The causes of incontinence dermatitis are outlined and a case study is provided to illustrate best practice on how to manage and prevent this condition
Jackie Rees, MSc, BSc, DipN, RGN, is nurse consultant (continence care); Fania Pagnamenta, MA, BSc, DipN, RGN, is nurse consultant (tissue viability), both at Newcastle-upon-Tyne Hospitals Foundation Trust.
Rees, J., Pagnamenta, F. (2009) Best practice guidelines for the prevention and management of incontinence dermatitis. Nursing Times; 105: 36, early online publication.
This article outlines the causes of incontinence dermatitis and risk factors associated with this skin problem. The authors describe how simple guidance on skin care can improve patient care and use a case study to illustrate this.
Keywords: Incontinence, Dermatitis, Skin care
- This article has been double-blind peer reviewed.
- Incontinence can lead to damaged skin unless preventative action is taken.
- Simple guidelines can prevent incontinence dermatitis.
- Incontinence is common and debilitating following a stroke.
The skin is the largest organ in the body and has a number of functions (Box 1)
Box 1. Function of the skin
- Protection of underlying muscles, bones and organs
- Barrier to infection
- Storage and synthesis: lipids and water storage, synthesis of vitamin D
- Cutaneous sensation: nerve endings in the skin sense touch, vibration, warmth, cold, pain
(Nigam and Knight, 2008).
Ageing increases the risk of skin damage as the epidermis thins and there is a reduction in the surface contact between the epidermis and dermis, leading to reduced exchange of nutrients and metabolites between the two layers (Nigam and Knight, 2008). This means that the skin is more likely to be damaged by shearing forces such as moving or dragging a person up a bed or up a chair.
The superficial layer of the skin, the straturm cornea, provides a protective barrier. If the stratum corneum breaks down, the barrier function for the skin is impaired and this is a risk factor associated with the development of moisture lesions (Hardy, 1996).
The effects of age on the physiology of skin, combined with incontinence in the older population, can result in the skin becoming increasingly vulnerable to damage.
One such condition is incontinence dermatitis (ID) which is an irritant dermatitis, resulting in high moisture exposure, friction, bacteria and enzymatic activity. Incontinence dermatitis is a skin condition that affects people who are incontinent and results in inflamed, excoriated, infected and damaged skin that causes pain, discomfort and an increased risk of pressure ulcers.
Incontinence and older people
The incidence of urinary incontinences rises with age, 31% of older women and 23% of older men are affected in the general population and between 30% and 85% of residents in nursing homes are incontinent (Bale et al, 2004). The incidence of faecal incontinence also rises with age and around 12% of older people are affected (Goode et al, 2005).
Zimmaro et al (2006) undertook a large study in the US and concluded that 3.4% of incontinent older people had ID but it is unclear how common ID is in acute hospitals.
Risk factors and causes
Nazarko (2007) identified the main risk factors for ID as:
- Urinary incontinence and faecal incontinence;
- Friction and shear when moving and handling;
- Impaired cognition;
- Skin problems;
- Poor quality of care.
Incontinence is one of the major risk factors for the development of skin breakdown and Copson (2006) noted that older people are at particular risk of developing incontinence dermatitis. The condition is caused by several factors, such as changes in skin pH, wet soggy skin, skin damage caused by mixing urine and faeces and damage caused by faecal enzymes, such as proteolytic and lipolytic (Nazarko, 2007). When faeces and urine are mixed together, bacteria in the faeces convert urea in the urine to ammonia, which makes the skin more alkaline.
Normal skin has a pH of 5.5 and it should be maintained at this level of acidity.
Commercially available soaps and cleansers are alkaline with pH of 9, and when used to cleanse the skin following episodes of incontinence the pH of the skin can become alkaline stripping it of its acid mantle (Kirsner and Froelich, 1998). This acid mantle inhibits the growth of bacteria.
The mixing of urine and faeces creates an alkaline skin pH and this problem is compounded by inappropriate use of cleansing solutions.
A tissue viability risk assessment should be carried out on all patients on admission to hospital and at regular intervals depending on the results of the assessment and local policy.
Le Lievre (2001) focused guidance on the management of incontinence to prevent ID including the use of urinary catheters, penile sheaths and pads. However, skin care is the single most important aspect in the prevention and treatment of the condition.
Patients with incontinence will have their skin washed several times a day and the products used must maintain its acid pH. Cooper (2000) reviewed the use of Clinisan, a foam cleanser and found it to be more effective than the use of soap and water in the prevention of ID. Copson (2006), in a review paper published a few years later, also recommends the use of a foam cleanser.
Moisture must be donated to the skin in the process of skin cleansing and therefore a washing product that includes a moisturising agent is essential. Creams for the treatment of ID are usually silicone, titanium or zinc based and many nurses have their favourite, without necessarily knowing all the ingredients and when and where to use them (Nazarko, 2007).
Hoggarth et al (2005) conducted a controlled trial to investigate the barrier function and skin hydration properties of six skin protectants. They concluded that well known products such as zinc oxide-based products showed good protection against irritant but poor skin hydration and barrier properties. Water-in-oil petrolatum-based products performed the best, examples are Hydromol or Epaderm.
We devised a simple strategy for the prevention and management of ID. This is illustrated in Fig 1. This required ward staff to:
- Only use Hydromol/Epaderm in the treatment of ID. The ointment is mixed in a bowl with warm water, allowed to melt a little and then used to clean the skin;
- Spray the skin with a silicone based barrier spray (Cavilon);
- Stop using any other cleanser, creams and lotions.
Hydromol and Epaderm are moisturisers that contain sodium pyrrolidone carboxylate as the main active ingredient. When sodium pyrrolidone carboxylate is applied to the skin it penetrates the stratum corneum, where it absorbs and retains water. This increases the capacity of the skin to hold moisture, and the skin becomes rehydrated. It also contains various other ingredients that have moisturising properties, such as isopropyl myristate and liquid paraffin, which provides a layer of oil on the surface of the skin. This helps prevent water from evaporating from the skin surface. Both actions soothe and soften the skin.
Moisturisers are essential for the treatment of ID, which become worse when the skin is allowed to dry out. They help restore the skin’s smoothness, softness and flexibility by helping the skin retain moisture if used regularly, particularly after bathing or showering.
Our trust’s pharmacy department has standardised and removed other cleansers and creams from its medicine formulary. Since implementation of this guideline, referrals to tissue viability and continence service for ID have drastically reduced.
This case study describes part of a patient’s care following an acute stroke, focusing on continence and tissue viability care, and demonstrates that the evidence based guideline resulted in an effective and positive patient outcome.
Mr Elliott is 66 years old and lives alone. Over the past 12 months he noticed a gradual decline in his health and one Saturday evening, as he was preparing to go to bed, he developed a severe headache, collapsed and woke to find himself unable to move. He remained on the floor over the weekend and was found by a relative on the Monday morning. An ambulance was called and Mr Elliott was admitted to hospital.
On arrival at the hospital he was stabilised and received the appropriate acute medical interventions. He was then transferred to the stroke unit. The skin on Mr Elliott’s sacrum was assessed as extremely fragile and the tissue viability and continence advisers were asked to review his skin damage and continence needs.
It is estimated that 40-60% of people admitted to hospital after a stroke can experience problems with urinary incontinence, with 25% still having problems on discharge (Barrett, 2001).
The more severe the stroke, the greater the likelihood of urinary incontience. Addressing the problems of urinary incontinence and skin care while they are in hospital is fundamental to patients’ long term quality of life.
Mr Elliott had to be able to weight bear, appreciate the need to void, initiate voiding at an appropriate place and time, communicate that desire to someone and have the ability to motivate himself to remain continent. These had proved to be impossible when he was at home on the floor and as a consequence he developed severe ID as well as a pressure ulcer (Fig 2).
The initial aim was to treat the incontinence dermatitis. Damp skin caused by excessive moisture as a result of incontinence is at risk of loosing its barrier function and thus making it more vulnerable to shearing forces. The aim was to limit the number of frequent washings of the skin in order to prevent skin maceration and begin the process of healing.
The treatment was based on a three-stage approach:
- Treat the skin;
- Once the skin is healed, treat the pressure ulcer;
- Assessment and appropriate treatment of urinary incontinence.
A decision was made to insert a urinary catheter while the ID was treated. The urinary catheter was reviewed on a daily basis with the aim of removing it as soon as possible.
The skin guidelines (Fig 1) were then followed and the skin was gently washed with Hydromol or Epaderm ointment “melted” into a bowl of warm water and was then sprayed with Cavilon. After five days the skin had recovered sufficiently for a dressing to be applied to the pressure ulcer (Fig 3).
The urinary catheter was removed after six days and a continence assessment with the appropriate treatment was implemented with effective results.
Mr Elliott was discharged to a rehabilitation ward after three weeks in the acute hospital. He had no ID, his pressure ulcer was healing and he regained his normal bladder function.
This case study demonstrates that ID can be treated effectively with simple steps illustrated by our skin guidelines. Their implementation within the trust has resulted in a positive approach towards skin care and incontinence. Adopting strategies such as evidence based guidelines to aid practice is likely to enhance patient concordance with treatment and, most importantly, to enhance the outcomes achieved by that treatment.
- This case study won the ACA 2009 Dorothy Mandelstram award, which is sponsored by Bullen Healthcare. Information on the 2010 award can be found at www.aca.uk.com
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