Running head: INCONTINENCE-ASSOCIATED DERMATITIS

The Need for More Incontinence-associated Dermatitis Research Christina Ly Northeastern University

Running head: INCONTINENCE-ASSOCIATED DERMATITIS Abstract

Skin assessment is an extensive and costly part of nursing activity worldwide. It is important for nursing and health care staff to be able to observe the skin and accurately assess any changes that may be indicative of a disruption to skin barrier function. Therefore, this requires an understanding of the structure and function of the skin barrier and the factors that can cause disruption. There has been a surprising lack of relevant literature directly addressing the effectiveness of skin care assessment for incontinence, except for when it is mentioned as part of the estimation of associated risk for developing pressure ulcers. The precise nature of the risk to the skin barrier as a consequence of urinary incontinence remains unclear and as such, there is a need for further investigationespecially since there is a prevalence of incontinence-associated dermatitis (IAD) among incontinent patients. The aim of this paper is to provide information on the findings of continence care since IAD is becoming a widespread nursing problem, and in examining the literature, it is evident that the consequences of incontinence for the integrity of the skin and related care continue to be a neglected area of research. Thus, information for differentiation between pressure ulcers and IAD and its significance, as well as the prevention of IAD with recommendations for clinical practice is examined and presented in this paper.

Running head: INCONTINENCE-ASSOCIATED DERMATITIS Introduction In recent literature, perineal dermatitis has been now relabeled as incontinenceassociated dermatitis (IAD), which is an inflammation of the skin that occurs from being in contact with urine and/or stool. It is acknowledged that a larger area of the skin than just the

perineum is commonly affected (Haugen & Nix, 2010). According to Haugen & Nix (2010), IAD affects as many as 41% of adults in long term carewhich is costly to the facility, painful for the patients, yet for the most part, preventable. Beeckman, Woodward, Rajpaul, and Vanderwee (2011) presents a study conducted by Junkin and Selekof (2007), that reports a prevalence rate of IAD among hospitalized patients in the United States as 27%. IAD is a major concern when it comes to incontinent patients, and it should be distinguished from pressure ulcers because the prevention and treatment are different. However, as Beeckman et. al (2011) highlights in the past decade, there has been a significant increase in publications focusing on the complexity and inconsistency of the clinical observations of IAD and the differentiation between IAD and pressure ulcers. Being that, IAD and superficial pressure ulcers cause confusion in clinical practice when trying to determine the true nature and underlying pathology of the lesions. Moreover, it is a daily challenge for health professionals in hospitals, nursing homes, and in the community to maintain the skin integrity of patients with incontinence. It is shown that an effective plan of care for individuals with IAD must include the assessment and management of incontinence affected perineal skin, gentle cleansing and moisturization, and application of skin barriers. It is important to point out that incontinence and subsequent skin breakdown have a considerable effect on patients physical and psychological wellbeing. IAD can be complex since it is related to both chemical and physical irritation. Moisture from incontinence alters the skins

Running head: INCONTINENCE-ASSOCIATED DERMATITIS

protective pH and increases the permeability of stratum corneas, the outermost layer of the skin (Nix & Haugen, 2010). Indeed, urine and feces causes an increase in the pH causing this layer of the epidermis to swell, altering lipid rigidity and increasing the permeability of the skin, and reducing barrier function (Beeckamn et. al, 2011; Ersser, Getliffe, Voegeli, & Regan, 2004). In addition, bacteria can permeate through the stratum corneum and cause secondary infections. Friction from physical irritation increases when the skin rubs over clothing, diapers, and bed or chair surfaces. The combination of chemical and physical irritation results in a weakened skin barrier, increasing the likelihood of IAD and further skin breakdown. Multiple potentially harmful variables work together to cause perineal and surrounding skin breakdown. In addition, with incontinence, there is the need for more frequent cleansing which can lead to further pH changes and damage from friction, a problematic and concerning risk factor. Prolonged contact with moisture is known to be a factor in the development of irritant contact dermatitis and wetness also has the effect of macerating the skin increasing the risk of damage from friction (Bardsley, 2013). Significance There is a definite link between continence, IAD, and pressure ulcer development. According to Nix and Haugen (2010), perineal skin damage occurs in as many as 33% of hospitalized adults and 41% of adults in long-term care, but is preventable. As Bardsley (2013) explains incontinence-associated dermatitis typically presents as inflammation of the skin redness and if, left untreated, severe swelling and blisters. Once again, there are also many factors that exacerbate the problem. It is also important to note that IAD may bleed and progress rapidly into painful ulceration which may lead to secondary infection such as bacterial and yeast infections that potentially impact patient comfort and treatment costs. Additional significant

Running head: INCONTINENCE-ASSOCIATED DERMATITIS problems associated with IAD include pressure ulcer development, pain, and compromised

quality of life. Studies show that comprehensive preventative skincare interventions significantly reduce the incidence of sacral pressure ulcers (Nix & Haugen, 2010). Even, the Joint Commission for Accreditation of Health Care Organizations and Centers for Medicare and Medicaid Services recognize that skin breakdown is a key indicator for quality of life (Nix & Haugen, 2010). It is to be expected of health care professionals to implement appropriate interventions for patients to minimize the risk factors involved with as incontinence to prevent pressure ulcers. This would call for appropriate cleansing, rinsing, drying, and application of protective moisture barriers to prevent skin breakdown from incontinence. The Need for Differentiation between IAD and Pressure Ulcers Since recently, IAD has received little attention as a distinct skin disorder and is regularly confused with superficial pressure ulcers (Beeckman et. al, 2011). IAD is often associated with redness, rash, and blisters. The lesions may become slightly deeper if an infection occurs. Whereas the clinical observation of a pressure ulcer ranges from redness and tissue loss to tissue destruction involving skin, subcutaneous fat, muscle, and bone. According to Beeckman et. al(2011), there can be confusion differentiating IAD and surficial pressure ulcers. Furthermore, IAD can predispose patients to further pressure ulcer development. However, it is important to remember that IAD needs to be understood as a separate and different since it is due to incontinence whereas pressure ulcers are caused by the pressure and shear. Pressure ulcer prevention requires interventions which significantly reduce the duration and the amount of pressure and sheer such as applying appropriate support with the use of pillows, continuous repositioning, removing heels off of pressure, and using specialized devices for pressure redistribution (Beeckman et. al, 2011). It is very important to accurately differentiate between

Running head: INCONTINENCE-ASSOCIATED DERMATITIS

IAD and a pressure ulcer since there is a need for adequate documentation to start the correct prevention and treatment. Misclassification has significant implications and increase prevalence rates of what the patient really needs interventions for. Making an accurate differentiation between IAD and a pressure ulcer is important of adequate documentation and to start the correct prevention and treatment. Primarily, pressure ulcer preventive interventions are expensive and labor intensive for health professionals, when IAD is observed as a pressure ulcer, then these patients who need more effective prevention for IAD would instead have pressure ulcer previously described such as continuous repositioning and pressure redistribution with pillows to be applied to them instead of effective prevention for IAD would be detrimental to the patient and healthcare costs (Beeckman et. al, 2011). Incorrect assessment can lead to inappropriate treatment and are, prolonged hospitalization and increased costs (Bardsley, 2013). Bardsley (2013) informs readers that many soaps and cleansers are alkaline and when used routinely to cleanse the skin of patients with incontinence, these can alter the skins acid mantle. Cleansers with pH closer to the skins pH should be used and compared. In 2005, a pressure ulcer classification tool was developed known as PUCLAS that helped nurses currently differentiate IAD from pressure ulcers (Beeckman et. al, 2011). However, there is still lack of research addressing the effectiveness of different skin care regiments to prevent or treat IAD. Plan of Care Analysis of the literature leads to a consistent regimen of care that is suggested. Evidence shows that perineal skin cleansing should involve a product with a pH range that reflects the acid mantle of health skin between 5.4-5.9 (Beeckman et. al, 2011).Skin cleansers provide an alternative for soap and water and they work by emulsifying dirt and microorganisms that are on the skin so that they are easily removed. In addition, there are also no-rinse skin cleansers that

Running head: INCONTINENCE-ASSOCIATED DERMATITIS contain emollients and moisturizer, which is beneficial. Beeckman et. al, (2011) states that perineal skin cleansing should occur as soon as possible to limit the duration of the contact

between skin and the urine and stool. Furthermore, it is helpful to provide moisturization which involves repairing the skin barrier, retaining and increasing water content, restoring lipid barriers (Beeckman et. al, 2011). Indeed, according to Bardsley (2013), there is evidence that shows emollient-based moisturizers with low water content and skin protectants help protect skin prevent maceration, and maintain skin health. Supporting interventions include the use of absorptive or containment products. Body worn pads require regular changes and correct sizing to prevent stool and urine from being held in contact with the skin for too long (Bardsley, 2013) Hence, good essential nursing care can improve the patient experience and clinical outcomes. Counterargument Involving Inconsistencies in Literature Beeckman et. al (2011) reports that the prevalence of incontinence-associated dermatitis varies between 3.4% and 25% in different studies, and that these figures may be underestimated due to an absence of validated assessment and documentation. In addition, Gray, Bliss, Doughty, Ermer-Seltun, Kennedy-Evans, and Palmer (2007) reports the prevalence of IAD varying from 5.6% to 50% depending on the type of setting and population studied. Most epidemiological studies are performed in small sample sizes and limited to the facility (Gray et. al, 2007). A number of studies compared different types of skin regimens but study design weaknesses are commonly found from the limit of products. In addition, there seems to be contradictive evidence presented in literature. For example, there is evidence that indicates that key prevention recommendations involve a structured skin care regimen that includes gentle cleansing and this skin cleansing should occur almost immediately after incontinence episode, but then there is also evidence that indicates that a cumulative effect may exist between

Running head: INCONTINENCE-ASSOCIATED DERMATITIS

increased skin damage and cleansing frequently with water and soap, especially when there are frequent incontinent episodes (Beeckman et. al, 2011). Therefore, the routine washing of patients following each episode of urinary incontinence needs to be re-evaluated and washing frequencies reduced. However, this may just be for the usage of soap and water, although it is not clearly explained. There is empirical evidence on the nursing interventions to prevent and restore barrier disruption with the importance of limiting soap use (Ersser et. al, 2005). A drawback to literature findings is that much of available evidence draws from other literature and is linked to limited documented clinical observations and many incontinence remains a taboo subject for many patients (Bardsley, 2013). Caution in drawing conclusions due to design weakness in the studies comparing the effect of soap and cleaners on the skin. Currently, no systematic, valid and reliable measures have been identified for assessing urine and stool exposed skin. There are studies that compare the use and effect of skin cleansers with soap and water use, but design weaknesses are common with small sample size a frequent limitation, the reliability of skin condition scores, number of times patients skin was cleansed each day variable (Ersser et. al, 2005). According to Ersser et. al (2005), there are not sufficient studies that show statistical significance in comparing the use of foam cleaners maintained integrity more so than those who were cleaned with soap and water. Yet, there seems to be evidence that barrier function improved with the use of a barrier cream and was even greater with the cleanser and cream regimen variable (Ersser et. al, 2005). Despite being a small study, repeated observations revealed statistically significant differences although no clinical observable evidence of skin breakdown was identified. Much of the data in literature is based on clinical experience rather than through the use of defined and tested measures. It is concluded that it is very important to provide timely cleansing for each episode of fecal incontinence which is shown

Running head: INCONTINENCE-ASSOCIATED DERMATITIS

to be more greatly associated to IAD. Urine contains a variety of chemical irritants and moisture which can result in incontinence-associated dermatitis but although there are these generally accepted theories about how incontinence-associated dermatitis occurs, none are definitive and it is most possible that the cause is multifactorial (Bardsley, 2013). Conclusion The prevention of IAD can correctly be described as an important challenge for clinical practice and research. Too many patients suffer from it and still too little effort is to improve outcomes in these patients. Problems are mainly related to accurate observations, differentiation, and appropriate preventions. Nationwide efforts to educate health care professionals to improve differentiation between IAD and pressure ulcers and to improve the awareness to make the distinction. Referral to a continence specialist should be considered for assessment and treatment of the underling incontinence. As Bardsley (2013) suggests, identifying individuals at increased risk of developing incontinence-associated dermatitis is important to ensure timely implementation of preventative measures. Treatment will depend on the type of incontinence but may include behavioral management, such as pelvic floor muscle training or pharmacological management or intermittent catheterization. The prevention of IAD is an important challenge for clinical practice and research. Too many patients suffer from it and there still not enough effort to improve outcomes since there needs to be more observation, development and implementation of appropriate preventions. Incontinence care should be coordinated with treatment of the causative condition. IAD can be prevented and revered with appropriate skincare. Caring for individuals with potential or actual IAD begins with a thorough assessment of the skin. Incontinent skincare requires timely and appropriate cleansing and protecting that minimizes exposure s to urine and stool but also the use of appropriate products.

Running head: INCONTINENCE-ASSOCIATED DERMATITIS References

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Bardsley, A. (2013). Prevention and management of incontinence-associated dermatitis. Nursing Standard, 27(44), 41-46. Beeckman, D., Woodward, S., Rajpaul, K., & Vanderwee, K. (2011). Clinical challenges of preventing incontinence-associated dermatitis. British Journal of Nursing, 20(13), 784790. Ersser, S., Getliffe, K., Voegeli, D., & Regan, S. (2005). A critical review of the interrelationship between skin vulnerability and urinary incontinence and related nursing intervention. International Journal of Nursing Studies, 42(7), 823-835. Gray, M., Bliss, D. Z., Doughty, D. B., Ermer-Seltun, J., Kennedy-Evans, K. L., & Palmer, M. H. (2007). Incontinence-associated Dermatitis. Journal of Wound, Ostomy and Continence Nursing , 34(1), 45-54. Nix, D., & Haugen, V. (2010). Prevention and Management of Incontinence-Associated Dermatitis. Drugs & Aging, 27(6), 491-496.