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Incontinence and the skin irritation (dermatitis) associated with it are common problems. Treatment of dermatitis is effective, but requires effective cleaning and application of a barrier substance to prevent further contact between urine or feces and the skin. Water based cleansing with the addition of a pH balanced cleanser is more effective than standard abrasive cleansing with paper or a cloth, and is better tolerated by those with skin irritation. Zinc oxide based barriers effectively promote healing and prevent further skin damage. Spray forms are less cumbersome and generally preferred, but are difficult to for the patient to apply independently given the challenge of accessing the perineum. 40 patients, recruited from 3 specialty pelvic floor centers and 1 assisted living center will be provided a device that cleans, dries, and applies zinc oxide barrier spray with each use of the toilet. Dermatitis will be evaluated at the beginning of the study, and at weeks 1, 2 and 6 by medical staff using a standard scale (The Kennedy Scale).Quality of life will be measured using a visual analog scale derived from the quality of life in incontinence scale. The investigators hypothesize that the device will 1) effectively treat incontinence associated dermatitis, 2) prevent recurrence, and 3) be preferred over standard treatment.
Detailed Description: Incontinence and incontinence associated dermatitis (IAD) are common problems. A recent CDC study noted that up to 50% of noninstitutionalized patients aged 65 and older experienced episodes of incontinence at least monthly, and that 40% of those with incontinence develop secondary IAD The treatment of IAD is focused on effective cleaning and prevention of further exposure to irritant liquids and solids through barrier creams. Enzymatic washes have proven efficacy over soap and water, and zinc oxide is the standard of care for barrier function. Combined, effective cleansing and barrier use treats IAD in as little as 6 days, and effectively prevents recurrent skin damage. In one study, an effective preventive regimen of regularly applied skin therapy reduced the incidence of IAD in an at risk population from 25% to 5%. The combination of enzymatic skin cleanser and barrier protection is the standard of care for maintenance of skin integrity in patients with chronic urinary and fecal incontinence. Adherence to prescribed regimens is a major barrier to regular use of substances applied to the perineum. Difficulty in accessing the perineum make adherence challenging to those with both full and limited mobility, often requiring assistance from a caregiver. The associated loss of independence and dignity are major detriments to quality of life. Novel formulations of zinc oxide, using aerosol based spray application, facilitate use and improve patient acceptance. In a 2014 nursing home based industry study, spray based zinc oxide was preferred by 80% of patients and caregivers, and improved treatment and prevention of IAD in 70% of the study participants. Adequate cleansing and drying prior to the application of barrier products is key to effective prevention of skin breakdown. Water-based cleaning of the perineum after toileting has been demonstrated to improve hygiene over standard mechanical, paper-based cleansing, especially in those with limited mobility or incontinence. Evidence further demonstrates that the addition of pH balanced cleansers, applied without mechanical abrasion from cloths or wipes, advances hygiene and minimizes risk of secondary infection. Study Aims The aims of this study are to evaluate the efficacy of an automated delivery system for cleansing the perineum, and applying zinc oxide barrier spray to effectively treat and prevent incontinence associated dermatitis in a population with active or recurrent IAD. Secondary aims will be to assess preference for the automated delivery system over standard wash and manually applied barrier sprays.
 by the WoundSource Editors Although clinical practice is hampered by a lack of rigorous studies, standardized terminology, or definitions of incontinence-associated skin damage, it is well known among health care providers that this damage places patients at increased risk for pressure ulcer/injury development. The worldwide challenge represented by incontinence-associated skin damage prompted the development of a global expert panel on the topic in 2014. The group, chaired by Professor Dimitri Beeckman, a leading authority on the topic, collaborated to develop international best practice guidelines for prevention and treatment of incontinence-associated dermatitis (IAD) that were published in 2015.1 Definitions and Clinical Features of Incontinence-Associated DermatitisIAD is defined by Beeckman and colleagues1 as a type of moisture-associated skin damage, which describes skin damage associated with exposure to urine or stool. It causes considerable discomfort and can be difficult, time consuming, and expensive to treat. It is called by many names including diaper dermatitis, maceration, diaper rash, perineal dermatitis, and moisture lesions. IAD is a form of irritant dermatitis resulting from prolonged or chronic exposure to urine and/or stool, particularly liquid stool. These lesions are also often mistakenly labeled as stage 1 or stage 2 pressure injury.2 IAD occurs in the perianal area. In women this includes the perineum, labial folds, and vulva to the anus. In men the area involved is from the scrotum to the anus. In both men and women this can extend to the groin, buttocks, gluteal cleft, and even extend down to the inner and posterior thighs.3 Kottner and colleagues also found a statistically significant higher rate of IAD in men with diabetes mellitus, a higher body mass index, and mobility issues. However, the IAD was more often associated with fecal rather than urinary incontinence.2
Prevention and Treatment of Incontinence-Associated DermatitisPrevention begins with assessing an individual’s risk, and numerous risk assessments have been developed over the years. The Perirectal Skin Assessment Tool was developed in the early 1990s. However, it lacked validity but was a start to IAD data collection. 4 Next was work by Brown and Sears, who identified tissue tolerance, perineal environment, and toileting ability as factors in perineal dermatitis.5 Validity and reliability were not established, however, because the instrument required the patient’s being alert enough to report symptoms. In 2002, Denise Nix6 developed the Perineal Assessment Tool, or PAT, that looked at type and intensity of irritant, amount of time the skin is exposed to the irritant, perineal skin condition, and contributing factors that can lead to loose or watery diarrhea stools. After testing validity, it was believed that this instrument measured risk versus actual dermatitis. The Incontinence-Associated Dermatitis and Its Severity Instrument, or IADS, was developed in 2010 by Borchert and colleagues and evaluated four components.7 First is location of the IAD, and each area of the entire perineal, perianal, perirectal, and perivaginal area is numbered so that the location can be specific and consistent. When measuring for redness there are computer-generated red tones to assist with accuracy. For the measurement of skin loss there is a reminder that a pressure injury is not IAD and should not be assessed here. Finally, the caregiver is reminded that a fungal infection must be addressed and treated appropriately. Prevention entails a thorough nursing assessment of urinary and fecal incontinence that leads to implementation of protocols aimed at preventing IAD and promoting healing of already damaged skin, as well as being linked to pressure ulcer/injury prevention. This is a two-pronged approach: 1) assessing and managing the incontinence to reduce skin exposure to the caustic components of urine and stool; and 2) using a targeted skin care regimen to maintain skin integrity plus protect from moisture and irritant exposure that compromise the brick and mortar structure of the skin.8 Using this approach also provides additional opportunities for identifying reversible causes of incontinence such as medications (for example, diuretic therapy for those with mobility issues), urinary tract infections, and constipation. Other incontinence management approaches include nutrition and fluid management, toileting techniques, urinary sheaths for men, and the use of absorbent products that wick moisture away from the skin that also reduce overhydration without occluding the skin. If these methods are not successful or if IAD is severe, then the use of urinary catheters (only as a last resort because of the risk of infection) or fecal containment devices should be considered.3 Implementing a skin care regimen following any incontinent episode, especially when stool is present, is the most important step in preventing IAD. Soap and water are too harsh because the pH of soap is too alkaline and can lead to irritation of the skin. Instead, gentle cleansers that protect the lipid profile of the skin yet cleanse contaminants away easily should be chosen, followed by a skin protectant. The protectant should be one that does not disintegrate easily in the presence of stool and urine and provides a barrier to moisture and caustic agents. The emergence of all-in-one-no-rinse products also has made this process easier. If the skin is compromised, then choosing a barrier that can stick to moist skin is imperative. When the assessment indicates the possibility of a fungal infection, then an antifungal agent should be incorporated into the skin care regimen.1 SummaryThe common clinical issue of IAD affects over 50% of patients with urinary or fecal incontinence despite the use of absorptive products. Although confusion still exists in differentiating IAD from pressure injury, thorough and careful assessment can help make the appropriate determination and enable the accurate choice of prevention and treatment strategies. Successful prevention and treatment of IAD include careful and accurate assessment, followed by implementation of evidence-based practice in continence and skin care protocols.1 References The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.
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How do you manage incontinenceSpecific prevention and care strategies for older adults with IAD included using specific assessment tools, applying skin cleansing pH from 4.0 to 6.8, body positioning, and promoting food with high protein. Other strategies were similar to those reported for adult patients.
What is the most effective method of preventing and treating incontinenceTo prevent and treat IAD, skin cleansing and skin care products are recommended. Many skin care products and procedures are available. The skin care products can be divided into cleansers, moisturisers, and protectants which may be combined (for example, a cleanser/moisturiser).
What does incontinenceTypically IAD presents as inflammation of the skin surface characterised by redness and, in extreme cases, swelling and blister formation (Figure 1). In urinary incontinence this generally affects the labia in women, and the scrotum in men, as well as the inner thigh and buttocks in both sexes.
Can dermatitis cause incontinence?Incontinence-associated dermatitis (IAD), sometimes referred to as perineal dermatitis, is an inflammation of the skin associated with exposure to urine or stool. Elderly adults, and especially those in long-term care facilities, are at risk for urinary or fecal incontinence and IAD.
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