Transcript Associated Dematitis

INCONTINENCE-ASSOCIATED
DERMATITIS
Nancy Fox RN BN IIWCC
OBJECTIVES

Describe Incontinence-associated dermatitis
(IAD)

Differentiate IAD from other conditions

Identify who is at risk

Discuss assessment and categorization of IAD

Identify strategies for prevention and
management
DEFINING IAD

Skin inflammation manifested as redness with or
without blistering, erosion, or loss of the barrier
function that occurs as a consequence of chronic
or repeated exposure of the skin to urine or fecal
matter (Gray, et al 2007)
SIGNIFICANCE OF THE PROBLEM

Urinary and/or fecal incontinence reported in 19.7%
of patients in acute care; up to 78.6% in long term
care

Of those incontinent patient in acute care….~43%
have associated skin injury

Precise number of patients affected by IAD is not
known

Prevalence of 5.6%-50%

Incidence of 3.4%-25%
RECOGNIZING IAD

Appears initially as
erythema…ranging from
pink to red

Darker skin tones..skin may
be paler, darker, purple, dark
red or yellow

Poorly defined edges

May be patchy or continuous
over large areas
Courtesy of Medetec with permission
RECOGNIZING IAD CONTINUED

May feel warmer and firmer
than surrounding unaffected
skin

Lesions may include vesicles or
bullae, papules or pustules

Epidermis may be damaged to
varying depths

Entire epidermis may be
eroded exposing moist ,
weeping dermis
AND MORE

Patients can experience
discomfort, pain, burning,
itching or tingling

Patients with IAD are
susceptible to secondary
skin infections,
candidiasis one of the
most common
HOW DOES INCONTINENCE CAUSE IAD




Stratum Corneum (SC)..
outermost layer and
main barrier
Comprised of 15-20
layers of corneocytes
This matrix…regulates
water movement into
and out of the SC
Natural Moisturizing
Factor(NMF) within the
corneocytes
Chu, David H., Goldman-Cecil Medicine, 435, 26322637.Copyright © 2016 by Saunders, an imprint of
Elsevier Inc.
HOW …CONTINUED


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Healthy skin surface has acidic pH 4-6
Incontinence …water is pulled into and held in
the corneocytes
Overhydration →swelling and disruption of SC
structure (maceration).
Irritants more easily penetrate the SC→
inflammation→ more prone to injury from friction
HOW…CONTINUED

Exposure to urine and
feces ↑pH..alkaline
which allows microorganisms to thrive and
↑es risk of infection.

Feces contain lipidand protein- digesting
enzymes capable of
damaging the SC
Image provided with permission by Sage Products LLC.
DOES IAD CONTRIBUTE TO PU
DEVELOPMENT?




Both have risk factors in
common
Once IAD occurs high risk for
PU dev.; ↑risk of infection
and morbidity
Different etiologies: IAD “top
down” injury while PUs are
believed to be “bottom up”
injuries
Incontinence is a risk factor
for both….IAD can occur in
the absence of any PU assoc.
risk factors and vice versa
DIFFERENTIATING IAD
IAD
Urinary and/or fecal
incontinence
 Pain, burning, itching,
tingling
 Affects perineum,
perigenital area.
 Affected area is
diffuse with poorly
defined edges

Pressure Ulcers (PU)
Exposure to
pressure/shear
 Pain
 Usually over a bony
prominence/assoc.
with a medical device
 Distinct edges or
margins

DIFFERENTIATING IAD
IAD
Intact skin with
erythema,
with/without
superficial, partial
thickness skin loss
 Secondary superficial
skin infection may be
present

Pressure Ulcers (PU)
Varies from intact
skin with nonblanchable erythema
to full-thickness skin
loss
 Secondary soft tissue
infection may be
present

KEY RISK FACTORS FOR
Incontinence; fecal
and/or urinary
 Frequent episodes
 Use of occlusive
containment products
 Poor skin condition
(e.g. due to
aging/steroid
use/diabetes)
 Compromized mobility
 Pain

IAD
Diminished cognitive
awareness
 Inability to perform
personal hygiene
 Fever
 Medications (antibiotics,
immunosuppressants)
 Poor nutritional status
 Critical illness

RISK ASSESSMENT
Perineal Assessment Tool (Nix 2002)
 Validated tool with 87% interrater reliability

4 item tool and assessment based on
Type and intensity of irritant
 Duration of contact with the irritant
 Condition of perineal skin
 Presence of contributing factors e.g. low albumin,
antibiotics, tube feeding


Each item is rated with a score ranging from 1-3;
total scores ranging from 4 (least at risk) to 12
(most at risk)
PREVENTION OF IAD
Structured skin care regimen that consists of 2 key
interventions:



Cleansing the skin…to remove urine and/or feces
Protecting the skin…to avoid or minimize
exposure to the irritants
Restoring (when appropriate) to support and
maintain skin barrier function
PRINCIPLES OF CLEANSE


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Cleanse daily and after every episode of fecal
incontinence
Use gentle technique with minimal friction, avoid
rubbing/scrubbing the skin
Avoid standard alkaline soaps
Choose a gentle no-rinse liquid cleanser or premoistened wipe with a pH similar to normal skin

If possible use a soft, disposable non-woven cloth

Gently dry skin if needed after cleansing
PRINCIPLES OF SKIN PROTECTION


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Apply skin protectant at a frequency consistent with
its ability to protect the skin
Ensure skin protectant is compatible with any other
skin care products e.g. cleansers
Apply the skin protectant to all skin that comes in
contact with or potentially will contact urine /feces.
Image provided with permission by Sage Products LLC.
CHARACTERISTICS OF THE MAIN TYPES OF
SKIN PROTECTANTS
Principle
ingredient
Description
Notes
Petrolatum
•Derived from
petroleum processing
•Common base for
ointments
Forms occlusive layer
↑ skin hydration
Dimethicone
Silicone-based
Non-occlusive; opaque
or becomes
transparent after
application
Acrylate terpolymer
Polymer forms a
transparent film
Does not require
removal; transparent
Zinc oxide
White powder mixed
with a carrier to form
an opaque cream,
ointment or paste
Can be difficult to
and uncomfortable to
remove
RESTORE

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Additional step to support and maintain the integrity
of the skin barrier
Use of a topical leave-on skin care product ( often
termed moisturizers)
Emollients..contain lipids and are intended to reduce
dryness and restore lipid matrix
Humectants…function by drawing in and holding
water in the SC e.g. urea, alpha hydroxyl acids,
glycerin, lanolin or mineral oil
Can be used by themselves or in combination with
barriers
IAD ASSESSMENT AND CLASSIFICATION

Inspect skin ( perineum, perigenital areas,
buttocks, gluteal fold, thighs, lower back, lower
abdomen and skin folds)for…




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Maceration
Erythema
Presence of lesions
(vesicles, papules, pustules etc)
Erosion or denudation
Signs of fungal or bacterial infection
Assess severity using standardized tool e.g.
Perirectal Skin Assessment Tool, IADIT
IAD INTERVENTION TOOL
Categorize IAD based
on the level and
severity of skin injury
 Includes interventions
according to severity to
prevent further
damage and heal the
skin

INTERVENTIONS BASED ON SEVERITY OF
IAD (IADIT, JOAN JUNKIN 2008)

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High Risk – skin is
not red or warmer
than nearby skin;
person unable to self
care or communicate
need; incontinent of
stool at least 3 x/24
hours
Early or Mild IAD skin is dry and intact
but is pink or red with
diffuse, often irregular
borders
INTERVENTIONS FOR HIGH RISK AND
EARLY IAD
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Use a disposable barrier cloth containing
cleanser, moisturizer, and protectant
Use acidic cleanser (pH 6.5 or lower), not soap;
cleanse gently – no scrubbing; and apply
protectant (i.e. dimethicone, liquid skin barrier or
petrolatum)
Allow skin to be exposed to air for 30 minutes
twice daily by positioning semi-prone;
Manage cause of incontinence
MODERATE IAD
Skin is bright or
angry red
 usually appears shiny
and moist with
weeping or pinpoint
areas of bleeding
 may have raised areas
or small blisters
 small areas of skin
loss
 painful whether of not
the patient can
communicate the pain

INTERVENTIONS FOR MODERATE IAD
Plus…
 Consider applying zinc oxide-based product for
weeping or bleeding areas 3 times daily or
following stool episodes
 May apply ointment to a non-adherent dressing
and gently place on injured skin to avoid rubbing
 Do not scrub the paste completely off…gently
soak stool off top then reapply new paste dressing
to area
 If denuded areas remain to be healed after
inflammation is reduced, consider BTC ointment
(contains Balsam of Peru, trypsin, castor oil)
SEVERE IAD

Skin is red with areas
of denudement
(partial thickness skin
loss) and
oozing/bleeding
INTERVENTIONS FOR SEVERE IAD
Plus…
 Consider treatments that reduce moisture; low
air loss mattress/overlay, more frequent turning,
astringent such as Domeboro soaks.

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Consider the air flow type underpads
Consider use of external catheter or fecal
collector
Consider short term use of urinary catheter in
cases of IAD complicated by secondary infection
FUNGAL-APPEARING RASH

This may occur in
addition to any level
of IAD injury; usually
spots are noted near
edges of red areas that
may appear as
pimples or just flat
red areas; patient may
report itching which
may be intense
INTERVENTIONS FOR FUNGAL-APPEARING
RASH
Anti-fungal powder or ointment ( avoid creams as
they add moisture to an already moisture
damaged area)
 If using powder, lightly dust powder to affected
areas…seal with ointment or liquid skin barrier
to prevent caking
 Continue treatments according to level of IAD
 Assess for thrush, and vaginal fungal infection in
women
 Assess skin folds
 If no improvement, culture area for possible
bacterial infection

TAKE HOME POINTS
Identify and treat the reversible causes of
incontinence
 Assess the risk of IAD and monitor patient
 Maximize nutritional intake, hydration and
toileting techniques
 Implement a structured skin care regimen:
cleanse, protect and restore
 Educate patients and caregivers regarding
strategies.

REFERENCES
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Beeckman, D., et al. Proceedings of the Global IAD Expert
Panel. Incontinence –associated dermatitis: moving
prevention forward. Wounds International. 2015. Available
to download from www.woundsinternational.com.
Gray, M., Bliss, D.Z., Doughty, D.B., et al. Incontinence –
Associated Dermatitis: a consensus. Journal of Wound,
Ostomy, and Continence Nursing. 2007;34(1): 45-54.
Junkin, J., Selekof, J.L. Beyond “diaper rash”:
Incontinence –associated dermatitis. Does it have you
seeing red? Nursing. 2008; 38(11 Suppl.):1-10.
LeBlanc, K., Christensen, D., Robbs, L., et al. Best Practice
Recommendations for the Prevention and Management of
Incontence-associated Dermatitis. Wound Care Canada.
2010; 8(3): 6-23.
Questions?
THANK YOU!