Incontinence Associated Dermatitis

Incontinence Associated
Dermatitis
Mikel Gray, PhD, FNP, PNP, CUNP, CCCN, FAANP, FAAN
Professor & Nurse Practitioner
University of Virginia Department of Urology

Functions of the Skin
Thermoregulation
Sensory organ/
communication
Immune functions; acts as a
first line of defense
Vitamin D metabolism
Barrier against toxins in
external environment and
against fluid & electrolyte
loss from internal
environment
Burns T et al. Textbook of Dermatology, 2004. Mass: Blackwell Science.
Figure: Verdier-Sevrain
S, Bonte F. Journal of Cosmetic Dermatology 2007; 6:75.

Barrier Function: The Bricks
Corneocytes (keratinocytes)
– Anucleated cells filled with
keratin & other molecules created
by breakdown of filaggrin
– Collectively referred to as natural
moisturizing factor (NMF)
– Surrounded by cornified
envelope (corneodesmosomes(
corneodesmosomes)
that degrade as they move to
surface of skin
– 20% content is H 2 0
Verdier-Sevrain
S, Bonte F. J Cosmetic Dermatology 2007; 6:75.
Gray M. American Journal of Clinical Dermatology 2010; 11(3): 201.
Figure:
http://www.bioskinregeneration.com/wrinkles/skin.j
pg

Moisture Barrier:
Natural Moisturizing Factor (NMF)
NMF contains various hygroscopic molecules 1 :
– Amino acids 40%
– pyrrolidone carboxylic acid 12%
– Lactate 12%
– Urea 7%
NMF levels ↓ by:
– Repeated washing with soaps or detergents 2
– Low humidity (

Skin’s s Moisture Barrier:
The Mortar (Lipid Matrix)
Primary components 1 :
– Ceramides 50%
– Cholesterol 23%
– Free fatty acids 15%
– Organized in lamellar arrangement as bi-layers with
water; stores water needed for adequate hydration and
slows water passage
Lipid Matrix ↓ by:
– Age 2
– Seasonal effects 1
– Atopy 2
1. Verdier-Sevrain
S, Bonte F. Journal of Cosmetic Dermatology 2007; 6:75.
2. Rogers J et al. Archives in Dermatologic Resarch 1996; 288: 756.
3. Chamlin SL et al. Archives in Dermatology 2001; 137: 1110.

Moisture Barrier:
Additional Factors
Aquaglyceroporin AQP3 1
– Membrane protein that forms water channels across
cell facilitating transport of water, urea, glycerol
within epidermis but preventing excessive loss via SC
– Expressed from the granulosum to just below the SC
Tight Membrane Junctions 2
– Water gradient steepest at junction or stratum
corneum and stratum granulosum
– TMJ comprises transmembrane proteins that control
skin permeability
1. Verkman AS, Mitra American J Physiology Renal Phys 2000; 278: F13.
2. Madara JL. Annual Review of Physiology 1998; 60: 143.

Moisture Barrier:
Vulnerable at the
Extremes of Life
Neonates: less efficient moisture barrier,
especially in premature infants 1
– More hydrophobic than older infants; result is
dryer more brittle skin 2
– TEWL ; ; skin capacitance
Cornification begins about GW 20
– Full-term skin contains 10-20 layers of SC, skin
in premature baby has 2-32
3 layers of SC
– Ability to regenerate skin cells considerable
1. Lund C et al. JOGNN 1999; 28(3): 241.
2. Matsumoto T et al. Journal of Dermatology 2007; 34: 447.

Moisture Barrier
Vulnerable at the Extremes of
Life
Aging Skin: gradual decline
in barrier function
– Thickness
– NMF content
– hydration
– TEWL
Comparatively slow to
regenerate
.

Water
Adverse Effects of
Urine on Skin
– skin hardness, rendering it more susceptible
to friction and erosion 1-3
– Compromises barrier function of skin 4
permeability to pathogenic species
permeability to irritants in urine or stool
– Effects exacerbated by presence of occlusive
device such as warp around incontinence
brief
brief
1. Berg W et al. Pediatric Dermatology 1986; 3: 102.
2. Leyden JJ et al. Archives of Dermatology 1977; 113: 1678.
3. Gray M. Journal of WOC Nursing 2004; 31(1 Suppl):S2-9.
4. Zimmerer RE et al. Pediatric Dermatology 1986; 3: 95.

Ammonia
Adverse Effects of
Urine on Skin
– From urine itself; ammonia also produced by
conversion of urea in presence of certain bacteria,
such as Corynebacterium and fungal species such
as candida albicans 1-3
– Especially with double UI & FI
– No direct evidence ammonia damages intact skin;
probably aggravates already compromised skin 1
– Alkaline urine may provoke or exacerbate
inflammation 2
1. Leyden JJ et al. Archives of Dermatology 1977; 113: 1678.
2. Atherton DJ Eur Academy Dermatology Venerology 2001; 15 (Supp1): 1.
3. Berg W et al. Pediatric Dermatology 1986; 3: 102.

Adverse Effects of
Stool on Skin
Fecal enzymes
– Protease & lipase potentially break down both
principal elements of moisture barrier 1,2
– In vivo evidence shows that exposure to
digestive enzymes in human skin led to 3
TEWL
pH
Visible Visible damage only when occlusion present
Evidence Evidence of damage present after 12 days
1. Atherton DJ Eur Academy Dermatology Venerology 2001; 15 (Supp1): 1.
2. Gray M. Journal of WOC Nursing 2004; 31(1 Suppl):S2-9.
3. Anderson PH et al. Contact Dermatitis 1994; 30(3): 152.

Pathophysiology
Use of absorptive containment devices
– Exacerbate overhydration by promoting
perspiration & retaining urine and stool; with
padding alone:
TEWL TEWL increases 3-43
4 fold within days
COCO 2
emission increases > 4 fold
pH pH increases from 4.4 to 7.1 (without(
incontinence)
1. Grove GL et al. Clinical Problems in Dermatology 1998; 26:183
2. Zimmerer RE et al. Pediatric Dermatology 1986; 3: 95.
3. Zhai H et al. Skin Research & Technology 2002; 8:13.

IAD: Pathophysiology
Urine/ Stool and Skin Flora
– Flora of skin near groin usually
colonized with staphylococcus
epidermidis & diphtheroids such as
Corynebacterium
– Contains few gram negative bacilli
– Candida albicans found in stool of infants
with diaper dermatitis, but not infants
without dermatitis
Leyden JJ et al. Archives of Dermatology 1977; 113: 1678.

Beekman D et al. Journal of Advanced Nursing 2009; 65(6): 1141.

Definition:
Incontinence Associated Dermatitis
(IAD)
Irritation and inflammation
associated with exposure to stool
or urine
Often accompanied by erosion of
the skin
Sometimes accompanied by
secondary cutaneous infection
(ie: candidiasis)
Etiology and pathophysiology
distinct from pressure ulceration
Photograph courtesy Linda
Bohacek

IAD as One Form of
Moisture Associated Skin Damage (MASD)
– Intertrigo: : inflammation in skin folds related to
perspiration, friction and bacterial/ fungal
bioburden
– Periwound maceration: : skin breakdown from
wound exudate, related to volume,
constituents or exudate & bacterial bioburden
– IAD: : urine, stool, containment device,
secondary cutaneous infection –fungal or
bacterial
1. Gray M et al. Journal of Wound, Ostomy & Continence Nursing 2007; 2
34(2):134.

Prevalence in Acute Care
976
Total number of
patients surveyed
35% had
Foley catheter
(deemed continent)
20.3% (198)
prevalence of
incontinence
urine or stool
• 27% had IAD
• 33% had a pressure
ulcer
• 18% had a probable
fungal Infection
21% had more than 1 type of injury
Junkin J, Selekof J. IAD prevalence in acute care. WOCN National Conference, June 2006
Minneapolis, MN.

Prevalence in Acute Care
N = 608
33% had
Foley catheter
(deemed continent)
19.7% (120)
prevalence of
incontinence
urine or stool
• 42.5% perineal skin injury
• 20% had IAD
• 21.7% had PU
• 10% had a probable
fungal Infection
Junkin J, Selekof J. Journal Wound, Ostomy & Continence Nursing 2007; 34(3): 260.
.

Prevalence & Incidence
in Critical Care Setting
95% of 44 ICU patients with incontinence
(n=44) 1
MDS mined data suggests at least 5.7%
prevalence from 10, 217 residents in 31 states 2
3.4% incidence in 981 residents on IAD
prevention program (over 14 days)
Median (range) time to onset 13 days
39% still had IAD after 2 weeks
1. Peterson, AACN NTI abstract, 2007.
2. Bliss DZ et al. Nursing Research 2006; 55(4): 243.

Etiology: Pressure Ulcers
Pressure
Shear
Pressure + Shear
Histopathologic Analysis of PU: ischemia 1
1. Houwing RH et al. SKINmed 2007; 6(3): 113.

Etiology: IAD
Histopathologic Analysis of IAD: inflammation 1
1. Houwing RH et al.
SKINmed 2007; 6(3): 113.

IAD & Pressure Ulcers
Most experts believe that IAD impairs skin’s
tolerance for pressure/ shear
Ongoing debate & controversy reflects lack of
knowledge of underlying mechanisms…in in one
study subepithelial moisture differentiated
erythema and stage I PU; higher SEM predicted
greater likelihood of erythema/stage I PU 1
FI and double incontinence strongly associated
with PU risk, mixed evidence concerning UI
alone 2-6
1. Jensen BB. Journal of Wound, Ostomy and Continence Nursing, 20092
(in pres).
2. Maklebust J & Magnan MA Advances in Wound Care 1994; 7(6): 25.
3. Gunninberg L. Journal of Wound Care 2004; 13(7): 286.
4. Fader M et al. Journal of Clinical Nursing 2003; 12(3):374.
5. Berlowitz DR et al. Journal of the American Geriatrics Society 2001; 49(7):866
7):866-71. 71.
6. Narayan S et al. Jounal of WOCN 2005; 32(3): 163.

IAD: Screening begins with CNA
or Non-professional care provider

IAD:
Diagnosis
Relies solely on
inspection
– Inflammation (bright
red) in persons with
light skin tones
– IAD located in skin fold
or underneath
containment device,
borders are poorly
demarcated & irregular
– Surface of skin may
“glisten” owing to
serous exudate

IAD: Diagnosis in persons with
Darker Skin Tones
Inflammation not readily
apparent (ie: not bright
red); often presents as
area of
hyperpigmentation or
subtle red tone
Hypopigmented areas
with chronic
inflammation
Pattern of skin damage
does not vary

IAD: Diagnosis
Inspect Skin Folds
– Opposing skin surfaces trap
& harbor moisture
– Warm moist environment
encourages bacterial and
fungal colonization,
overgrowth and infection
– Friction occurs as skin folds
rub against one another

IAD: Diagnosis
Assess for skin
erosion
– Partial thickness
erosion occurs with
IAD
– Necrotic tissue:
eschar or slough, full
thickness damage
indicates pressure
ulceration

IAD: Diagnosis
Look for secondary
cutaneous infection,
especially candidiasis
– Opportunistic infection with
candida albicans
– Thrives in warm, moist
environment & damages
stratum corneum
– Seen in 18% of one group of
976 acute care inpatients 1
Junkin J, Selekof J. IAD prevalence in acute care. WOCN National l Conference, June 2006 Minneapolis, MN.

IAD: Diagnosis
Suspect PU when wound
is
– Over bony prominence
– Full thickness
– Necrotic tissue is present
– Skin is dark to purplish
red
Images: http://www.lhsc.on.ca/wound/p_chart.htm

Differentiate IAD from
Pressure Ulceration
Gray M et al. Journal of Wound, Ostomy and Continence Nursing 2007; 07; 34(2): 134.

IAD and its Severity
Instrument
Designed and validated by WOC nurses and
their faculty
2 WOC nurses established initial face validity
Content and criterion validity via 9 WOC nurses
in North Central Region of WOCN
Interrater reliability via 247 WOC nurses
attending 2007 National Conference
Descriptive, ranks severity allowing longitudinal
assessment; responsiveness has not yet been
tested
Borchert K et al. Journal of Wound, Ostomy and Continence Nursing 2010; 37(5): 527.

IAD and its Severity
Instrument
Borchert K et al. Journal of Wound, Ostomy and Continence Nursing 2010; 37(5): 527.

IAD and its Severity
Instrument
Borchert K et al. Journal of Wound, Ostomy and Continence Nursing 2010; 37(5): 527.

IAD and its Severity
Instrument
Borchert K et al. Journal of Wound, Ostomy and Continence Nursing 2010; 37(5): 527.

Clinical Evidence: How do we
Prevent and Treat IAD?
Structured skin care
regimen based on
available evidence and
followed routinely
Lyder, Journal of Enterostomal Therapy Nursing 1992
Hunter et al., Journal of Wound, Ostomy and Continence Nursing 20032
Zehrer et al., OWM 2004
Bale et al., J Tissue Viability 2004
Bliss, et al., Journal of Wound, Ostomy and Continence Nursing 20062

IAD: Prevention & Treatment

IAD: Cleanse
When frequent bathing necessary, current
evidence suggests….
– Gentle cleansing: NO scrubbing 1,2
– Select a cleanser with pH close to acid mantle of skin
– Select product that minimizes potential irritants,
scents, etc.
– Towel drying has been found to compromise
moisture barrier, consider no-rinse formulation for
frequent bathing 2
1. Gray M et al. Journal of Wound, Ostomy & Continence Nursing 2007; 2
34(2):134.
2. Voegeli D. Journal of Wound, Ostomy & Continence Nursing 2008; ; 35(1).

Moisturize
Three categories
– Humectants attract water to the skin
– Emollients replace lipids to stratum corneum;
designed to smooth skin surface
– Occlusives act to protect skin from exposure
to moisture and potential irritants; vary in
their ability to maintain skin hydration
– Some prefer emollient based on clinical
considerations, no research available to verify
or refute

Protect
Skin Protectants should
– Act as a “moisture barrier”, , protecting skin from
deleterious effects of exposure to irritants and
excess moisture
– Maintain hydration and favorable skin’s s normal
transepidermal water loss (TEWL)
– Avoid maceration when left on for prolonged
period of time
– Options
Ointment based skin protectants
Liquid acrylates (marketed as a skin barrier)
Gray M. Skin Protectants in the Treatment of Irritant Dermatitis In: Sek CK. Advances in Wound
Care, Volume 1. New Rochelle, NY: Mary Ann Liebert, , Inc.

Protect
Ointment based skin
protectants
– Petrolatum: : blend of
castor seed oil &
hydrogenated castor
oil
– Dimethicone: : silicone
based oil
– Zinc Oxide: : white
powder, mixed with
cream or ointment
base

Clinical Evidence
Petrolatum
– Good protection against irritant
– Avoided maceration
– Modest skin hydration
Dimethicone
– Variable protection against irritant
– Modest protection against maceration
– Good skin hydration
Zinc Oxide
– Good protection against irritant
– Did not avoid maceration
– Poor skin hydration
Hoggarth A et al. OWM 2005; 51(12): 30.

Protect
Skin barriers (polymer acrylate)
– Non-alcohol preferred
Less pain
Less drying
No different when compared to ointment based
skin protectants in one robust RCT (powered for
economic rather than efficacy outcomes)
Bliss DZ et al. Journal of Wound, Ostomy & Continence Nursing 2009; 09; 35 (2).

Cleanse, Moisturize & Protect:
Single Step Approach
Disposable Bathing
Cloth: : Cleanses &
moisturizes
Shield Cloths: : Tailored
cloths, cleanse
(chlorhexidine
gluconate), moisturize
(glycerine, aloe),
protect (3%
dimethicone)

Hospital
vs.
Washcloth Disposable
Washcloth

Preventive Skin Care
Typical Protocol
– Routine daily cleansing &
moisturization for all
patients
– For Incontinent and High
Risk Patients
Cleanse, Cleanse, moisturize &
protect daily and after
each major incontinent
episode

IAD: Treatment
Establish or continue structured
program based on “cleanse,
moisturize & protect”, , consider
changing skin protectant
Minimize exposure to irritants
(Aggressively manage UI or FI)
Treat secondary cutaneous
infections
Allow skin to heal or apply
protectant with active ingredients
designed to promote healing

IAD: What about
Dressings
Topical Dressings
– Hydrocolloids
– Thin film dressings
Act as barrier to urine & stool
Promote moist environment
for wound healing
Can be combined with topical
treatments

Dressings:
Practical Concerns
Topical Dressings
– Maintaining adherence
significant challenge
– Skin surfaces complex
– Borders often roll when
ointments or
moisturizing products
have been applied
– Undermining of urine
or stool may occur

IAD Treatment
Aluminum sulphate or acetate (Burow’s
Solution) with Stomahesive powder:
– Applied as compress; causes protein
precipitation & has antimicrobial properties
– Exerts drying & soothing effect; followed by
application of moisture barrier
– Often used when dermatitis complicated by
extensive erosion and serous exudate

IAD: Treatment
BCT Agents
– BCT Ointment (Xenaderm)
Balsam Peru, Castor Oil, Trypsin in
ointment base
Applied to dermatitis twice daily or with
major cleansing
Goal is to combine skin protectant
with active ingredients that promote
wound healing

IAD Treatment:
Secondary Complications
Candidiasis
– Topical antifungals are effective for the
treatment of cutaneous infections
– Effective agents include the polyene
antibiotics, azoles and the allylamines 1
– Resistance to antifungals is emerging, careful
monitoring of research literature is essential
1. Evans E & Gray M, Journal of Wound, Ostomy & Continence Nursing 2003; ,30(1).

Conclusion
IAD is a prevalent and clinically relevant
condition,
Relationship to PU risk poorly understood,
etiology appears distinct, some
pathophysiologic mechanisms shared
Structured skin regimen key to prevent &
treat
Principles of skin regimen: cleanse,
moisturize & protect