Preventing IAD: Appropriate barriers decrease risk of incontinence-associated dermatitis

September 1, 2008

It's imperative for woundcare specialists to ensure that urine and stool are kept away from the skin. To ensure this, clinicians need to use appropriate barriers. It's also paramount that the barriers be properly removed. If they are not, that can trigger skin damage. Whatever the choice of products used to protect the skin, following structured protocols will keep the integrity of the skin intact.

Key Points

Toronto - Using appropriate barriers to keep urine and stool away from the skin can decrease the risk of incontinence-associated dermatitis (IAD).

At the World Union of Wound Healing Societies meeting held here recently, Dorothy Doughty M.N., R.N., C.W.O.C.N., F.A.A.N., a woundcare clinician based at Emory University in Atlanta, Ga., said skincare is critical for patients with either urinary or fecal incontinence.

"You want to select a barrier that does a really good job at keeping the urine and stool away," says Ms. Doughty, who has authored textbooks on the management of urinary and fecal incontinence.

A totally occlusive barrier would actually "trap" the perspiration next to the skin, which would cause maceration. Occlusive products can also transfer to the absorptive product and limit its effectiveness.

She says that dimethicone-based products are effective against urine and solid stools, are not occlusive in that they allow for moisture vapor transfer, and are non-greasy.

They are, however, not as effective with liquid stool or when the skin is already damaged, unless used in combination with an absorptive powder.

Zinc oxide-based products are advantageous in situations involving liquid stool or the management of damaged skin; however, these products are often thick, sticky and opaque.

"It's a major challenge for you as a woundcare clinician to appropriately educate all caregivers on the proper removal of these products," Ms. Doughty tells Dermatology Times.

A soft cloth or cotton ball, moistened with either a perineal cleanser or mineral oil, should be used to remove a zinc oxide-based product, she says.

Simple protocol

Having a formal, but simple, protocol for skincare promotes the correct use of available products and maintenance of skin integrity.

In terms of prevention, toileting is the first step that clinicians should take when treating a patient with incontinence. If that measure is not successful, the next step is to consider containment measures, such as a perianal pouch or external catheters.

IAD

Incontinence-associated dermatitis (IAD) is an inflammation of the skin that occurs when urine or stool comes into contact with perineal or perigenital skin. The skin breakdown is associated with increased risk of pressure ulceration.

"When you are dealing with mild-to-moderate IAD, you might have mild erythema and tenderness, but no skin loss. These patients can be effectively managed by instituting a prevention program as described above and by assuring that any absorptive products being used have the ability to wick moisture away from the skin and by avoiding occlusion," Ms. Doughty says.

Clinicians may need a more resistant barrier product to treat severe IAD or moderate IAD that does not respond to standard preventive care.

In one study of residents at a nursing home, the majority of whom had both urinary and fecal incontinence, four different regimens were used to prevent IAD. The majority of the study subjects were female and aged 65 and older.

In three regimens, a moisture barrier ointment or cream of different compositions was applied after an episode of incontinence. In one regimen, a polymer-based barrier film was applied three times in a week.

All regimens were effective in preventing IAD; however, a polymer-based barrier film applied three times per week was associated with reduced costs.