Top

Current Dermatology Reports

Published in:

14-09-2023 | Fecal Incontinence | REVIEW

Incontinence-Associated Dermatitis: a Practical Guide for the Consulting Dermatologist

Authors: Narges Maskan Bermudez, Brianna Christina Sa, Marita Yaghi, Abby Hargis, Scott A. Elman

Published in: Current Dermatology Reports | Issue 4/2023

Abstract

Purpose of Review

Incontinence-associated dermatitis (IAD) is a common irritant contact dermatitis associated with exposure to urine or feces. This review provides an overview of the etiology, diagnosis, and clinical management of IAD.

Recent Findings

Incontinent patients should follow a comprehensive preventive care regimen to minimize the occurrence of IAD. This regimen includes daily and as-needed cleansing using specialized “no-rinse” cleansers to cleanse the skin, remove irritants, and provide protection. Additionally, cleansers containing miconazole may be added to provide additional defense and reduce candidal infections. To reduce frictional irritation and preserve the skin barrier, it is recommended to minimize towel drying and apply an emollient moisturizer and skin protectant. Additionally, incorporating fecal collection devices or protective hydrocolloid dressings in combination with or as alternatives to adult containment briefs has proven effective in reducing the prevalence of IAD by minimizing exposure to moisture, irritants, and friction.

Summary

IAD causes significant discomfort and is a risk factor for pressure ulcers and skin infections. Elderly hospitalized patients and individuals with fecal incontinence are at a high risk for developing IAD. Diagnosing IAD can be challenging as it is often misdiagnosed as stage I and II pressure ulcers. Visual indicators of pressure ulcers include distinct lesions over bony prominences, non-blanchable erythema, and localized skin changes with or without necrosis. Prevention of IAD involves minimizing exposure to stool and/or urine and implementing a skincare regimen that includes gentle cleansing, moisturization, and application of a skin protectant.

Bliss DZ, Savik K, Harms S, Fan Q, Wyman JF. Prevalence and correlates of perineal dermatitis in nursing home residents. Nurs Res Jul-Aug. 2006;55(4):243–51. https://doi.org/10.1097/00006199-200607000-00004.CrossRef

Beeckman D, Schoonhoven L, Verhaeghe S, Heyneman A, Defloor T. Prevention and treatment of incontinence-associated dermatitis: literature review. J Adv Nurs. 2009;65(6):1141–54. https://doi.org/10.1111/j.1365-2648.2009.04986.x.CrossRefPubMed

Gray M, Giuliano KK. Incontinence-associated dermatitis, characteristics and relationship to pressure injury: a multisite epidemiologic analysis. J Wound Ostomy Continence Nurs Jan/Feb. 2018;45(1):63–7. https://doi.org/10.1097/WON.0000000000000390.CrossRef

Demarre L, Verhaeghe S, Van Hecke A, Clays E, Grypdonck M, Beeckman D. Factors predicting the development of pressure ulcers in an at-risk population who receive standardized preventive care: secondary analyses of a multicentre randomised controlled trial. J Adv Nurs. 2015;71(2):391–403. https://doi.org/10.1111/jan.12497.CrossRefPubMed

Lachenbruch C, Ribble D, Emmons K, VanGilder C. Pressure ulcer risk in the incontinent patient: analysis of incontinence and hospital-acquired pressure ulcers from the international pressure ulcer prevalence survey. J Wound Ostomy Continence Nurs May-Jun. 2016;43(3):235–41. https://doi.org/10.1097/WON.0000000000000225.CrossRef

Beeckman D, Van Lancker A, Van Hecke A, Verhaeghe S. A systematic review and meta-analysis of incontinence-associated dermatitis, incontinence, and moisture as risk factors for pressure ulcer development. Res Nurs Health. 2014;37(3):204–18. https://doi.org/10.1002/nur.21593.CrossRefPubMed

Johansen E, Bakken LN, Duvaland E, et al. Incontinence-associated dermatitis (IAD): prevalence and associated factors in 4 hospitals in southeast Norway. J Wound Ostomy Continence Nurs Nov/Dec. 2018;45(6):527–31. https://doi.org/10.1097/WON.0000000000000480.CrossRef

Kottner J, Blume-Peytavi U, Lohrmann C, Halfens R. Associations between individual characteristics and incontinence-associated dermatitis: a secondary data analysis of a multi-centre prevalence study. Int J Nurs Stud. 2014;51(10):1373–80. https://doi.org/10.1016/j.ijnurstu.2014.02.012.CrossRefPubMed

Wei M, Yang D, Wu L, Chen W, Chen Y, Fu Q. The prevalence of incontinence-associated dermatitis in hospitalized patients in china: a systematic review and meta-analysis. Adv Skin Wound Care. 2020;33(10):1–7. https://doi.org/10.1097/01.ASW.0000695764.47424.aa.CrossRefPubMed

10.

Hodl M, Blanar V, Amir Y, Lohrmann C. Association between incontinence, incontinence-associated dermatitis and pressure injuries: a multisite study among hospitalised patients 65 years or older. Australas J Dermatol. 2020;61(1):e144–6. https://doi.org/10.1111/ajd.13163.CrossRefPubMed

11.

Gray M. Optimal management of incontinence-associated dermatitis in the elderly. Am J Clin Dermatol. 2010;11(3):201–10. https://doi.org/10.2165/11311010-000000000-00000.CrossRefPubMed

12.

Wang X, Zhang Y, Zhang X, Zhao X, Xian H. Incidence and risk factors of incontinence-associated dermatitis among patients in the intensive care unit. J Clin Nurs. 2018;27(21–22):4150–7. https://doi.org/10.1111/jocn.14594.CrossRefPubMed

13.

Mugita Y, Minematsu T, Nakagami G, Sanada H. Influence of digestive enzymes on development of incontinence-associated dermatitis: inner tissue damage and skin barrier impairment caused by lipidolytic enzymes and proteases in rat macerated skin. Int Wound J. 2018;15(4):623–32. https://doi.org/10.1111/iwj.12906.CrossRefPubMedPubMedCentral

14.

Beeckman D, Van den Bussche K, Alves P, et al. Towards an international language for incontinence-associated dermatitis (IAD): design and evaluation of psychometric properties of the Ghent Global IAD Categorization Tool (GLOBIAD) in 30 countries. Br J Dermatol. 2018;178(6):1331–40. https://doi.org/10.1111/bjd.16327.CrossRefPubMed

15.

Gray M, Beeckman D, Bliss DZ, et al. Incontinence-associated dermatitis: a comprehensive review and update. J Wound Ostomy Continence Nurs Jan-Feb. 2012;39(1):61–74. https://doi.org/10.1097/WON.0b013e31823fe246.CrossRef

16.

Mugita Y, Minematsu T, Huang L, et al. Histopathology of incontinence-associated skin lesions: inner tissue damage due to invasion of proteolytic enzymes and bacteria in macerated rat skin. PLoS One. 2015;10(9):e0138117. https://doi.org/10.1371/journal.pone.0138117.

17.

Beeckman D. A decade of research on incontinence-associated dermatitis (IAD): Evidence, knowledge gaps and next steps. J Tissue Viability. 2017;26(1):47–56. https://doi.org/10.1016/j.jtv.2016.02.004.CrossRefPubMed

18.

Campbell JL, Coyer FM, Osborne SR. Incontinence-associated dermatitis: a cross-sectional prevalence study in the Australian acute care hospital setting. Int Wound J. 2016;13(3):403–11. https://doi.org/10.1111/iwj.12322.CrossRefPubMed

19.

Foureur N, Vanzo B, Meaume S, Senet P. Prospective aetiological study of diaper dermatitis in the elderly. Br J Dermatol. 2006;155(5):941–6. https://doi.org/10.1111/j.1365-2133.2006.07423.x.CrossRefPubMed

20.

Campbell JL, Coyer FM, Mudge AM, Robertson IM, Osborne SR. Candida albicans colonisation, continence status and incontinence-associated dermatitis in the acute care setting: a pilot study. Int Wound J. 2017;14(3):488–95. https://doi.org/10.1111/iwj.12630.CrossRefPubMed

21.

Takahashi H, Oyama N, Tanaka I, et al. Preventive effects of topical washing with miconazole nitrate-containing soap to diaper candidiasis in hospitalized elderly patients: a prospective, double-blind, placebo-controlled study. J Dermatol. 2017;44(7):760–6. https://doi.org/10.1111/1346-8138.13781.CrossRefPubMed

22.

Lear JL, Pratt JP, Roberts DR, Johnson T, Feyerabend A. Gamma camera image acquisition, display, and processing with the personal microcomputer. Radiology. 1990;175(1):241–5. https://doi.org/10.1148/radiology.175.1.2315488.CrossRefPubMed

23.

Liu H, Du A, Tian Y, et al. The ability of critical care nurses to identify pressure injury and incontinence-associated dermatitis: a multicentre cross-sectional survey. Nurs Open. 2023;10(3):1556–64. https://doi.org/10.1002/nop2.1406.CrossRefPubMed

24.

Beeckman D, Schoonhoven L, Fletcher J, et al. Pressure ulcers and incontinence-associated dermatitis: effectiveness of the Pressure Ulcer Classification education tool on classification by nurses. Qual Saf Health Care. 2010;19(5):3. https://doi.org/10.1136/qshc.2008.028415.

25.

Barakat-Johnson M, Stephenson J, Basjarahil S, et al. Clinician knowledge of incontinence-associated dermatitis: a multisite survey of healthcare professionals in acute and subacute settings. J Wound Ostomy Continence Nurs. 2022;49(2):159–167. https://doi.org/10.1097/WON.0000000000000846.

26.

Barakat-Johnson M, Lai M, Barnett C, et al. Hospital-acquired pressure injuries: are they accurately reported? A prospective descriptive study in a large tertiary hospital in Australia. J Tissue Viability. 2018;27(4):203–10. https://doi.org/10.1016/j.jtv.2018.07.003.CrossRefPubMed

27.

Beeckman D, Schoonhoven L, Fletcher J, et al. EPUAP classification system for pressure ulcers: European reliability study. J Adv Nurs. 2007;60(6):682–91. https://doi.org/10.1111/j.1365-2648.2007.04474.x.CrossRefPubMed

28.

Clarke-O’Neill S, Farbrot A, LagerstedtEidrup ML, Cottenden A, Fader M. Is it feasible to use incontinence-associated dermatitis assessment tools in routine clinical practice in the long-term care setting? J Wound Ostomy Continence Nurs Jul-Aug. 2015;42(4):379–88. https://doi.org/10.1097/WON.0000000000000129.CrossRef

29.

Tezcan B, Eraydin C, Karabacak BG. Evaluating the scales used to diagnose incontinence-associated dermatitis: a systematic review. Adv Skin Wound Care. 2022;35(5):1–9. https://doi.org/10.1097/01.ASW.0000823988.56640.72.CrossRefPubMed

30.

Chen Y, Gao Y, Zhang J, et al. Quality and clinical applicability of recommendations for incontinence-associated dermatitis: a systematic review of guidelines and consensus statements. J Clin Nurs. 2023;32(11–12):2371–82. https://doi.org/10.1111/jocn.16306.CrossRefPubMed

31.

Van den Bussche K, Verhaeghe S, Van Hecke A, Beeckman D. The Ghent Global IAD Monitoring Tool (GLOBIAD-M) to monitor the healing of incontinence-associated dermatitis (IAD): design and reliability study. Int Wound J. 2018;15(4):555–64. https://doi.org/10.1111/iwj.12898.CrossRefPubMedPubMedCentral

32.

Koudounas S, Minematsu T, Mugita Y, et al. Bacterial invasion into the epidermis of rats with sodium lauryl sulphate-irritated skin increases damage and induces incontinence-associated dermatitis. Int Wound J. 2023;20(1):191–200. https://doi.org/10.1111/iwj.13864.CrossRefPubMed

33.

Beeckman D, Van Damme N, Schoonhoven L, et al. Interventions for preventing and treating incontinence-associated dermatitis in adults. Cochrane Database Syst Rev. 2016;11(11):CD011627. https://doi.org/10.1002/14651858.CD011627.pub2.

34.

Conley P, McKinsey D, Ross O, Ramsey A, Feeback J. Does skin care frequency affect the severity of incontinence-associated dermatitis in critically ill patients? Nursing. 2014;44(12):27–32. https://doi.org/10.1097/01.NURSE.0000456382.63520.24.CrossRefPubMed

35.

Beeckman D, Woodward S, Gray M. Incontinence-associated dermatitis: step-by-step prevention and treatment. Br J Community Nurs. 2011;16(8):382–9. https://doi.org/10.12968/bjcn.2011.16.8.382.CrossRefPubMed

36.

Cooper P, Gray D. Comparison of two skin care regimes for incontinence. Br J Nurs. 2001;10(6 Suppl):S6, S8, S10 passim. https://doi.org/10.12968/bjon.2001.10.Sup1.5346.

37.

• Glass GF, Jr., Goh CCK, Cheong RQ, Ong ZL, Khong PCB, Chan EY. Effectiveness of skin cleanser and protectant regimen on incontinence-associated dermatitis outcomes in acute care patients: a cluster randomised trial. Int Wound J. 2021;18(6):862–873. https://doi.org/10.1111/iwj.13588. This study examined the effectiveness of a specialized skin cleanser and protectant regimen in treating incontinence-associated dermatitis (IAD) in acute care patients. The trial compared this regimen to the standard use of body wipes and a zinc oxide protectant. The results showed that the specialized regimen improved IAD healing within 7 days, especially in patients with skin loss, and that the overall risk of skin deterioration was reduced with the use of skin cleansers and protectants. These findings highlight the importance of incorporating specialized skin cleansers into the treatment of IAD in acute care settings and emphasize the need for a structured skin care regimen to prevent IAD skin deterioration.

38.

Lewis-Byers K, Thayer D. An evaluation of two incontinence skin care protocols in a long-term care setting. Ostomy Wound Manage. 2002;48(12):44–51.PubMed

39.

Hoggarth A, Waring M, Alexander J, Greenwood A, Callaghan T. A controlled, three-part trial to investigate the barrier function and skin hydration properties of six skin protectants. Ostomy Wound Manage. 2005;51(12):30–42.PubMed

40.

• Zhang X, Wang X, Zhao X, Zhang Y. A structured skin care protocol for preventing and treating incontinence-associated dermatitis in critically Ill patients. Adv Skin Wound Care. 2022;35(6):335–342. https://doi.org/10.1097/01.ASW.0000828972.70137.8a. This study aimed to assess the effectiveness of a structured skin care protocol in preventing and treating IAD. The results showed that the application of the structured skin care protocol significantly reduced the incidence of IAD from 35.9 to 17.7% and decreased the severity of IAD. These findings demonstrate that the implementation of the structured skin care protocol effectively lowers the incidence and severity of IAD and delays its development in critically ill patients.

41.

Beeckman D, Verhaeghe S, Defloor T, Schoonhoven L, Vanderwee K. A 3-in-1 perineal care washcloth impregnated with dimethicone 3% versus water and pH neutral soap to prevent and treat incontinence-associated dermatitis: a randomized, controlled clinical trial. J Wound Ostomy Continence Nurs Nov-Dec. 2011;38(6):627–34. https://doi.org/10.1097/WON.0b013e31822efe52.CrossRef

42.

Takahashi H, Oyama N, Amamoto M, Torii T, Matsuo T, Hasegawa M. Prospective trial for the clinical efficacy of anogenital skin care with miconazole nitrate-containing soap for diaper candidiasis. J Dermatol. 2020;47(4):385–9. https://doi.org/10.1111/1346-8138.15257.CrossRefPubMed

43.

Li Q, Zhu D, Liu Y, Qin L, Long X, Yu X. Efficacy of modified isolation in incontinence associated dermatitis. Am J Transl Res. 2023;15(2):1326–33.PubMedPubMedCentral

44.

• Zhang Y, Leng M, Guo J, Duan J, Wang Z. The effectiveness of faecal collection devices in preventing incontinence-associated dermatitis in critically ill patients with faecal incontinence: a systematic review and meta-analysis. Aust Crit Care. 2021;34(1):103–112. https://doi.org/10.1016/j.aucc.2020.04.152. This article presents a systematic review and meta-analysis that examines the effects of different types of fecal collection devices on incontinence-associated dermatitis (IAD) in critically ill patients with fecal incontinence. The findings indicate that the use of fecal collection devices significantly reduces the incidence of IAD.

45.

Denat Y, Khorshid L. The effect of 2 different care products on incontinence-associated dermatitis in patients with fecal incontinence. J Wound Ostomy Continence Nurs Mar-Apr. 2011;38(2):171–6. https://doi.org/10.1097/WON.0b013e31820af24e.CrossRef

46.

Mugita Y, Koudounas S, Nakagami G, Weller C, Sanada H. Assessing absorbent products’ effectiveness for the prevention and management of incontinence-associated dermatitis caused by urinary, faecal or double adult incontinence: a systematic review. J Tissue Viability. 2021;30(4):599–607. https://doi.org/10.1016/j.jtv.2021.07.002.CrossRefPubMed

47.

Beeckman D, Campbell J, Campbell K, et al. Incontinence-associated dermatitis: moving prevention forward. 02/13 2015;

48.

Gray M, Ratliff C, Donovan A. Perineal skin care for the incontinent patient. Adv Skin Wound Care. 2002;15(4):170–5;177–8. https://doi.org/10.1097/00129334-200207000-00008.

49.

Gray M, Bliss DZ, Doughty DB, Ermer-Seltun J, Kennedy-Evans KL, Palmer MH. Incontinence-associated dermatitis: a consensus. J Wound Ostomy Continence Nurs. 2007;34(1):45–54;55–6. https://doi.org/10.1097/00152192-200701000-00008.

Title: Incontinence-Associated Dermatitis: a Practical Guide for the Consulting Dermatologist
Authors: Narges Maskan Bermudez
Brianna Christina Sa
Marita Yaghi
Abby Hargis
Scott A. Elman
Publication date: 14-09-2023
Publisher: Springer US
Keywords: Fecal Incontinence
Urinary Incontinence
Urinary Incontinence
Candidiasis
Candidiasis
Published in: Current Dermatology Reports / Issue 4/2023
Electronic ISSN: 2162-4933
DOI: https://doi.org/10.1007/s13671-023-00403-x

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Incontinence-Associated Dermatitis: a Practical Guide for the Consulting Dermatologist

Abstract

Purpose of Review

Recent Findings

Summary

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose of Review

Recent Findings

Summary

Please log in to get access to this content

Other articles of this Issue 4/2023

Minimal Eliciting Allergic Contact Dermatitis Concentrations in Normal versus Damaged Skin: Clinical and Toxicologic Relevance

Incidence and Characteristics of Melanoma in Multiple Sclerosis Patients Treated With Fingolimod: A Systematic Review

Immune Checkpoint Inhibitors and Systemic Side Effects: Overview for the Inpatient Dermatologist

Allergic Contact Dermatitis in Older Adults

Patch Testing in Atopic Children: Is There a Difference?

JAK Inhibitor Use for the Inpatient Dermatologist