Karen Zulkowski, DNS, RN • Associate Professor • Montana State University-Bozeman • Bozeman, Montana
Dr Zulkowski has disclosed that she is/was a consultant/advisor to Mountain Pacific Quality; is a consultant/advisor to Hill-Rom; and is/was a member of the speaker’s bureau for Derma Sciences, and her spouse/life partner (if any) has nothing to disclose.
All staff and planners, including spouses/partners (if any), in any position to control the content of this CME activity have disclosed that they have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity.
Lippincott CME Institute has identified and resolved all conflicts of interest concerning this educational activity.
To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least 13 of the 18 questions correctly.
This continuing educational activity will expire for physicians on May 31, 2013.
PURPOSE: To enhance the learner’s competence in identifying and treating moisture-associated skin damage.
TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.
OBJECTIVES: After participating in this educational activity, the participant should be better able to:
1. Differentiate moisture-associated skin damage and related pathophysiology from other skin conditions.
2. Use incidence data related to urinary and fecal incontinence to help guide case-finding activities and provide patient education for this health problem.
3. Apply knowledge of moisture-related skin changes and their treatment to patient care scenarios.
ABSTRACT: Certain types of moisture can cause debilitating damage to the skin. Terms such as perineal dermatitis, diaper rash, incontinence-associated dermatitis, or moisture-associated skin damage describe some of the conditions caused by moisture from wound drainage, fecal and/or urinary incontinence, and perspiration. It is important for clinicians to correctly diagnose and to locally treat the cause of skin damage, as well as promote appropriate cleaning techniques, to keep patients’ skin healthy.
Perineal dermatitis, diaper rash, incontinence-associated dermatitis, or moisture-associated skin damage are all names used to describe damage to skin caused by moisture. Regardless of what the condition is called, this damage is painful and costly. Moisture can come from many sources, including perspiration or wound drainage, but fecal and/or urinary incontinence are the most common causes. Lesions caused by the moisture are characterized by an erosion of the epidermis and a macerated appearance of the skin.1 A secondary cutaneous infection may also occur.
This article will help clinicians identify the cause of skin damage and determine the appropriate treatment path.
PREVALENCE OF INCONTINENCE
Estimates of the number of people affected with incontinence are widely varied. People are often reluctant to discuss the issue and consider urinary incontinence a normal part of aging (Table 1). In community-dwelling women, the prevalence of urinary incontinence was found to increase from 19% in women 45 years or younger, and up to 29% in those 80 years or older.2 Only half of community-dwelling women with incontinence reported discussing the issue with their physician, and for those who did, only one-third received any treatment.3,4 Urinary incontinence has not been as well studied in community-dwelling men and reported prevalence rates range from 5% to 15%.2
Fecal incontinence in community-dwelling women is estimated to affect 8.9% of women and 7.7% of men, with rates for both sexes increasing to 15% in persons 70 years or older.5 However, some studies have found a higher incidence (12%) of fecal incontinence when patients were directly questioned.6 Among both men and women, approximately 50% with fecal incontinence will also experience urinary incontinence.2
Prevalence of fecal and urinary incontinence increases dramatically for long-term-care residents. Up to 50% of long-term-care residents are reported to have urinary incontinence and 23% to 66% are reported to have fecal incontinence.7 Combination incontinence was reported as present in 50% of the residents.7 For critically ill7 adults in the intensive care unit, moisture-associated skin damage developed in 36% of the patients in 4 days.8 Costs associated with urinary incontinence alone are estimated to be more than $26.3 billion annually, and 66% of women and 58% of men report incontinence-associated quality-of-life issues.9
EFFECT OF MOISTURE ON SKIN
The etiology of moisture-associated skin damage is complex (Table 2). Moisture from any source increases the skin’s permeability and decreases its barrier function. The stratum corneum or outermost layer of the epidermis is normally slightly acidic and, when intact, protects the body from pathogens. When the skin is compromised by moisture alone or moisture with friction, a break in the surface may occur, allowing pathogens to enter.2,12 The most common pathogens are Candida albicans and Staphylococcus. In addition, the alkaline nature of urine increases the skin’s pH, changing it from acidic to alkaline.13 In addition, the alkaline urine may promote the enzymatic activity of proteinases and lipases when fecal incontinence is present and further erode the skin’s surface. Cleaning the skin frequently, especially with soap and water, also decreases the acid mantle and promotes a chemical and physical irritation of the area with associated epidermal damage.2,12
When the skin is moist, the effects of friction are more damaging. Sliding across bed linens during transfer or repositioning may cause friction injury to the wet skin.13 Even in persons with containment briefs, the microclimate between the brief and the skin is warm and moist; this may make the skin more susceptible to moisture-related damage and friction. Little evidence supports the use of diapers over underpads, but polymer-based products have appeared to be more effective in preventing skin breakdown than nonpolymer.14
EXAMINATION OF THE SKIN
It is often difficult even for an expert to distinguish between moisture-associated skin damage and a Stage I or II pressure ulcer (Figure 1 and Table 3). Both conditions usually occur over the buttocks in very ill patients. Consequently, it is necessary to correctly identify the causative issue or issues to provide appropriate treatment. Moisture-associated skin damage should not be documented as a Stage I or II pressure ulcer. Complicating the issue, however, is the fact that it is not uncommon for the incontinent patient to also be unable to effectively shift his/her body weight; thus, pressure-related injury may be occurring to the skin simultaneously.15 In this case, the damage is mixed etiology and is classified as both moisture damage and a pressure ulcer. However, it is also important to realize that friction may be the reason moisture-damaged skin has an open area in the epidermis. Thus, in this case the wound is classified as moisture-associated damage only. There are several assessment tools that can help with differentiation in clinical practice.16
Moisture-associated skin damage appears as a diffuse area of erythema. It can extend into the skin folds and between the buttocks and down the inner thighs. There may be scaling of the skin with papule and vesicle formation. These may open with “weeping” of the skin, which exacerbates skin damage. Skin damage is shallow or superficial, and edges are irregular or diffuse. Maceration or a whitening of the skin may also be observed. Moisture-associated skin damage is more difficult to see in persons with darkly pigmented skin, but hyperpigmentation or hypopigmentation may be present.2,13 Necrosis is not present in moisture-associated skin damage. The patient may report burning, itching, and pain.
Pressure ulcers must have pressure and/or shear present. Pressure ulcers normally occur over a bony prominence and may be full or partial thickness. A Stage I pressure ulcer will be unbroken reddened skin that is nonblanchable. A Stage II pressure ulcer is a partial-thickness wound involving the epidermis. Unlike moisture-associated skin damage, a pressure ulcer usually has distinct edges. In full-thickness pressure ulcers, necrotic tissue may be present. Although moisture may also be present, the underlying cause of the wound is pressure-related skin damage.17
TREATING THE CAUSE OF MOISTURE-ASSOCIATED SKIN DAMAGE
Treatment starts with identification of the moisture source. Test to determine the type of urinary incontinence or if there are underlying causes of fecal incontinence such as Clostridium difficile or tube feeding–related diarrhea. Note the time of day the incontinence occurs and monitor that for patterns. Foods such as caffeine, carbonated beverages, spicy foods, or acidic foods such as citrus products and fruit juices may trigger bladder spasms that lead to incontinence. Some incontinence cases can be treated surgically or with medication. Remember that medication may cause constipation, which can worsen the incontinence by straining at stool or because the rectal vault is full of hard stool that is pressing on the bladder. The incidence of fecal incontinence is increased if stool is liquid. Fiber added to food may help, or active yogurt cultures, such as lactobacillus, may be given.18 If the diarrhea is related to tube feeding, the dietitian should be consulted to adjust the rate or type of formula (Table 4).
Next, the skin needs to be protected from exposure to further irritants. Skin should be cleansed gently using a no-rinse skin cleanser with a pH similar to normal skin.2,12 These types of cleansers are as effective as soap and water in removing both Gram-negative and Gram-positive bacteria from the skin.
After cleansing, a barrier ointment or a no-sting barrier film should be applied to protect the skin from the constant moisture. 10,20–22 Products should be applied according to the manufacturer’s directions or after each incontinent episode and cleaning. Keeping the patient clean and dry, changing underpads or briefs after soiling, and using barrier creams or ointments are usually all that is required for moisture-associated dermatitis to resolve.23 It is helpful to keep the individual off the affected area to promote dryness and reduce potential friction. If a secondary infection is present, appropriate treatment should be implemented. In some cases, diversion devices, such as Foley or condom catheters, or fecal containment devices are used to keep the skin dry. However, use of these devices also has risks, including bladder infection, ulceration of the penis, or anal mucosal erosion. Be sure to monitor for such complications.
In some patients, a Stage I or II pressure ulcer may be present along with moisture-associated skin damage. All staff members need to know and follow the plan of care for these patients. When moisture creams are used to treat the moisture, a dressing will not stick to the pressure ulcer. This makes it difficult to keep feces out of the broken skin and increases the risk of a secondary infection. If the pressure is partial thickness, keeping the person off the affected area and treating the moisture-related skin damage may be all that is needed to resolve both issues. Treatment, however, must be decided by the wound team on an individual basis.
THE AGING POPULATION
Older adult skin is particularly susceptible to moisture-related damage. Skin becomes drier, thinner, and less elastic. The epidermis and dermis are no longer attached, and friction-related tearing becomes more problematic. Bladder changes also occur. The bladder empties less effectively and becomes less elastic. Women may have weakened pelvic floor muscles from childbearing. Consequently, the combination of physiologic changes in skin and bladder function, multiple medical comorbidities experienced during aging, and age-related mobility problems leads to an increased risk of incontinence and moisture-related skin damage.24
On a positive note, because baby boomers are aging, the topic of incontinence is being more openly discussed. Adult absorbent pads are now available over the counter for light, moderate, and heavy urinary incontinence. Pads, as well as the customary briefs, are also available from medical supply companies and may offer the older adult more dignity by allowing them to wear the underpants with the pad. Products that are placed between the buttocks are also available for small amounts of fecal incontinence. In mobility-impaired persons, pads or briefs may become very “heavy” if not changed after each incontinent episode. The weight and bulk of a full pad or brief may make ambulation more difficult and increase fall risk. A combination of mobility limitations and communication problems is common in many long-term-care patients. In these patients, it is important to keep track of the time of incontinent episodes so toileting patterns can be established, and prompted voiding or timed toileting can be started. In many cases, falls that occur right after a meal are the result of the person’s need to toilet but inability to communicate the need.
Incontinence or leakage of some amount of urine is present in millions of people. Yet, this subject is not well discussed or routinely assessed as part of general medical care. Incontinence is especially problematic for aging adults whose skin changes make them more susceptible to moisture-associated skin damage. Correct diagnosis and treatment of the cause, as well as correct cleaning procedures and localized treatment, are necessary to keep skin healthy. Prevention of moistureassociated skin damage is important, and care planning must be individualized to meet care needs appropriately.
PRACTICE PEARLS...Image Tools
1. 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: 45–54.
2. Landefeld CS, Bowers BJ, Feld AD, et al.. National Institutes of Health state-of-thescience conference statement: prevention of fecal and urinary incontinence in adults. Ann Intern Med 2008; 148: 449–58.
3. Melville JL, Newton K, Fan MY, Katon W. Health care discussions and treatment for urinary incontinence in U.S. women. Am J Obstet Gynecol 2006; 194: 729–37.
4. Newman DK. Talking to patients about bladder control problems. Nurse Pract 2009; 34 (12): 33–45.
5. Whitehead WE, Borrud L, Goode PS, et al.. Fecal incontinence in US adults: epidemiology and risk factors. Gastroenterology 2009; 137: 512–7.
6. Alsheik EH, Coyne T, Hawes SK, et al.. Fecal incontinence: Prevalence, severity, and quality of life from an outpatient gastroenterology practice. Gastroenterol Res Pract 2012; 2012: 947694.
7. Newman DK. Double taboos: urinary and fecal incontinence. The state of the science. Ostomy Wound Manage 2007; 53 (12): 6–7.
8. Bliss DZ, Savik K, Thorson MA, Ehman SJ, Lebak K, Beilman G. Incontinence-associated dermatitis in critically ill adults: time to development, severity, and risk factors. J Wound Ostomy Continence 2011; 38: 433–45.
9. Temml C, Haidinger G, Schmidbauer J, Schatzl G, Madersbacher S. Urinary incontinence in both sexes: prevalence rates and impact on quality of life and sexual life. Neurourol Urodyn 2000; 19: 259–71.
10. Gray M. Incontinence-related skin damage: essential knowledge. Ostomy Wound Manage 2007; 53 (12): 28–32.
11. Farage M, Miller K, Berardesca E, Maibach H. Incontinence in the aged: contact dermatitis and other cutaneous consequences. Contact Dermatitis 2007; 57: 211–7.
12. Beeckman D, Schoonhoven L, Verhaeghe S, Heyneman A, Defloor T. Prevention and treatment of incontinence-associated dermatitis: literature review. J Adv Nurs 2009; 65: 1141–54.
13. Black JM, Gray M, Bliss DZ, et al.. MASD part 2: incontinence-associated dermatitis and intertriginous dermatitis: a consensus. J Wound Ostomy Continence Nurs 2011; 38: 359–70.
14. Brown DS. Diapers and underpads, part 1: skin integrity outcomes. Ostomy Wound Manage 1994; 40 (9): 20–22, 24-26, 28 passim.
15. Zulkowski K. Perineal dermatitis versus pressure ulcer: distinguishing characteristics. Adv Skin Wound Care 2008; 21: 382–8.
16. Junkin J, Selekof J. Beyond “diaper rash”: incontinence-associated dermatitis: does it have you seeing red? Nursing 2008; (11 Suppl):56hn1-10; quiz 56hn10-1.
17. National Pressure Ulcer Advisory Panel. Updated staging definitions. 2007. http://www.npuap.org/pr2.htm
. Last accessed February 24, 2012.
18. Junkin J. Prevalence of incontinence and associated skin injury in the acute care inpatient. J Wound Ostomy Continence 2007; 34: 260–9.
20. Guest JF, Greener MJ, Vowden K, Vowden P. Clinical and economic evidence supporting a transparent barrier filmdressing in incontinence-associated dermatitis and peri-wound skin protection. J Wound Care 2011; 20 (2):76, 78–84.
21. Gray M. Preventing and managing perineal dermatitis: a shared goal for wound and continence care. J Wound Ostomy Continence Nurs 2004; 31 (1 Suppl): S2–9.
22. Gray M, Ratliff C, Donovan A. Perineal skin care for the incontinent patient. Adv Skin Wound Care 2002; 15: 170–5.
23. Atherton DJ. The aetiology and management of irritant diaper dermatitis. J Eur Acad Dermatol Venereol 2001; 15 Suppl 1: 1–4.
24. Junkin J, Selekof JL. Prevalence of incontinence and associated skin injury in the acute care inpatient. J Wound Ostomy Continence Nurs 2007; 34: 260–9.
© 2012 Lippincott Williams & Wilkins, Inc.