, itching, papules, weeping and eruptions. It commonly occurs in areas where an incontinence brief or underpad has been used.3

Complications of IAD

Tip: Skin damage from IAD starts on the surface and works its way inward, while skin damage from pressure ulcers occurs from the inside out.

Residents with IAD are susceptible to developing secondary cutaneous infections, especially candidiasis, which thrives in warm, moist areas.2 These complications can increase resident discomfort and treatment costs. Residents who develop IAD are also at a higher risk of developing pressure ulcers when other risk factors are present.1

IAD prevention through skin care

Studies suggest that a structured skin care regimen is one of the most effective methods for preventing IAD. The three primary components of a skin care regimen are cleansing, moisturizing and protecting.1

Cleanse

The use of no-rinse cleansers has been tied to a significantly lower risk of skin tears. One study found that no-rinse cleansers reduced skin tears by 90 percent compared to the use of traditional soap and water. These cleansers also save valuable nursing time. A soap and water bath takes an average of 29 minutes, while a no-rinse bath averages 16 minutes.5 A number of products on the market contain skin-softening emollients or moisturizers that help to preserve the skin's lipid barrier.2

There is also evidence to suggest that using a soft, disposable cloth when cleansing residents better protects the moisture barrier of the skin than the use of a traditional washcloth.1 Pre-moistened, disposable washcloths that contain a barrier product are recommended for cleansing, moisturizing, deodorizing and protecting residents from IAD.6

Moisturize and protect

After cleansing the skin, it is crucial to apply a moisturizer. Moisturizers help maximize the skin's lipid barrier, a natural defense against harmful substances. Moisturizers applied to dry skin have been shown to be especially effective in preventing skin breakdown.6

The final step in perineal skin care is to apply a barrier product. Experts recommend that barrier products be applied to residents who have significant urinary incontinence as well as those with fecal or double incontinence.2

Managing moisture

Development of IAD is sometimes associated with the regular use of incontinence management products, which can increase perspiration.1 Wet skin is softer, breaks down more easily and is more conducive to developing rashes.6 A number of disposable incontinence management products are made from a breathable, cloth-like material that doesn't trap heat next to the skin like plastic-backed products. Other features, such as super-absorbent polymers, are also being integrated into incontinence management products with the goal of providing better skin care.

When choosing an incontinence management product, it's also important to consider the wearer's level of incontinence as well as gender, fit and ease of use.3

While common, IAD is both manageable and preventable. A combination of education and a carefully thought out skin care protocol can help banish this painful condition from your facility.

References

  1. Gray M. Incontinence-related skin damage: essential knowledge. Ostomy Wound Manage. 2007 Dec;53(12):28-32.
  2. Gray M. Incontinence associated dermatitis. Available at: http://www.sageproducts.com/documents/pdf/education/studies_articles/iad/sage10212.pdf. Accessed April 7, 2011.
  3. State Operations Manual. Appendix PP Guidance to Surveyors for Long Term Care Facilities. Rev. 70, 01-07-11. Available at: http://www.cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf. Accessed January 25, 2011.
  4. Birch S, Coggins T. No-rinse, one-step bed bath: the effects on the occurrence of skin tears in a long-term care setting. Ostomy Wound Manage. 2003 Jan;49(1):64-7.
  5. Gray M, Bliss DZ, Doughty DB, Ermer-Seltun J, Kennedy-Evans KL, Palmer MH. Incontinence-associated dermatitis: a consensus. J Wound Ostomy Continence Nurs. 2007;34(1):45-54.
  6. 5 Million Lives Campaign. Getting Started Kit: Prevent Pressure Ulcers How-to Guide. Cambridge, MA: Institute for Healthcare Improvement; 2008.