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SKIN CARE: MANAGING THE SKIN
OF THE INCONTINENT PATIENT
 Both urinary and faecal incontinence can have a significant impact on skin integrity. Inappropriate
 management can cause the skin to become excoriated, leading to large areas of incontinence-associated
 dermatitis (IAD), which can cause pain and discomfort. This article examines how to manage the skin in the
 presence of incontinence.
                                         long-term nursing home residents              of incontinence on the skin
                                         (Newman et al, 2007).                         surrounding the peri-anal area. All
Pam Cooper, is a CNS Tissue Viability,
NHS Grampian, Aberdeen                                                                 refer to the effects of inflammation
                                         Incontinence is one of the                    of the skin that occurs when
                                         major risk factors for the                    urine, faeces or both come into
Preserving functionality of the          development of skin breakdown                 contact with the perineal area
skin in patients with incontinence       or incontinence-associated                    (Langemo et al, 2011).
can prove to be challenging and          dermatitis (IAD) (Beekman et al,
problematic to both patients and         2009; Rees and Pagnamenta,                    The perineal area includes the
their care providers.                    2009). This article aims to look              areas between the vulva/scrotum
                                         at the impact of incontinence                 and anus, buttocks, and perianal,
Skin breakdown is characterised          on skin integrity, the importance             coccyx and inner/upper thigh
by erosion of the epidermis,             of assessment and treatment                   region (Brown and Sears, 1993).
the upper layer of skin                  options available.
and the moist, macerated                                                               IAD is generally characterised
appearance of the skin, (Gray,                                                         by superficial erosion of the
2004). Incontinence and its              Incontinence-associated                       epidermal layer of the skin
associated skin breakdown                dermatitis                                    along with a wet macerated
can have a considerable effect           IAD, moisture lesions, irritant               appearance (Figure 1). This
on the patients physical and             dermatitis and/or perineal                    can be further complicated by
psychological well being (Sibbald        dermatitis are all terms used to              spreading redness, erythema of
et al, 2003).                            commonly describe the effects                 the surrounding tissue, pain and

Incontinence is known to increase
with age with 31% of older women
and 23% of older men affected
and between 30–85% of nursing
home residents recognised as
incontinent (Bale et al, 2004).
Studies indicate that chronic faecal
incontinence affects between
1–10% of the adult population
and that 0.5-1.0% experience
regular incontinence affecting their
quality of life (National Institute
of Health and Clinical Excellence
[NICE], 2007). Combined urinary
and faecal incontinence has been
reported to be as high as 50% in         Figure 1. Incontinence-associated dermatitis (IAD).

                                                                                                      Wound Essentials • Volume 6 • 2011   69
 Review

                                                                                   MOISTURE

                                                  Urine                   Faeces            Double incontinence Frequent cleansing


                                            Urea-ammonia            Faecal enzyme           Urea-ammonia            Chemical irritation
                                            pH                       activity                pH
                                            Microbes                pH                      Faecal enzyme                   +
                                                                     Microbes                 activity
                                                                                              Microbes                Physical irritation



                                                                     Permeability of the skin
Figure 2. IAD with spreading erythema
and induration across the buttocks.                                  Barrier function


induration (a hardness or firmness
of the area, compared to the feel                                               Bacterial overgrowth
of non-affected areas) (Figure 2).

There are some generally                                                        Cutaneous infection
recognised theories as to how
IAD occurs but none of these are
definitive and it is possible that
                                                                                 WEAKENED SKIN
the cause is a combination of
them (Figure 3):                                                                                                        Friction: rubbing
8 Urine and faeces convert urea                                                                                        of perineal skin on
    to ammonia, which destroys                                                                                       containment devices,
    the skin’s acid mantle. At                                                                                        clothing and bed, or
    the same time, due to the                                                                                            chair surfaces
    presence of urine and faeces
    the skin’s pH becomes                                          INCONTINENCE-ASSOCIATED DERMATITIS
    more alkaline activating
    both proteolytic and lipolytic        Figure 3. Aetiology of IAD.
    enzymes, i.e. proteases and           Source: based on Jeter and Lutz (1996); Newman et al (2007) and Beeckman et al (2009).
    lipases cause irritation and
    tissue breakdown (Leyden,                 to mechanical forces, such                     pressure ulcers can lead to the
    1986)                                     as friction and shear, the skin                inappropriate use of limited
8 The skin becomes                            can break down more quickly                    resources and suboptimal care
    overhydrated — this can                   (Langemo et al, 2011).                         (Beeckham et al, 2009).
    be due to urine and/or
    washing methods, such as                                                                 It is, therefore, essential that
    overwashing. The skin is then         IAD and pressure ulcers                            when clinicians are trying
    more permeable to irritants, at       It is important to be able to                      to identify the cause of skin
    greater risk of breakdown and         determine the difference between                   breakdown they perform a full
    more vulnerable to bacterial          IAD and superficial pressure                       review of the clinical evidence,
    growth and fungal invasion            ulcer development (Grade1 and                      including the location of any
    (Langemo et al, 2011)                 2) (European Pressure Ulcer                        skin breakdown, the patient’s
8 When skin exposed to                    Advisory Panel [EPUAP], 2001).                     risk factors and any symptoms
    incontinence is also exposed          Confusion between IAD and                          present (Beeckman et al, 2010).

70   Wound Essentials • Volume 6 • 2011
                                                                                                                                   Review

                                                                                           Any assessment should include:
                                                                                           8 Relevant medical history
                                                                                           8 Assessment of the patient’s
                                                                                              general physical condition
                                                                                           8 In the case of an acute
                                                                                              problem: clinicians should
                                                                                              collect samples of urine,
                                                                                              faeces or both and send for
                                                                                              microbiological examination
                                                                                              to determine if there is any
                                                                                              infection, i.e. Clostridium
                                                                                              difficile. If a sample has been
                                                                                              taken, clinicians should
                                                                                              ensure there is a full history
Figure 4. Clearly defined area of pressure   Figure 5. Multiple Grade 2 pressure ulcers
                                             to the sacrum and buttocks.
                                                                                              including the reason for
across the buttocks.
                                                                                              taking the sample, symptoms
                                                                                              and any medications
Pressure ulcers are generally located        not localised to one spot (Figure 6).            prescribed. This will help
over a bony prominence such as               The edges of the IAD lesions are                 microbiologists in their
the coccyx, whereas IAD tissue               usually irregular in shape and the               analysis and diagnosis
breakdown can occur anywhere                 surrounding tissue can often be               8 In the case of a chronic
in the perianal area. Pressure               red due to the irritant effects of the           problem, any assessment
ulcers also tend to be localised to          incontinence (Figure 7) (Defloor et              should take note of any
one spot, involving partial or full          al, 2005; Beeckman et al, 2008).                 previous tests, examinations
thickness tissue loss, with defined                                                           and the current
wound margins (Figures 4 and 5).                                                              management plan.
                                             Prevention of IAD
IAD on the other hand, involves              It is essential that when presented           Regardless of whether the
moisture and any tissue                      with a patient who is incontinent,            incontinence is an acute episode,
involvement is superficial in nature         clinicians take a full history and            which should resolve when
involving the epidermis and the              assessment to ensure that an                  treated, or a chronic condition
upper dermal layer. This usually             effective treatment plan can be               that the patient has to learn to
covers a large area of skin and is           implemented (Bardsley, 2008).                 design his or her life around, it is




Figure 6. IAD will usually cover a large     Figure 7. The effects of urinary incotinence and poor hygiene prior to admission
area.                                        to hospital.

                                                                                                             Wound Essentials • Volume 6 • 2011   71
 Review

                                          the female’s labia area, whereas      vulnerable to skin breakdown
                                          in men it will irritate the area      (Bale et al, 2004).
                                          underneath the scrotum.
                                                                                Therefore, when caring for a
                                          Faecal incontinence tends to          patient with incontinence it is
                                          affect the perianal region and        essential to choose a cleanser
                                          in severe cases can spread to         that does not reduce the skin’s
                                          the thighs, presenting as a burn      moisture content but rather
                                          on initial appearance, or a red       preserves or enhances it (Cooper
                                          blistering reaction (Figure 8).       and Gray, 2001). Products
                                                                                such as emulsions, foams or
                                          It is essential that a thorough       liquid sprays, which contain
                                          examination of any skin folds         humectants such as glycerine,
                                          is carried out as these areas         esters, lanolin or, cetyl-stearyl
Figure 8. The impact of faecal            are not only prone to excess          alcohol, as well as mineral oils,
incontinence on perianal and sacral       moisture through sweating, but        are useful as they can prevent the
areas.                                    are also vulnerable to extensive      loss of natural moisture from the
                                          tissue loss if contamination from     skin (Nix, 2006).
important that an assessment,
                                          incontinence is not identified.
diagnosis and treatment plan is
                                          The warm moist environment of         Skin protection
implemented.
                                          a skin fold encourages bacterial      It is important that all patients
                                          and fungal colonisation (Figure 9),   have their skin moisturised. A
The prevention of IAD is based
                                          in particular candidiasis (thrush)    moisturiser is designed to hydrate
upon:
                                          (Langemo et al, 2011), therefore it   the skin, preserving suppleness
8 Routine skin inspection
                                          is essential that this is treated.    and enhancing the barrier function
8 Cleansing regime
                                                                                (Langemo at al, 2011). The active
8 Skin protection
                                                                                ingredients in moisture barrier
8 Treatment and management
                                          Skin cleansing                        creams include petrolatum,
   of incontinence
                                          Historically, soap and water was      dimethicone, lanolin or zinc oxide.
8 Education – patient and
                                          the main cleansing agent of           Barrier products can be placed
   carers.
                                          choice, however, over the last        into three broad categories.
                                          decade clinicians have moved
                                          away from this practice. This is      Generic skin protectors
Routine skin inspection
                                          due to ongoing awareness of the       These products generally have
A full inspection of the skin should
                                          skin’s properties.
be carried out on admission
to ensure that an effective
                                          The skin has an acid mantle,
prevention and treatment plan
                                          which has a pH of 4–6.8. This
can be individualised to the
                                          naturally acidic pH reduces the
patient’s needs. This should be
                                          growth of bacteria. However,
periodically reviewed during the
                                          urine and faeces are alkaline
patient’s stay (Langemo et al,
                                          and when they are combined
2011). It is important that when
                                          with soap, which is also
the skin is inspected its condition
                                          alkaline, this can increase the
is recorded within the patient’s
                                          skin’s pH encouraging bacterial
health records along with any
                                          growth (Korting and Braun-
interventions.
                                          Falco, 1996). In addition, the
                                          surfactants found in soaps,
The type of incontinence present
                                          when combined with                    Figure 9. This patient is both faecally
can affect the sexes differently
                                          water, increase the skin’s            incontinent and also presents with a
— urinary incontinence will affect                                              viral complication.
                                          permeability making it more

72   Wound Essentials • Volume 6 • 2011
                                                                                                              Review

either zinc oxide or paraffin      the faeces is contained away          sizes depending on the volume
as their base. They repel          from the skin.                        of fluid expected. The super-
irritants and prevent them from                                          absorbent materials absorb
penetrating the skin. They can,    Faecal management devices             fluid and turn into a gel-like
however, have limitations, for     have existed for many years.          substance, which removes the
example, clogging the pores        These originally consisted of a       fluid from the skin and prevents
of protective garments and         pouch which was attached to           enzymes in the faecal and
making skin inspection difficult   the buttocks by a hydrocolloid        urinary matter reacting with the
due to their thick consistency     wafer. These were successful if a     skin and causing IAD.
(Penzer, 2008).                    seal could be obtained, but this
                                   was often difficult due to the very   Changing soiled products
Barriers                           location where the device was to      regularly is essential, as is the use
These products have been           be applied.                           of an appropriate cleansing and
specifically designed for skin                                           skin barrier regime.
protection in incontinent          This concept of faecal
patients. They come in various     management has been advanced
forms, including creams,           over the years and current            Education
liquid wipes, and sprays.          systems consist of soft silicone      Education of clinicians and
When applied to the skin they      tubes, which are directly inserted    patients is essential in effectively
apply a transparent coating,       into the anus. A small balloon cuff   managing and preventing IAD
which prevents the active          is inflated, which holds the tube     as is determining whether tissue
enzymes within urine and           in place and faeces is collected      breakdown is caused by pressure
faeces from penetrating the        in a containment bag (Ousey and       or incontinence.
skin. Manufacturers of these       Gillibrand, 2010). The device can
products supply clear guidance     be left in situ for 29 days. These    If a clinician’s organisation has
on the amounts that should         devices can be very effective in      a protocol for the prevention
be used and the frequency of       terms of:                             and management of pressure
application, which depends on      8 Prevention of IAD                   ulcers and incontinence
the degree of incontinence.        8 Reduced pain                        management then these should
                                   8 Reduced nursing time                be followed. Clinicians should
Antibacterial and anti-yeast       8 Increased patient comfort           also attend any associated
products                           8 Prevention of infection.            educational sessions, but if
These are products contain                                               none are available the support
bacterial and/or yeast enzymes                                           of colleagues and relevant
and are designed to protect the    Treatment of underlying               specialists should be sought
skin from incontinence. They       incontinence                          out to ensure that any practice
usually come in a cream or         The ultimate goal for any             is accurate and relevant to
ointment form (Penzer, 2008).      clinician caring for a patient        patients’ needs.
                                   with faecal or urinary
                                   incontinence is alleviation           Conclusion
Management of acute faecal         and control of bowel/bladder          Urinary and faecal incontinence
incontinence                       function. However, this may           can have a significant impact
The impact of faeces on the        not be possible, especially           on skin integrity. Inappropriate
skin can be catastrophic for       when caring for frail elderly         management can cause the skin
the patient, both in terms of      patients where functional             to become excoriated and lead to
extensive IAD, and increased       control does not exist or in the      large areas of IAD, which can be
pain. Due to the extent            acute or critically ill patient.      highly distressing to the patient
and frequency of faecal            In these cases the aim is to          due to pain and discomfort.
incontinence, some patients        manage the incontinence with
may benefit from a more direct     disposable patient-worn body          It is the role of any clinician
management approach where          pads. These come in various           to try and prevent this from

                                                                                        Wound Essentials • Volume 6 • 2011   73
 Review

happening by ensuring that                of incontinence-associated               Langemo D, Hanson D, Hunter
patients who presents with                dermatitis: literature review. J Adv     S, Thompson P, Oh IE (2011)
incontinence have access to the           Nurs January: 1141–54                    Incontinence and incontinence-
following:                                                                         associated dermatitis. Adv Skin
8 Full assessment of their                Beeckman D, Defloor T, Verhaeghe         Wound Care 24(3): 126–40
    incontinence and a                    S, Demarré L, Schoonhoven
    management plan in place              L, Vanderwee K (2010) What               Leyden JJ (1986) Diaper dermatitis.
8 Routine skin inspection                 is the most effective method             Dermatol Clin 4(1): 23–28
8 Appropriate and effective               of preventing and treating
    cleansing regime                      incontinence associated                  Newman DK, Preston AK, Salazar
8 Appropriate skin protection             dermatitis? Nurs Times 106(38):          S, Sarshik S (2007) Moisture control,
8 Treatment and management                22–4                                     urinary and faecal incontinence,
    of incontinence using                                                          and perineal skin management.
    body-worn pads or faecal              Brown D, Sears M (1993)                  In: Krasner D, Rodeheaver GT,
    management systems                    Perineal dermatitis: a conceptual        Sibbald RG et al (eds) Chronic
8 Education about IAD and                 framework. Ostomy Wound                  Wound Care: A Clinical Source for
    its prevention, both for              Manage 39(7): 20–5                       Healthcare Professionals, 4th edn.
    themselves and their carers.                                                   HMP Communications Malvern:
                                          Cooper P, Gray D (2001)                  609–27
Incontinence can be distressing           Comparison of two skin care
for patients and it is the role           regimes for incontinence. Br J Nurs      NICE (2007) Faecal Incontinence:
of clinicians to treat them with          10(6 Suppl): 6–20                        the management of faecal
care and dignity. It is also the                                                   incontinence in adults. NICE,
role of clinicians to be aware of         Defloor T, Schoonhoven L,                London
the implications of incontinence          Fletcher F, et al (2005) Statement
and its impact on skin integrity.         of the European Pressure Ulcer           Nix D (2006) Skin matters:
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T (2009) Prevention and treatment         Dermatol 17: 663–6                       Wound Manage 49: 27–33

74   Wound Essentials • Volume 6 • 2011

				
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