INCONTINENCE-ASSOCIATED DERMATITIS

Nancy Fox RN BN IIWCC

OBJECTIVES

Describe Incontinence-associated dermatitis (IAD)

Differentiate IAD from other conditions

Identify who is at risk

Discuss assessment and categorization of IAD

Identify strategies for prevention and management

DEFINING IAD

Skin inflammation manifested as redness

with or without blistering, erosion, or loss of

the barrier function that occurs as a

consequence of chronic or repeated exposure

of the skin to urine or fecal matter (Gray, et

al 2007)

SIGNIFICANCE OF THE PROBLEM

Urinary and/or fecal incontinence reported in 19.7% of

patients in acute care; up to 78.6% in long term care

Of those incontinent patient in acute care….~43%

have associated skin injury

Precise number of patients affected by IAD is not

known

Prevalence of 5.6%-50%

Incidence of 3.4%-25%

RECOGNIZING IAD

Appears initially as

erythema…ranging from

pink to red

Darker skin tones..skin may

be paler, darker, purple,

dark red or yellow

Poorly defined edges

May be patchy or

continuous over large areas

Courtesy of Medetec with permission

RECOGNIZING IAD CONTINUED

May feel warmer and firmer

than surrounding unaffected

skin

Lesions may include vesicles

or bullae, papules or pustules

Epidermis may be damaged to

varying depths

Entire epidermis may be

eroded exposing moist ,

weeping dermis

AND MORE

Patients can experience

discomfort, pain, burning,

itching or tingling

Patients with IAD are

susceptible to secondary

skin infections,

candidiasis one of the

most common

HOW DOES INCONTINENCE CAUSE IAD

Stratum Corneum (SC).. outermost layer and main barrier

Comprised of 15-20 layers of corneocytes

This matrix…regulates water movement into and out of the SC

Natural Moisturizing Factor(NMF) within the corneocytes

Chu, David H., Goldman-Cecil Medicine, 435, 2632-2637.Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

HOW …CONTINUED

Healthy skin surface has acidic pH 4-6

Incontinence …water is pulled into and held in the corneocytes

Overhydration →swelling and disruption of SC structure (maceration).

Irritants more easily penetrate the SC→ inflammation→ more prone to injury from friction

HOW…CONTINUED

Exposure to urine and feces ↑pH..alkaline which allows micro-organisms to thrive and ↑es risk of infection.

Feces contain lipid- and protein- digesting enzymes capable of damaging the SC

Image provided with permission by Sage Products LLC.

DOES IAD CONTRIBUTE TO PU DEVELOPMENT?

Both have risk factors in common

Once IAD occurs high risk for PU dev.; ↑risk of infection and morbidity

Different etiologies: IAD “top down” injury while PUs are believed to be “bottom up” injuries

Incontinence is a risk factor for both….IAD can occur in the absence of any PU assoc. risk factors and vice versa

DIFFERENTIATING IAD

Urinary and/or fecal incontinence

Pain, burning, itching, tingling

Affects perineum, perigenital area.

Affected area is diffuse with poorly defined edges

Exposure to pressure/shear

Pain Usually over a bony

prominence/assoc. with a medical device

Distinct edges or margins

IADPressure Ulcers (PU)

DIFFERENTIATING IAD

Intact skin with erythema, with/without superficial, partial thickness skin loss

Secondary superficial skin infection may be present

Varies from intact skin with non-blanchable erythema to full-thickness skin loss

Secondary soft tissue infection may be present

IADPressure Ulcers (PU)

KEY RISK FACTORS FOR IAD

Incontinence; fecal and/or urinary

Frequent episodes Use of occlusive

containment products Poor skin condition

(e.g. due to aging/steroid use/diabetes)

Compromized mobility Pain

Diminished cognitive awareness

Inability to perform personal hygiene

Fever Medications

(antibiotics, immunosuppressants)

Poor nutritional status Critical illness

RISK ASSESSMENT

Perineal Assessment Tool (Nix 2002) Validated tool with 87% interrater reliability

4 item tool and assessment based on Type and intensity of irritant Duration of contact with the irritant Condition of perineal skin Presence of contributing factors e.g. low

albumin, antibiotics, tube feeding Each item is rated with a score ranging from

1-3; total scores ranging from 4 (least at risk) to 12 (most at risk)

PREVENTION OF IAD

Structured skin care regimen that consists of 2 key interventions:

Cleansing the skin…to remove urine and/or feces

Protecting the skin…to avoid or minimize exposure to the irritants

Restoring (when appropriate) to support and maintain skin barrier function

PRINCIPLES OF CLEANSE

Cleanse daily and after every episode of fecal incontinence

Use gentle technique with minimal friction, avoid rubbing/scrubbing the skin

Avoid standard alkaline soaps

Choose a gentle no-rinse liquid cleanser or pre-moistened wipe with a pH similar to normal skin

If possible use a soft, disposable non-woven cloth

Gently dry skin if needed after cleansing

PRINCIPLES OF SKIN PROTECTION Apply skin protectant at a frequency consistent

with its ability to protect the skin

Ensure skin protectant is compatible with any other skin care products e.g. cleansers

Apply the skin protectant to all skin that comes in contact with or potentially will contact urine /feces.

Image provided with permission by Sage Products LLC.

CHARACTERISTICS OF THE MAIN TYPES OF SKIN PROTECTANTSPrinciple ingredient

Description Notes

Petrolatum •Derived from petroleum processing•Common base for ointments

Forms occlusive layer↑ skin hydration

Dimethicone Silicone-based Non-occlusive; opaque or becomes transparent after application

Acrylate terpolymer Polymer forms a transparent film

Does not require removal; transparent

Zinc oxide White powder mixed with a carrier to form an opaque cream, ointment or paste

Can be difficult to and uncomfortable to remove

RESTORE

Additional step to support and maintain the integrity of the skin barrier

Use of a topical leave-on skin care product ( often termed moisturizers)

Emollients..contain lipids and are intended to reduce dryness and restore lipid matrix

Humectants…function by drawing in and holding water in the SC e.g. urea, alpha hydroxyl acids, glycerin, lanolin or mineral oil

Can be used by themselves or in combination with barriers

IAD ASSESSMENT AND CLASSIFICATION

Inspect skin ( perineum, perigenital areas, buttocks, gluteal fold, thighs, lower back, lower abdomen and skin folds)for… Maceration Erythema Presence of lesions

(vesicles, papules, pustules etc) Erosion or denudation Signs of fungal or bacterial infection

Assess severity using standardized tool e.g. Perirectal Skin Assessment Tool, IADIT

IAD INTERVENTION TOOL

Categorize IAD based on the level and severity of skin injury

Includes interventions according to severity to prevent further damage and heal the skin

INTERVENTIONS BASED ON SEVERITY OF IAD (IADIT, JOAN JUNKIN 2008)

High Risk – skin is not red or warmer than nearby skin; person unable to self care or communicate need; incontinent of stool at least 3 x/24 hours

Early or Mild IAD - skin is dry and intact but is pink or red with diffuse, often irregular borders

INTERVENTIONS FOR HIGH RISK AND EARLY IAD

Use a disposable barrier cloth containing cleanser, moisturizer, and protectant

Use acidic cleanser (pH 6.5 or lower), not soap; cleanse gently – no scrubbing; and apply protectant (i.e. dimethicone, liquid skin barrier or petrolatum)

Allow skin to be exposed to air for 30 minutes twice daily by positioning semi-prone;

Manage cause of incontinence

MODERATE IAD

Skin is bright or angry red

usually appears shiny and moist with weeping or pinpoint areas of bleeding

may have raised areas or small blisters

small areas of skin loss

painful whether of not the patient can communicate the pain

INTERVENTIONS FOR MODERATE IAD

Plus… Consider applying zinc oxide-based product for

weeping or bleeding areas 3 times daily or following stool episodes

May apply ointment to a non-adherent dressing and gently place on injured skin to avoid rubbing

Do not scrub the paste completely off…gently soak stool off top then reapply new paste dressing to area

If denuded areas remain to be healed after inflammation is reduced, consider BTC ointment (contains Balsam of Peru, trypsin, castor oil)

SEVERE IAD

Skin is red with areas of denudement (partial thickness skin loss) and oozing/bleeding

INTERVENTIONS FOR SEVERE IAD

Plus… Consider treatments that reduce moisture;

low air loss mattress/overlay, more frequent turning, astringent such as Domeboro soaks.

Consider the air flow type underpads

Consider use of external catheter or fecal collector

Consider short term use of urinary catheter in cases of IAD complicated by secondary infection

FUNGAL-APPEARING RASH

This may occur in addition to any level of IAD injury; usually spots are noted near edges of red areas that may appear as pimples or just flat red areas; patient may report itching which may be intense

INTERVENTIONS FOR FUNGAL-APPEARING RASH

Anti-fungal powder or ointment ( avoid creams as they add moisture to an already moisture damaged area)

If using powder, lightly dust powder to affected areas…seal with ointment or liquid skin barrier to prevent caking

Continue treatments according to level of IAD Assess for thrush, and vaginal fungal

infection in women Assess skin folds If no improvement, culture area for possible

bacterial infection

TAKE HOME POINTS

Identify and treat the reversible causes of incontinence

Assess the risk of IAD and monitor patient Maximize nutritional intake, hydration and

toileting techniques Implement a structured skin care regimen:

cleanse, protect and restore Educate patients and caregivers regarding

strategies.

REFERENCES Beeckman, D., et al. Proceedings of the Global IAD

Expert Panel. Incontinence –associated dermatitis: moving prevention forward. Wounds International. 2015. Available to download from www.woundsinternational.com.

Gray, M., Bliss, D.Z., Doughty, D.B., et al. Incontinence –Associated Dermatitis: a consensus. Journal of Wound, Ostomy, and Continence Nursing. 2007;34(1): 45-54.

Junkin, J., Selekof, J.L. Beyond “diaper rash”: Incontinence –associated dermatitis. Does it have you seeing red? Nursing. 2008; 38(11 Suppl.):1-10.

LeBlanc, K., Christensen, D., Robbs, L., et al. Best Practice Recommendations for the Prevention and Management of Incontence-associated Dermatitis. Wound Care Canada. 2010; 8(3): 6-23.

THANK YOU!

Questions?Questions?