Practical Prevention and Treatment of Incontinence-Associated Dermatitis ‚Äî a Risk Factor for Pressure Ulcers
Ms. Ermer-Seltun is a Family Nurse Practitioner, Bladder Control Solutions, LLC, Mason City, Iowa; email: email@example.com.
Incontinence-associated dermatitis (IAD) is a painful and costly inflammatory condition that arises with perineal skin breakdown secondary to urinary incontinence (UI), fecal incontinence (FI), or both.1 IAD affects all ages, races, and genders and is prevalent in up to 42% of hospitalized adults,2,3 83% of incontinent patients in intensive care units,4 6% to 41% of residents in long-term care (LTC) facilities,5-7 and 50% of community residents who suffer fecal incontinence.7 IAD may be underestimated due to an historic lack of validated diagnostic criteria to assess its presence and severity.8 However, it is now possible to apply practical, evidence-based knowledge to identify, prevent, and treat IAD, which will improve patients’ quality of life, improve actual and perceived quality of care, and reduce complications and costs for healthcare institutions.
Incontinence is a Predictor of IAD
FI, or the combination of urinary and fecal incontinence, is an established predictor of IAD.7 In LTCs, the prevalence of FI is as high as 29.5% and combination incontinence 25.6% 9,10 In hospitalized elderly, FI alone affects 16% to 66% of patients.11 IAD arises with prolonged exposure to moisture from urine, feces, and perspiration and is exacerbated by contact with surface irritants such as pads, clothing, bed linens, and washcloths.1 Inflammation caused by incontinence and the use of occlusive containment devices increases water loss through the skin’s epidermal layer.12,13 This loss compromises the skin’s natural moisture barrier while raising skin surface pH and reducing protection against infection.13-16
Signs and Consequences of IAD
The physical signs of IAD, which range widely in severity, are erythema, swelling, oozing, vesiculation, crusting, and scaling on the perineum and buttocks.11 Multiple variables work together to injure perineal skin and cause IAD. Fecal bacteria can permeate the stratum corneum, allowing for secondary Staphylococcal infections, while frequent skin cleansing can lead to further pH changes, Candida albicans infections, and skin damage from friction.11,17 Severity of damage is dependent upon18 : • Type of irritant (double incontinence and liquid stool are most caustic); • Duration of irritant exposure; • Frequency of exposure. Aging skin is particularly vulnerable to IAD due to lower baseline function and prolonged healing. 19 A vicious cycle of incomplete skin cell repair with increasing inflammation and damage ensues when skin is exposed to an irritant repeatedly and over extended time.1 Damaged skin is a sign of reduced blood flow, collagen loss, or loss of elastic fibrous connective tissues.20 Such damage makes incontinence a major risk factor for acquiring secondary infections and developing pressure ulcers, which can cost $3,500 to $55,000 per ulcer to treat.21 Patients with FI are 22 times more likely to develop pressure ulcers than patients without incontinence. 22 Combination UI and FI is even more virulent.23 It is imperative that the nursing staff distinguishes skin damage caused by incontinence versus pressure alone. The Centers for Medicare and Medicaid Services will not reimburse costs associated with facility-acquired pressure ulcers and, under recent revisions to the F-Tag 314, LTCs can be cited for avoidable pressure ulcers. Borchert et al8 recently developed a simple, validated instrument to help staff identify IAD, grade its severity, and distinguish IAD from pressure-induced skin damage. This instrument offers a much-needed standardization of IAD diagnostic criteria and measurement. Its use also can help distinguish IAD from other perineal skin damage and provide an objective means to evaluate the effectiveness of incontinence skin care. Another consequence of IAD is discomfort and pain. IAD-related pain further increases the risk of pressure ulcers by limiting patient movement and increasing tissue loads, especially over bony protrusions. Recent studies evaluating the effectiveness of skin care products reveal a direct association between pain intensity and the degree of skin damage from incontinence.17, 24 The best way to reduce pain in these patients is to prevent or manage its cause. Increased costs of IAD arise largely from nosocomial pressure ulcer development in LTCs and a five-fold increased length of stay in hospital patients.25,26 Products and labor for managing IAD and treating secondary infections drive additional monetary costs. The occurrence of IAD also may reduce perceived quality of care within the facility, diminishing patient and family satisfaction, creating susceptibility to litigation, and lowering utilization of services.
Solution: Guidelines for Prevention and Management of IAD
The three keys to preventing and managing IAD are cleanse, moisturize, and protect the skin. These elements are simple to achieve but require daily vigilance by the nursing staff and adherence to an established protocol. Based on the author’s experience in hospitals and LTCs, the Wound Ostomy and Continence Nurses Society (WOCN) offers the most practical, evidence-based guidelines for preventing and treating IAD. Foremost among recommendations27: • Establish a bowel and bladder program for incontinent patients; • Avoid excess friction on the skin; • Cleanse skin gently at each soiling with pH-balanced cleansers; • Use skin barriers as needed to protect and maintain intact skin; • Select absorbent underpads, diapers, or briefs that wick moisture away from skin. Studies28 suggest a soap-and-water regimen alone is less effective at preventing skin breakdown compared with moisture barriers and no-rinse incontinence cleansers. After cleansing, the use of a skin protectant, such as 3M™ Cavilon™ Durable Barrier Cream or 3M™ Cavilon™ No Sting Barrier Film, is critical for preventing or reducing IAD and for preserving intact skin cells. Calculations by this author and Nix29 estimate the amount spent on skin protectants per patient is 10 cents per day; however, the average cost per application for the top five skin protectants should be 23 cents per day. This strongly suggests widespread under-utilization of skin barrier products. Published evidence demonstrates compliance with product usage for preventing and treating IAD may be strengthened and made more consistent when regimens are simplified and “one-step” products are available. Among these are 3M™ Cavilon™ 3-in-1 Incontinence Care Lotion. When minimal supplies are required to follow a protocol, the nursing staff is less likely to breech incontinence protocols and infection control measures and staff monitoring can be minimized.29,30 The author recommends conducting periodic evaluations to ensure incontinence care products are applied according to manufacturer directions and that evaluations include costs of product use and labor. Bliss et al31 in a multisite, nationwide study in LTCs, compared the efficacy of four skin care regimens to prevent IAD and found all were effective (only 3.4% IAD incidence), but the cost of product use and labor was significantly reduced in the 3M™ Cavilon™ No Sting Barrier Film protocol (applied three times a week) compared with other regimes requiring application after every incontinence episode.31 To reduce the prevalence of IAD in your hospital or LTC facility, ensure the right personnel are educated to provide excellent perineal skin care and determine what obstacles stand in the way of providing quality care to incontinent patients. Regardless of which products you use to cleanse, moisturize, and protect, ensure they: • Are applied after every cleaning episode; • Are easy to use and disposable to minimize contamination risk; • Create a durable barrier that protects against irritation caused by urine and feces; • Minimize cost and labor utilization.
In summary, IAD can easily be identified, prevented, and managed with adherence to a simple routine. Keep your incontinence protocol updated and simplified to reduce process variation among staff and promote adherence. Ensure your staff is alert to daily changes in patients’ skin, evaluate and document changes observed by staff, utilize complimentary interventions to address the cause and management of incontinence — such as identifying reversible causes, toileting schedules and behavioral interventions — and, above all, keep perineal skin clean and protected.
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This article was not subject to the Ostomy Wound Management peer-review process.