What is the most effective method of preventing and treating incontinence associated dermatitis?

Authors

Dimitri Beeckman, MA, RN, is PhD candidate in nursing science, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Belgium and member of research staff, Department of Bachelor in Nursing, University College Arteveldhogeschool Ghent, Gent, Belgium; Tom Defloor, PhD, RN, is professor of nursing science; Sofie Verhaeghe, PhD, RN, and Katrien Vanderwee, PhD, RN, are assistant professors of nursing science; Liesbet Demarre, MA, RN, is PhD candidate in nursing science; all at the Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University. Lisette Schoonhoven, PhD, RN, is assistant professor of nursing science, IQ Healthcare, Radboud University Nijmegen Medical Centre, Netherlands.

Introduction

Incontinence-associated dermatitis (IAD) is a clinical manifestation of moisture-associated skin damage and is a common problem in patients with faecal or urinary incontinence (Gray et al, 2007). IAD presents clinically as skin redness with or without blistering, skin erosion or loss of skin barrier function (Junkin and Selekof, 2007). Skin lesions are characterised by erosion of the epidermis and a macerated appearance of the skin (Gray et al, 2007). Fig 1 illustrates the clinical appearance of incontinence dermatitis.

Older patients, especially those in long term care facilities, are at increased risk of developing IAD (Newman et al, 2007). Its prevalence varies in different studies from 5.6% to 50% and the incidence rates are between 3.4% and 25% depending on the type of setting and population studied. Gray et al (2007) reported that around 50% of patients with urinary or faecal incontinence are affected by IAD. Faecal incontinence appears to be more strongly associated with the condition than urinary incontinence (Gray et al, 2007; Junkin et al, 2007). Skin breakdown related to incontinence has a considerable effect on patients’ physical and psychological wellbeing (Sibbald et al, 2003).

IAD development

The aetiology of IAD is complex and multifactorial (Jeter and Lutz, 1996; Lekan-Rutledge, 2006; Beeckman et al, 2009). When the skin is exposed to urine, faeces, double incontinence or frequent cleansing, its permeability increases and the barrier function reduces.

Increased skin pH can cause it to become more alkaline, increasing the risk of bacterial and fungal colonisation. This can lead to bacterial overgrowth which can cause cutaneous infections. The most common organisms are Candida albicans (from the gastrointestinal tract) and Staphylococcus (from the perineal skin). In addition, friction increases significantly when perineal skin rubs over containment materials, such asabsorbent pads, or clothingand, bed and chair surfaces. The combination of chemical irritation and friction results in weakened skin. If these mechanisms continually affect the integrity of the skin, IAD and further skin breakdown will develop (Lekan-Rutledge, 2006).

Traditionally, IAD has received little attention as a distinct skin disorder and is sometimes confused with superficial pressure ulcers (Beeckman et al, 2007).  Fig 2 summarises the development of IAD.

IAD and pressure ulcers

IAD is often combined with skin damage caused by pressure and shear – a force parallel to the skin caused by two opposing surfaces sliding and displacing against each other (Bouten et al, 2003). This can lead to confusion among clinicians about the aetiology and diagnosis of IAD (Defloor and Schoonhoven, 2005).

It is important to distinguish correctly between pressure ulcers and IAD in clinical practice because preventive measures are different for the two conditions (Beeckman et al, 2008; Defloor et al, 2004). Confusion between IAD and pressure ulcers can lead to inappropriate use of limited resources and suboptimal care. Expensive and labour intensive measures to prevent pressure ulcers will often be used with patients who have IAD. As a result, those needing pressure ulcer prevention may not receive optimal care because limited resources have been diverted wrongly.

The availability of unambiguous clinical descriptors to help distinguish between IAD and pressure ulcers could help avoid confusion and inadequate preventive interventions. Efforts to clarify the difference between IAD and pressure ulcers are being made; the Pressure Ulcer CLASsification (PUCLAS) Workgroup of the European Pressure Ulcer Advisory Panel (EPUAP) (www.epuap.org/epuap) has developed an educationaltool to teach and learn about IAD differentiation. This is based on the EPUAP position statement on pressure ulcer classification and IAD differentiation outlined in Table 1. It provides an overview of causative factors and of typical wound-related characteristics, including location, shape, depth, necrosis, edges, and colour (Defloor et al, 2005; Beeckman et al, 2008).

Prevention and treatment

Current IAD prevention strategies include cleansing, moisturising and the application of skin protectants or moisture barriers (Gray et al, 2002). Treatment includes protecting the skin from further exposure to irritants, establishing a healing environment, and eradicating cutaneous infections (Gray et al, 2002). Many skin care protocols, cleansers, moisturisers, moisture barriers, skin protectants and absorbents are available to support prevention and treatment but little is known about their efficacy and effectiveness (Gray et al, 2007).

Aim

The aim of this review was to assess the effectiveness of the different interventions for the prevention and treatment of IAD.

Method

A literature review of studies focusing on the prevention and treatment of IAD was carried out to assess the effectiveness of different methods. The incidence of IAD and skin condition were identified as the main outcome measures to assess the effectiveness of IAD preventive interventions. The effectiveness of IAD treatment methods was assessed using healing rate and skin condition.

Literature review

The study reviewed clinical trials, meta-analyses and comparative, evaluation and validation studies. The Cochrane Library Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE and PubMed were used, along with a number of conference proceedings from the last five years. Only studies published in English, Dutch, French and German with patients over age 18 were included. The literature review was performed up to September 2008 and there were no limitations on the year of publication, authors or participating institutions. Study design was not used as a selection criteria due to the explorative nature of the literature review and the scarce literature available on this issue. Thirty six publications were included in the final analysis, of which 25 studies were reported. Thirteen studies focused on treatment, eight focused on prevention and four focused on treatment and prevention of IAD.

Results

Prevention

Skin protectants

One study reported a significant reduction of IAD incidence when a skin protectant incorporated into a thick disposable washcloth - active ingredient dimethicone 3% - was used to clean and moisturise the skin of patients with continence problems (Clever et al, 2002).

Perineal skin cleansers

Two studies found skin cleansers to be more effective than soap and water for the prevention of incontinence related skin problems (Cooper and Gray, 2001; Byers et al, 1995). Reduced skin erythema was observed in four studies which looked at the effect of combining a perineal skin cleanser and a skin protectant (Dieter et al, 2006; Hunter et al, 2003; Warshaw et al, 2002; Whittingham et al, 1998).

Structured skin care and incontinence care regimes

One study found implementing a structured skin care protocol resulted in significantly lower incidence of IAD (4.7% v 25.3%). When product costs were calculated together with staff time, using a newly implemented skin care protocol also significantly reduced costs (Bale et al, 2004).  Bates-Jensen et al (2003) conducted a randomised controlled trial to examine the health outcomes of incontinence training. They found that patients who received training had significantly better urinary and faecal incontinence and skin wetness outcome measures than those who were not given training.

Body worn pads v underpads

Brown (1994) found no statistical differences in the incidence of skin alteration - colour, integrity or symptoms - between patients wearing body worn pads and those managed with underpads, or waterproof mattress protectors.  Significantly more patients in a non-polymer body worn pads and underpads group experienced alterations, such as skin colour change, tingling, itching, burning and pain, than those in a polymer group (Brown et al, 1994). Leiby and Shanahan (1994) observed improvements in skin condition when underpads with a more absorbent capacity and greater ability to keep the skin dry were used.

Treatment

Skin protectants

Anthony et al (1987) found that a topical zinc oxide preparation with added antiseptic properties was superior to traditional zinc cream for the treatment of IAD. Campbell et al (2000) and Hampton (1998) observed a reduction of erythema, skin maceration and skin stripping when comparing a no sting barrier film and a petrolatum based ointment in patients with IAD.

Moisturisers

One study observed reduced erythema, roughness and desquamation of the skin when a hydrogel barrier repair cream was compared to a petrolatum based moisturizing cream for the treatment of IAD (Draelos, 2000).

Perineal skin cleansers

Reduced skin erythema was observed in four studies which looked at the effect of combining different formulas of perineal skin cleansers and skin protectants (Dieter et al, 2006; Hunter et al, 2003; Warshaw et al, 2002; Whittingham and May 1998).

Discussion and recommendations

The number of patients included in the reviewed studies was small with an average of 64 in each study. The length of the study periods was also rather short - in some studies, patients were only observed for seven days. A wide range of instruments was used to observe incontinence-associated skin problems but these instruments were not validated, or were only validated to a small extent. This resulted in difficulties comparing the outcomes of the different studies.

Soap and water applied with a washcloth has traditionally been considered the ‘gold standard’ for skin hygiene and management. However, this review found it was not the most appropriate method for skin care of patients with incontinence. Soap can strip the skin of natural oils and puts it at risk of secondary infection from fungus and bacteria (Junkin et al, 2007). The use of perineal skin cleansers was found to be more effective for the prevention and treatment of IAD. Another option is the use of a no rinse cleansing foam.

Researchers in the reviewed studies recommend a routine perineal skin care programme. This includes cleansing with a product with a pH as near as possible to that of normal skin and applying a moisturiser incorporated into a specially designed cleanser or cleansing system.

The use of a skin protectant is recommended for patients experiencing high volume or frequent incontinence or double urinary and faecal incontinence.

IAD is more strongly associated withfaecal incontinence than urinary incontinence. Optimal skin care following each incontinent episode – especially if faeces are present - is important because of the significant contribution of faeces in the development of IAD.

Optimal skin care should be provided according to a structured skin care regimen containing a skin cleanser and a skin protectant. A skin protectant should be applied more frequently in patients with high volume or frequent episodes of incontinence.

Combined products can be used to optimise time efficiency and to encourage adherence to the skin care regimen. Combined products include moisturising cleansers, moisturising skin protectant creams, and disposable washcloths that incorporate cleansers, moisturisers, and skin protectants into a single product. Polymer productsappear to be more effective in preventing skin breakdown than non-polymer products.

Conclusion

Incontinence-associated dermatitis is an important problem in nursing care. However, this study showed there is limited evidence on the effectiveness of various skin regimens available to prevent and treat the condition. Additional research is needed to identify and evaluate the efficacy and effectiveness of various interventions for IAD and larger sample studies are needed to determine the safety and effectiveness of commonly used products and procedures. In view of the limited validation of observation instruments used in the studies, additional research in this area is also recommended.

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