Stop the Rash...Preventing IAD

As seen in Consultant Connection November 2012 Issue
By Irene Sours, RN, WCC

Incontinence-associated dermatitis (IAD) is a prevalent complication of incontinence that compromises skin integrity, predisposes to cutaneous infection, and increases pressure ulcer risk. IAD is an infl ammation of the skin as a result of chronic or repeated exposure to urine or feces. Reported IAD incidence rates in long-term care settings vary from 3.4% to 25% and up to 65% in the presence of double incontinence, urine and stool.

Clinical manifestations includes erythema, edema, maceration, denudation, papular/vesicular formations, erosion of the epidermis and/or dermis, poorly demarcated borders, flaking, crust formation, weeping, development of secondary cutaneous infection and sensations of tenderness, pain burning and itching. Complications occurring form IAD is bacterial (appearing as red scaling areas) or fungal infection (appearing as discreet satellite lesions), pressure ulcers, and severe pain. IAD is not confi ned to areas over bony prominences. It is usually diffuse, found in skin folds and often falls with the confi nement area of a containment garment if worn.

IAD may be due to any combination of the following: increased pH, duration and frequency of moisture exposure, mechanical chafi ng, cutaneous infection, and presence of other irritants or allergens, degree of chemical/enzymatic activity, co-morbidities, age, nutritional status, cleansing method, and use of occlusive containment devices. The severity of IAD is dependent upon the concentration of the irritant, the degree of skin sensitization and specifi c microfl ora present. Skin is normally acidic, with a pH range of 5.5 to 5.9. When feces and urine are mixed together, bacteria in the feces convert urea in the urine to ammonia, which make the skin more alkaline.

Management Considerations of Incontinence-Associated Dermatitis

  • Minimize incontinence with scheduled toileting programs.
  • Consider using drug therapy to control noninfectious diarrhea.
  • Use skin care products that cleanse, moisturize, and protect.
  • Most “pH balanced” (5.0-5.9) perineal skin cleansers are designed to maintain the acid mantle of skin.
  • Avoid soap because it is alkaline and causes skin irritation.
  • Skin should be cleansed gently avoiding friction and patted dry.
  • A variety of skin protectant products are available to shield the skin from moisture, urine and feces. Some skin protectants contain active ingredients designed to promote wound healing (Balsam-Peru, castor oil, trypsin ointment, antifungal, antibacterial agent)
  • Barrier pastes should be applied in a thick a layer following each incontinence episode while barrier creams, ointments and sprays may be applied in a thinner layer and be effective. Follow  manufactures recommendations.
  • Some manufacturers of barrier pastes advice not to remove barrier pastes entirely during cleansing but leave a thin coat and reapply. If needed, mineral oil is a gentle and effective method for removing ointments or pastes.
  • Evaluate for use of absorptive products that wick urine and liquid stool away from the skin.  Consider using briefs when out of bed and disposable under pads when in bed to minimize moisture and heat trapping.
  • Ensure adequate nutrition, hydration, oxygenation and reduce pressure.
  • Treat fungal infections with topical antifungal powder or cream.
  • Treat bacterial infections with organism specifi c antibiotic.
  • Consider use of devices for incontinence such as fecal containment devices.
  • Clean intermittent catheterization.
  • Consult wound certified nurse.
Upon admission it is importance to evaluate residents for incontinence and interventions are implemented immediately. Provide supplies at the bedside of each at-risk resident who is incontinent. This provides the staff with the supplies that they need to immediately clean, dry, and protect the resident skin after each episode of incontinence. Provide under-pads that pull the moisture away from the skin and limit the use of disposable briefs or containment garments if at all possible. Provide premoistened, disposable barrier wipes to help cleanse, moisturize, deodorize, and protect resident from perineal dermatitis due to incontinence. Being proactive can reduce incidents of incontinence associated dermatitis within your facility.

Feel free to discuss bowel and bladder protocols, as well as cleansing and moisturizing skin routines with your ICP Nurse Consultant at any time.

Gray, M. (2007). Incontinence-related skin damage: Essential knowledge. Ostomy/Wound Management, 53(12), 28-32.
Wound Ostomy and Continence Nurses Society (2010-2011). Incontinence Associated Dermatitis (IAD): Best Practice for Clinicians.
http://www.ihi.org/IHI/Programs/Campaign/


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