Moisture-associated skin damage (MASD) is the term used to describe a range of skin damage caused by the direct contact of body fluids with the skin (Gray et al, 2021). Recently, the International Classification of Diseases-11 (ICD-11) (World Health Organization, 2022) referred to this class of skin damage as irritant contact dermatitis due to friction, sweating or contact with body fluids (EK02.2). The MASD umbrella term currently incorporates incontinence-associated dermatitis, intertriginous dermatitis (intertrigo), periwound dermatitis and peristomal dermatitis (Dowsett and Allen, 2013).
ICD-11 expanded the classification of skin damage by adding two categories: contact dermatitis due to saliva and dermatitis due to contact with prostheses or surgical appliances. At present, there is still no international consensus on terminology and no international evidence-based published guidelines on MASD. For this reason, clinicians must follow local guidance when documenting MASD. Documentation has implications for healthcare providers and institutions looking to quantify the quality of care and benchmark against other institutions internationally. An international consensus framework would also inform evidence-based guideline development in the prevention and treatment of MASD.
Gray et al (2011) defined MASD as inflammation and/or skin erosion due to prolonged exposure to moisture and body fluids such as urine, faeces, perspiration, wound exudate and saliva, among others. However, they believed that moisture alone is unlikely to cause skin breakdown, given that while it may overhydrate the affected area, it is unlikely to cause direct skin damage. Additional factors such as chemical irritants to the skin, enzymes, pathogens and mechanical forces, including friction and shear, play an essential role in triggering the inflammation process and skin breakdown (Dissemond et al, 2021).
MASD is a complex topic, and poor decision-making can lead to wound healing delays and a burden on the patient and the healthcare economy (Dowsett, 2019). Therefore, a structured, evidence-based assessment can help clinicians identify the underlying aetiology and guide a thorough evaluation to enable a comprehensive care plan for treatment and/or prevention (Parnham et al, 2020).
A clinical decision support tool
The authors propose using the TIME Clinical Decision Support Tool (CDST) (Moore et al, 2019) to approach MASD effectively. TIME stands for:
- T: tissue non-viable
- I: infection/inflammation
- M: moisture imbalance
- E: edge, which is not advancing or undermining.
This evidence-based tool is a structured approach where the concept of TIME (Schulz et al, 2003) is expanded to include:
- A: accurate assessment, measurement and diagnosis of the patient and their wound
- B: bringing in the multidisciplinary team (MDT) to promote holistic care
- C: control and treat systemic causes
- D: decide the appropriate treatment
- E: evaluate and reassess the treatment and wound management goals (Moore et al, 2019).
Here, the authors will provide an overview of the TIME CDST tool to help clinicians guide their decision-making when managing MASD.
A: accurate assessment, measurement and diagnosis of the patient and their wound
Patient assessment is vital to establish the correct aetiology, deliver appropriate wound treatment and avoid wound complications. Guest et al (2017) found that inappropriate diagnosis affects timely wound healing, with failure to conduct an accurate patient assessment significantly contributing to this. An accurate assessment involves taking a complete history, recording symptoms, examining at-risk/affected anatomical locations, and noting cognitive status and socioeconomic factors. These should be investigated during this first approach to provide a comprehensive patient profile to enable a detailed, patient-specific care plan.
MASD is caused by trapped moisture and bodily fluids that come into contact with the skin, and patients with prolonged exposure to these fluids are at risk of skin damage. When starting the patient's assessment, it is crucial to investigate the cause of the skin damage or if the patient is at risk of developing MASD. Attention should be directed towards areas where MASD is most likely to occur, including between skin folds, as sweat and friction may lead to intertriginous dermatitis. Even in non-obese patients, at-risk areas such as the inner thighs, abdominal creases, armpits, groin and under the breasts are common areas where perspiration, moisture and friction may cause skin breakdown. Particular attention should be given to these anatomical sites.
Patients with an ostomy, fistula, catheter or exudative wounds are also at risk of developing peristomal or periwound MASD. It is essential to conduct frequent skin assessments and educate the patient or carers to identify and report early signs of skin damage such as erythema, pain, tingling, a burning sensation or maceration of the periwound/peristomal area.
Another common source of damage results from incontinence, known as incontinence-associated dermatitis (IAD). This is a significant problem and is often misdiagnosed as contact dermatitis or, more frequently, as a pressure ulcer/injury (PU/PI) category/stage I and II (Beeckman et al, 2014). As previously mentioned, failure to conduct an accurate skin assessment can lead to misdiagnosis. PU presentation varies from non-blanchable erythema with intact skin to full-thickness damage with more delimited margins (National Pressure Injury Advisory Panel et al, 2019). Whereas PUs are caused by pressure and shear, IAD is caused by urine and/or faeces destroying the skin barrier. IAD lesions appear around the area exposed to those fluids and are diffuse with poorly-defined areas of skin damage with or without loss of skin integrity (Beeckman, 2015). This anatomical area affected by IAD is complex. It needs careful assessment as other sources of moisture such as perspiration can lead to intertrigo, or other aetiologies such as contact dermatitis and other skin infections can be mistaken for IAD (Beeckman, 2015). Accurately identifying aetiology will lead to effective treatment and/or prevention strategies (Parnham et al, 2020).
B: bringing in the multidisciplinary team (MDT) to promote holistic care
Patients with or at risk of developing wounds are complex and require an MDT approach (Moore et al, 2014). Equally crucial to the inclusion of a variety of professionals within the clinical team is the inclusion of the patient and formal and informal carers to promote optimal care while enhancing patient satisfaction, adherence to treatment and wound healing rates (Dowsett, 2019).
The ability to involve members of the MDT will be determined by the healthcare setting in which the patient is being cared for. Patients in the acute hospital setting are likely to be linked with multiple MDT members at a given time, including nurses, the medical team, physiotherapists and occupational therapists. All members of the MDT should be familiar with the steps involved in skin assessment so that this can be escalated to the necessary members of the MDT. For example, suppose a physiotherapist is mobilising a patient out of bed for the first time postoperatively and identifies an area of skin damage. This information should be escalated appropriately to ensure prompt intervention. Referral to a tissue viability service (if available) should be prioritised for those patients suspected of developing skin damage of any aetiology. The same principles in MDT care apply to patients in the community or long-term care.
C: control and treat systemic causes
From data collected during assessment and shared among members of the MDT, it is vital to agree on relevant risk factors that may impair wound progression for the patient. The primary underlying diagnoses related to the development of MASD are chronic diseases such as diabetes, obesity, systemic infections, critical illness, incontinence, dementia, stress, mental health issues, and patients with wounds, catheters, ostomies or fistulas.
It is essential to understand that factors such as critical illness or even advanced age alone are not the cause of MASD. However, it must be appreciated that patients with a critical illness may experience pyrexia, leading to increased perspiration, or may be suffering from incontinence. Both of these are sources of moisture, thus increasing their likelihood of skin damage (Beeckman 2015; Parnham et al, 2020). Limited mobility is another frequent risk factor linked to MASD, and although immobility is not a source of moisture, it is related to increased friction and shear. In the presence of body fluids, the skin has a diminished ability to withstand friction forces, becoming more prone to damage (Shaked and Gefen, 2013). Furthermore, Shaked and Gefen (2013) argued that ageing and diabetic patients may develop stiffer skin tissue over time, enhancing the skin's vulnerability to moisture.
Understanding the modifiable factors that can be managed or controlled in the short term, such as infection, pyrexia, exposure to friction during mobilisation, good fitting of the ostomy bag, prompt cleansing and changing of continence products after incontinence episodes, for example, is essential. Then, a detailed care plan for other long-term actions around non-modifiable factors such as diabetes and obesity can occur. Promoting a holistic approach to the patient's health and wellbeing should be a priority, preventing future MASD.
D: decide appropriate treatment
This step focuses on deciding on the most appropriate treatment modality, which is only possible if an accurate diagnosis is made. The wound bed will be prepared following TIME, linking it with available treatment options (Dowsett, 2019). Management of MASD should focus on the aetiology of the problem, aiming to alleviate the skin's exposure to body fluids, chemical irritants, sources of friction and/or infection identified during assessment (Beeckman, 2015).
Treatment and prevention start with cleansing the area to remove body fluids and dead tissue and reducing the bioburden and the risk of infection. Powder and standard alkaline soaps should not be used as the latter can cause further damage to corneocytes and disrupt skin barrier function (Beeckman, 2015; Dissemond, 2021). Water alone can also impair the skin barrier function as it increases trans-epidermal water loss (TEWL) (Voegeli, 2012). Avoid friction on the area as wet skin is more prone to further damage (Shaked and Gefen, 2013). For adequate cleansing, Beeckman (2015) suggested using surfactants to allow body fluids, cell debris, or old skin products to be gently removed from the skin surface.
Barrier products are an excellent option to protect the skin against bodily fluids. Different formulations such as creams, ointments, pastes, lotions and films are water repellent and form a barrier on the skin (Beeckman, 2015). To help product selection in clinical practice, there are practical tools to guide the use of these products, such as the Skin Moisture Alert Reporting Tool for MASD (Medicareplus International, 2019), which has been endorsed by the National Institute for Health and Care Excellence) and the document by Beeckman (2015) for IAD. Barrier products should be applied after cleansing; however, when local infection of the treated area is present, some barrier products should be avoided so the topical antimicrobial can act effectively on the infected area. Furthermore, some formulations may not be compatible with other medical devices as they can interfere with the product's adherence. Therefore, staff are advised to follow the manufacturer's instructions in all cases.
When treating and preventing MASD, another vital step is to promote skin restoration to support and maintain the integrity of the skin barrier using moisturisers. Moisturisers are essential, but the lack of agreed terminology can lead clinicians to choose the wrong product. Surber and Kottner (2017) highlighted that moisturiser is often used interchangeably with emollients, humectants and occlusive products. The authors explained that a moisturiser product is intended to add moisture to the skin, whereas emollients soften the tissue, making it more flexible. The function of humectants is to attract and retain water. They are less effective in repairing the skin barrier when MASD is present and can add to the wetness problem by overhydrating the skin (Beeckman, 2015; Surber and Kottner, 2017). Humectants commonly contain urea and glycerine in their formulation. For MASD management, it is preferable to use products with lipophilic properties, known as emollients, including oils, petrolatum, dimeticone and paraffin (Surber and Kottner, 2017). Some products on the market combine different properties by cleansing, protecting and/or restoring the skin in a single product.
E: evaluate and reassess the treatment and wound management goals
Wound management is cyclical, and evaluation and reassessment of the patient and the wound are paramount to identify whether the wound is in a healing trajectory or to maintain the skin integrity during the prevention stage (Dowsett, 2019). At this final step, the at-risk area or the area of damage must be reassessed and documented frequently, including using wound measurement, photographs and repeated assessments performed in the initial phase. At this stage, it is also essential to prevent secondary cutaneous infection and possible contact dermatitis from the products used (Gray et al, 2011). During the patient's reassessment visit, education and self-care behaviours should be promoted and encouraged, as well as continually involving the patient in the treatment and prevention process to enhance skin integrity outcomes.
Conclusion
MASD is a frequently encountered, potentially avoidable adverse event experienced by patients. There is a need for a consensus approach to determine best practice recommendations in the assessment, prevention and treatment of MASD. A standardised approach, such as the TIME CDST, an easily accessible tool, is an evidence-based framework that may benefit clinicians dealing with MASD in clinical practice.