Protecting incontinence-associated dermatitis with evidence-based innovation and treatment

September 29, 2017

The skin is an amazing structure. Forming a barrier between our tissues and the world that we live in. Making us waterproof and keeping water in. Protecting us against UV light but playing a part in Vitamin D synthesis. Protecting deeper tissues from injury and containing nerve endings that allow us to detect temperature, pain, as well as the texture of surfaces that we touch. Most importantly, however, it provides a fantastic barrier to infectious agents: we are constantly under attack but the skin architecture, tears and saliva protect us.

 

As we age, the skin starts to thin, leaving less of a barrier. One of the challenges facing those who care for our, increasingly ageing and infirm, population is dealing with incontinence. This is an issue of increasing importance: urinary catheters are no longer being used to manage continence due to risk of serious infections. Studies have shown that 3–17% of women and 3–11% of men suffer from incontinence—with prevalence rapidly increasing in the over 70s[1]. Unfortunately, if incontinence is not effectively managed, it can lead to further problems for the individual; one of these issues is inflammation of the skin, or, dermatitis.

 

Incontinence-associated dermatitis (IAD) is skin inflammation caused by lengthy exposure to urine and/or faeces—particularly if the faeces are of liquid form—the resulting moisture macerating the skin. Urea from urine breaks down to form ammonia, which is corrosive to the already macerated epithelial layers of the skin. Residual digestive enzymes in faeces can cause further damage to the skin[2]. Traumatised skin is vulnerable to pathogenic bacteria, resulting in wound infection[3]. Candidiasis is a particularly common secondary infection—with up to 32% of patients with IAD also having a fungal infection[4].

Protecting incontinence-associated dermatitis with evidence-based innovation and treatment

Inflamed skin is a risk factor for pressure-related skin problems: macerated and damaged skin results in increased shear forces being exerted[5,6]. This pressure damage is difficult to manage until the initial cause has been dealt with: protecting the skin from the effects of incontinence.

 

Prevention is always better than cure and, to prevent and treat IAD, skin cleansing and skin care products are recommended. In reality, products and procedures are the same for both prevention and treatment. A range of products and procedures are available, and can be divided into cleansers, moisturisers and protectants; some of these products may be available individually and some may be combined (for example, a cleanser/moisturiser/protector).

 

It is important, for reasons mentioned previously, that urine and faeces do not remain in contact with the skin for extended periods; the skin must be cleansed and protected. A 2007 consensus panel recommended that a structured skin regimen should be adopted to protect and treat those at risk of IAD[7]. Used in post-incontinence episodes, it consists of a three-step process of cleansing, moisturising and protection of the skin. Research shows soap-and-water performs poorly in the prevention and treatment of IAD[5]. Application of leave-on products (moisturisers, skin protectants, or a combination) and avoiding soap seems to have a positive effect.

 

Performance of leave-on products depends on the combination of ingredients, overall formulation and usage (e.g. amount applied). Ready-made, purpose-specific wipes can provide all three aspects of the structured skin regimen in one, reducing the need to gather multiple items when caring for patients. Case studies have shown that this is an effective approach[8] and a randomised, controlled trial of wipes containing 3% dimethicone as a skin protectant has provided the best quality evidence of their effectiveness—demonstrating a 64% reduction in the prevalence of IAD in nursing homes[9]. Clinell Barrier Cloths contain even more dimethicone (4%); 6% liquid paraffin, glycerine, and extracts of camomile and witch hazel (to calm irritated skin and reduce patient touching/itching).

Protecting incontinence-associated dermatitis with evidence-based innovation and treatment

The other key attribute of a wipe-based product is that they are an all-in-one solution, meaning a well-formulated product will contain agents to cleanse, moisturise and protect the skin. They are an effective way of ensuring consistency of application and can be placed at the point of care—increasing accessibility and likelihood they will be used. Studies have shown that this aspect is greatly favoured by carers[10].

 

Soap and water is a traditional approach to skin cleansing and some staff may feel that the use of a non-rinse cloth may mean that the skin is not properly cleansed, however studies comparing soap and water with non-rinse cloths have shown that there is no difference in terms of bacterial counts remaining on the skin, concluding that no-rinse cleansers can be safely used as an alternative to soap and water washing of fragile skin[11].

 

In these challenging times—where there is an increasing burden of incontinence and a diminishing amount of time for care of the vulnerable—a structured skin regimen of cleansing and protecting skin, using single-step barrier wipes containing all effective ingredients, will have a profound clinical and cost-effective impact.

 

Clinell Barrier Cloths are now available from most healthcare distributors and Amazon.

Find out more here.

 

1.                  Nitti, V.W., The prevalence of urinary incontinence. Rev Urol, 2001.
3 Suppl 1: p. S2-6.

2.                  Kottner, J. and D. Beeckman, Incontinence-associated dermatitis and pressure ulcers in geriatric patients. G Ital Dermatol Venereol, 2015.

3.                  Gray, M., L. McNichol, and D. Nix, Incontinence-Associated Dermatitis: Progress, Promises, and Ongoing Challenges. J Wound Ostomy Continence Nurs, 2016. 43(2): p. 188-92.

4.                  Ouslander, J.G., Intractable incontinence in the elderly. BJU Int, 2000. 85 Suppl 3: p. 72-8; discussion 81-2.

5.                  Beeckman, D., et al., Interventions for preventing and treating incontinence-associated dermatitis in adults. Cochrane Database Syst Rev, 2016. 11: p. CD011627.

6.                  Bliss, D.Z., et al., Incidence and Predictors of Incontinence-Associated Skin Damage in Nursing Home Residents With New-Onset Incontinence. J Wound Ostomy Continence Nurs, 2017. 44(2): p. 165-171.

7.                  Gray, M., et al., Incontinence-associated dermatitis: a consensus. J Wound Ostomy Continence Nurs, 2007. 34(1): p. 45-54; quiz 55-6.

8.                  Baadjies, R., Karrouze, I. & Rajpaul, K., Using no-rinse skin wipes to treat incontinence-associated dermatitis. British Journal of Nursing, 2014. 23(20): p. 23.

9.                  Beeckman, D., et al., 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, 2011. 38(6): p. 627-34.

10.                  Schmitz, T., Promoting adherence to structured skin care regimen: QI project. Nursing Management, 2012. 4(12): p. 44-9.

11.                  Ronner, A.C., et al., The hygienic effectiveness of 2 different skin cleansing procedures. J Wound Ostomy Continence Nurs, 2010. 37(3): p. 260-4.

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