Incontinence Associated Dermatitis

By Sharon Osgood, RN, BSN, CWON, CCCN

Originally appeared in the September, 2011 issue of Quality Care®

The skin is the largest organ in the body and it is our first line of defense against germs and infection. Damage to the skin can occur for many reasons such as the sun, surgery, pressure or trauma, to name a few. But did you know that long-term exposure to moisture could also cause damage to the skin? The moisture from urine or stool actually causes the skin to soften. This weakens the skin’s ability to act as a protective barrier and can lead to incontinence associated dermatitis - also known as diaper dermatitis, diaper rash or perineal dermatitis.

When someone has frequent incontinent episodes skin damage (incontinence associated dermatitis) can occur. With this type of skin irritation, you will typically see a shiny redness and there may be burning pain in the area around the buttocks, gluteal cleft, rectum, labial folds, groin or between the legs. With continued, persistent moisture from urine and/or stool, these symptoms increase and put you at risk for infection, pain and possibly pressure ulcer formation. In fact, some people mistakenly identify incontinence associated skin damage as a pressure ulcer.

How do I take care of this problem?
First, you will want to consult with your health care provider to try to treat or eliminate what may be causing the issue of incontinence. Although incontinence is more common among elderly females, it is certainly a problem with males and females of all ages. It can be related to medical issues such as weakened pelvic muscles, anal sphincter muscles or an enlarged prostate. It is often associated with neurological issues such as Multiple Sclerosis, Spina Bifida, or spinal cord injuries. Constipation, diet, and medications can also contribute to incontinence. Many times, the underlying reason for incontinence can be recognized and corrected. Never assume that incontinence is just part of the normal aging process or that there is nothing that can be done. In the meantime, it is really important to know how to protect your skin from the irritating effects of urine/ stool.

There are several important steps to take in caring for your skin.

Step 1:  Cleanse the Skin
  1. First remove and throw away any soiled briefs or underpads.

  2. Wash the skin over the entire affected area with each episode of incontinence. You should use a mild, pH balanced, no-rinse cleanser designed specifically for incontinence care.

    1. If these are not available to you, avoid harsh bar soaps perfumes or anti-microbial hand-washing soaps. These can further dry out the skin and lead to skin damage.

  3. Gently clean the area from front to back using a soft cloth.

  4. Pat the skin dry. Do not rub!

Step 2: Protect the Skin

A skin protectant is used to prevent moisture and irritants from the urine and stool coming in contact with the skin. These skin protectant products can be in the form of a moisture-barrier cream, ointment or paste. Most of these skin protectants contain petrolatum, dimethicone, zinc oxide or a combination of these ingredients. Take caution if using moist wipes, they may contain irritating ingredients. Your health care professional can direct you to the one that is best suited to your individual needs.

  1. Apply a thin, even layer of the skin protectant to the skin.

  2. Some people use an absorbent underpad or brief. Change the pad or brief if it is soiled.  You may want to avoid products that do not have breathable panels or that have a plastic lining.

Some products that have proven to be useful are the Bedside Care® Foam and the Bedside Care® Perineal Wash®, made by Coloplast Corporation; the 3M™ Cavilon™ Skin Cleanser, made by 3M Skin and Wound Care; and the Comfort Bath™ Cleansing System, made by Sage Products, Inc. A full listing of useful products can be found in the National Association For Continence's (NAFC) Resource Guide.

Step 3: Containment or Collection of Urine/Stool
Absorbent pads or briefs, male external catheters and intermittent or indwelling Foley catheters are all methods available to contain or collect urine and keep it off of the skin. Absorbent products are also used for fecal management. It is important to recognize that feminine hygiene products are NOT suitable for the collection of urine or stool. Specific products are manufactured for these purposes.

There are also instances when surgery may be an option. Working with your health care provider will help determine which method may work best for your situation. If management products do not work for you, other treatment should be pursued. The FDA has recently approved new devices and procedures and others are waiting approval. Contact NAFC for a listing of continence care experts in your area.

Prevention
Of course, the best way to handle the problem of incontinence-associated dermatitis is through prevention. If you have consistent incontinence or are caring for someone with this problem, a good skin care regimen should be part of your everyday routine.

Key points:

  • Cleanse and protect the skin after each episode of incontinence

  • Change underpads or briefs when they become wet/soiled

  • Work with your health care provider to find the best method to manage the incontinence: Medications, surgical options, bladder training or other methods to collect or contain the urine/stool are among the many options available.

If the skin is not improving, is getting worse or if you have any other concerns, notify your health care provider.

References

  1. Nix, D, etal. A review of perineal skin care protocols and skin barrier product use. Ostomy Wound Management. 2004; 50(12)59-67.
  2. Hoggarth A, etal. Ostomy Wound Management. A controlled, three- part trial to investigate the barrier function and skin hydration properties of six skin care protectants. 2005; 51(12) 30-42.
  3. Black, J, etal. MASD Part 2: Incontinence-Associated Dermatitis and Intertriginous Dermatitis. 2011; 38 (4)359-372.

About The Author
Sharon Osgood, RN, BSN, CWON, CCCN, is a clinical project coordinator for Coloplast Corporation. She has clinical experience in acute care, home care and hospice care. Osgood has lectured in the following areas of expertise: continuing education programs in Ostomy and Wound/Skin care, clinical support to staff and clinicians, and clinical investigation implementation and oversight.