The promotion and maintenance of skin integrity is a common challenge in all care settings and is often used as an indicator of the overall quality of nursing care provided. In simple terms, skin integrity can be defined as the skin being ‘whole, intact and undamaged’ and disruption to skin integrity can have a negative effect on patient wellbeing and quality of life (Woo et al, 2017; Fletcher et al, 2020).
While the threats to skin integrity presented by pressure, shear and friction are well known, frequent exposure of a patient's skin to excessive moisture is often overlooked as a major cause of skin breakdown.
The term moisture-associated skin damage (MASD) has been adopted to describe the spectrum of damage that results from prolonged exposure of a patient's skin to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus and saliva (Voegeli, 2019). However, MASD is a general umbrella term to describe any skin damage caused by moisture, and generally considered to include four commonly encountered separate conditions that often coexist. These are: incontinence-associated dermatitis (IAD); intertrigo; periwound moisture-associated dermatitis; and peristomal moisture-associated dermatitis (Figure 1).
Figure 1. Conditions that fall under the umbrella term of moisture-associated skin damage
This article provides a general overview of the mechanisms of moisture-associated skin damage, focusing on IAD, and outlines the components of effective prevention strategies and interventions to manage MASD and promote skin health.
Normal skin barrier and control of moisture
A major function of healthy, intact skin (Figure 2) is the maintenance of a physical barrier against the external environment. This prevents the entry of noxious substances and pathogens, as well as providing an important moisture barrier, preventing excessive fluid gain and loss from the body.
Figure 2. Skin structure
This is achieved by the uppermost layer of the skin, the epidermis, in particular its outermost part, the stratum corneum (Figure 3). The stratum corneum is composed of tightly packed, flattened, protein-rich cells called corneocytes, which are held together by a lipid-rich matrix and protein ‘rivets’ called desmosomes; this is the so-called ‘bricks and mortar’ model (Rawlings, 2010).
Figure 3. Bricks and mortar arrangement of the stratum corneum
Enzymes within the epidermis act on phospholipids to produce a mixture of ceramides, free fatty acids and cholesterol (Darlenski et al, 2011), which help to regulate stratum corneum structure and function. The stratum corneum also contains a mix of substances that actively attract and hold water in the corneocytes, collectively termed natural moisturising factor. The natural moisturising factor acts by absorbing water from the atmosphere and deeper layers of the skin, enabling the outermost layers of the skin to remain hydrated, despite the drying action of the environment. By increasing intracellular water, they allow the corneocytes to retain their turgidity and shape, thus maintaining a flexible, barrier (Voegeli, 2012).
The skin barrier is further enhanced by the maintenance of an acidic surface with a pH of 4–6, termed the acid mantle. This helps to maintain a healthy balance of resident skin bacteria; it is also recognised that skin pH plays an important role in regulating skin health and stratum corneum cohesion (Ali and Yosipovitch, 2013).
Disruption of these carefully balanced mechanisms can lead to either excessive skin dryness (xerosis) or too much water (which can predispose the skin to MASD), both of which can cause the skin barrier to fail.
More recent models of skin barrier function suggest it comprises four separate components involving different layers of the skin (surface microbiome, chemical barrier, physical barrier and immune barrier) working in harmony to maintain overall skin integrity and offer some insight into the mechanisms involved in MASD (Eyerich et al, 2018).
Overhydration of the skin, particularly the stratum corneum, can precipitate inflammation by facilitating the passage of irritants into the skin, leading to dermatitis. The exact mechanisms by which excessive moisture causes irritation are still debatable and, to date, comparatively little work has been done to explore the mechanisms involved in each type of MASD. However, histological studies have shown that moisture damage appears to be a result of the intercellular lipid ‘mortar’ of the stratum corneum and the corneocytes being disrupted and, in effect, ‘dissolving’ the physical barrier (Warner et al, 2003).
Once saturated, wet skin is more susceptible to damage caused by friction and shearing forces, and further irritation and inflammation can occur as the normal skin flora is able to penetrate the disrupted skin barrier and activate the skin's well-developed immune defences (Newman et al, 2007).
Incontinence-associated dermatitis
IAD is perhaps the most widely recognised type of MASD, and certainly one of the most widely studied (Gray et al, 2012; Beeckman et al, 2015). It is suggested that prevalence rates for IAD vary from 5.6% to 50% across all healthcare settings and are highest in people with faecal incontinence and those who live in residential care settings (Beeckman et al, 2015; Voegeli, 2019).
A national audit conducted across 66 hospitals in Wales evaluated a total of 8365 patients and found IAD in 360, representing a prevalence of 4.3% (Clark et al, 2017). Several risk factors for the development of IAD have been identified, the main ones being incontinence of urine, faeces (or both), frequent incontinence episodes, use of occlusive containment products, pre-existing skin conditions, poor mobility/dexterity and an inability to maintain personal hygiene (Johansen et al, 2018; Van Damme et al, 2018). Given the large number of patients affected, the prevention and management of IAD presents a significant financial burden for healthcare systems. In the community in England alone 406 376 prescriptions for barrier products were issued in 2020, at a cost of £1.42 million (NHS Business Service Authority, 2021). However the true cost is likely to be much higher, with many patients self-funding their own preferred product.
Typically, IAD presents as inflammation of the skin surface characterised by redness and, in extreme cases, swelling and blister formation. In urinary incontinence, this generally affects the labia in women and the scrotum in men, as well as the inner thigh and buttocks in both sexes.
If untreated, IAD can rapidly lead to excoriation and skin breakdown. In obese individuals, it often coexists with a degree of intertrigo in the skin folds. This be followed by infection by the skin flora (eg candida), leading to a vicious circle of increased inflammation and skin breakdown. Although IAD is one of the forms of MASD that attract the most interest, the exact mechanisms remain poorly understood (Koudounas et al, 2020).
It is generally agreed that urinary incontinence on its own does not necessarily lead to IAD but, when combined with faecal incontinence or the passage of liquid stool, the risk increases significantly. This is thought to be because of overhydration of the epidermis and an increase in the skin pH away from the protective slightly acidic range. The change to a more alkaline pH activates digestive enzymes present in the faeces, which then further contribute to the damage caused to the epidermis. Liquid stool tends to be richer in digestive enzymes, and this, when combined with its elevated water content, is particularly damaging to the skin (Gray et al, 2012).
Preventing and treating moisture-associated skin damage
As the single causative agent in MASD is the overexposure of the skin to moisture, the main preventive measure should be to avoid excessive contact of the skin with moisture.
Although the quality of evidence for the prevention and management of the different forms of MASD varies and is generally low, there is now an accumulated body of knowledge and expert clinical consensus to guide practice (Wounds UK, 2018; Fletcher et al, 2020), and recommendations should ideally be reflected in local skin care protocols. In the case of IAD, a simple categorisation tool—the Ghent Global IAD Categorisation Tool (GLOBIAD)—has recently been developed and validated (Beeckman et al, 2017). This can be used in conjunction with current guidelines to deliver evidence-based practice.
In individuals assessed as being at a high risk of developing IAD, preventive measures should be instituted as soon as possible. It has been shown that IAD can occur in susceptible patients within four days of admission to a critical care unit (Bliss et al, 2011) and more recent work by Phipps et al (2019) demonstrated changes in skin barrier function after 15 minutes' exposure to a wet incontinence pad in healthy volunteers.
The provision of optimal skin care is one of the most important actions that can be taken. Ideally, skin care provided to any patient with any form of MASD should be based on a structured regimen and involve the use of a gentle skin cleanser, a protectant (barrier product) and moisturiser (if indicated). The use of ordinary soap and water should be avoided as, in most cases, the pH of the soap is too alkaline and may contribute to the skin irritation (Voegeli, 2012). Many newer cleansing products combine a cleanser with a protectant and moisturiser, and are pH balanced to help maintain the normal, slightly acidic skin pH.
Following cleansing, the skin needs to be protected against subsequent contact with moisture by a skin protectant or barrier product. It is important to recognise the difference between emollients (moisturisers) and barrier products, as the two are not interchangeable.
Barrier products are designed to repel moisture and protect the skin from the harmful effects of repeated exposure to excessive moisture. Basic barrier preparations consist of a lipid/water emulsion base with the addition of metal oxides (such as zinc or titanium), which form a thin layer on the surface of the skin to repel potential irritants. The more sophisticated ones, often contain a water-repellent, silicone-based ingredient dimethicone, such as Derma Protective Plus.
Unfortunately, there is always the potential for some of these ingredients to cause irritation in sensitive individuals, and this should always be kept in mind, particularly if the skin irritation appears to worsen when using any preparation. Should this occur, advice should be sought from the relevant nurse specialist.
Derma Protective Plus Skin Protectant management and prevention of IAD and MASD
The information in this section is from the information leaflet provided with Derma Protective Plus (Ennogen, Dartford).
Derma Protective Plus is a new 1% dimethicone skin barrier product with a uniform, gel-like and sticky consistency, and is non-greasy and less oily than market competitors. Applied directly to the skin, it provides long-lasting protection against chafing or further ingress of irritant urine and faecal materials, afforded by a comfortable and resilient barrier. The main benefits of Derma Protective Plus include the promotion of a healing environment for damaged skin exposed to urine and faecal matter and resistance to further maceration from IAD or persistent loose stools.
For patients at risk of or already experiencing moisture-injured skin, the area of concern should be fully and carefully cleansed with an appropriate cleansing solution. Once the tissue is clean, Derma Protective Plus should be generously applied by hand in a thicker layer for severely damaged skin and for more moist environments to enable its superior tissue adhesion to provide optimum moisture barrier protection. For prevention, reduce amount used to a thin layer. It may be reapplied as frequently as needed to ensure the integrity of the barrier is maintained; prolonged and consistent skin contact with the product is safe.
Extremely dry skin may also benefit from the regular application of Derma Protective Plus as the constituents of dimeticone and polyethylene glycol 3350 also aid vital moisture retention in this indication.
Derma Protective Plus is licensed for external use only and should not be used in infected, incised, deep or penetrating wounds. The manufacturer also advises against its use in cases of serious burns and animal bites.
For product risks, cautions and warnings please refer to the patient information leaflet.
Derma Protective Plus is up to 60% cheaper than other leading brands, and could therefore present a significant cost saving to the NHS.
Case 1. Skin vulnerable to IAD
A 68-year-old woman attended the continence clinic for management of recurrent and refractory urinary tract infections. The patient's older husband is her sole carer and she is a wheelchair user; she uses pads to manage urine leakage. For some time, she had been complaining of burning and irritation of her perinanal skin. In attempt to manage this, she applied liberal amounts of petroleum jelly daily. The patient had also recently developed antibiotic-associated diarrhoea (since hospitalisation for treatment with antibiotics) which increased the frequency of skin wiping with dry paper.
During continence assessment, the patient's vulnerability to IAD was readily identified. Examination of the skin found redness and inflammation; the skin had remained in prolonged contact with urine and there were some scratch marks from where the patient had experienced itching. Thankfully, no erosions were evident but urgent revision of the management plan was required to prevent more invasive skin damage. The findings were documented and the patient and her carer advised regarding a skin care regimen, including the use of Derma Protective Plus in place of petroleum jelly after each toilet visit and after bathing.
At 2-week follow-up, the skin was reviewed and the inflammation previously noted had disappeared. The patient was no longer experiencing burning and itchiness as the Derma Protective Plus allowed the continence management pads to absorb more effectively. As a result, the skin's integrity and resilience improved and the risk of incidental abrasions or moisture-associated damage was minimised.
Case 2. Minor/early IAD
Derma Protective Plus
An 87-year-old woman who was obese, confined to bed and experiencing urinary incontinence was exhibiting signs of self-neglect and refusing to accept personal care. She complained of burning in skin clefts and around her vulva. She felt she had thrush but, on examination, her skin was seen to be inflamed from contact with urine, the leakage of which she managed with bathroom towels within the bed. She also had intertrigo in the groin folds. The patient had been applying Sudocrem to the areas of skin soreness she could reach, but these areas had not improved.
The patient was fully counselled regarding the long-term risks to skin integrity from leaving incontinence unmanaged with the concomitant consequences including hospital admission for treatment. Once she had understood that she would be vulnerable to wound infection that would require more intense and regular intervention, the patient agreed to skin cleansing and treatment of skin folds with antifungal ointment. A continence assessment was undertaken and a management plan initiated with respect to urinary leakage. Regular application (three times a day) of Derma Protective Plus was integrated into the care plan. The reduced the skin pH and contact with body fluids, and promoted a healing environment where the antifungal could work optimally.
At continence follow-up at 1, 2 and 4 weeks, the patient's skin had much improved, with better protection against skin shearing from contact with wet sheets and general moisture contact.
Immediate application of Derma Protective Plus over antifungal treatment is not contraindicated if it is allowed to dry completely before applying. Good compliance with skin management regimen was facilitated by the carers, with obvious positive results.
Case 3. Moderate damage
A 78-year-old man living independently had a fall in his home and was brought into ED. During physical assessment, he was found to have overflow incontinence from chronic urinary retention. He also clearly had longstanding faecal incontinence as his buttocks were widely excoriated with focal indurations of faecal involvement of the tissues. Because of the patient's neurological and regenerative deficits in peripheral nerves, he was unaware of the damage to his skin, which had long remained in adverse conditions not conducive to healing.
Once admitted to hospital, the patient's skin was comprehensively assessed and found to be moderately moisture damaged but with no deeper ulcerations or breaks aside from the numerous sore patches where faeces had become ingrained. The tissue viability nurse specialist thoroughly cleansed the area, removing as much matter as possible without undue disruption of the wound matrices. Derma Protective Plus was then liberally applied across the whole buttock area. A plan was instituted to ensure consistent skin management while on the ward, with particular care taken not to allow the skin to dry out or further incontinence to remain suboptimally managed. Derma Protective Plus was applied at each toileting and pad change totalling at least 4 times in 24 hours.
Ten days later, the skin had dramatically improved, with all areas of faecal ingress expelled gradually from the dermal layers by virtue of moisture retention. Inflammation had dispelled, there were only very small pink patches where the faecal indurations had been and the overall skin integrity was much improved with no further evidence of moisture lesions.
All three cases demonstrated an improvement in the patient's skin condition after the product was introduced as part of their skin care regimen.
Conclusion
The risks of moisture-associated skin damage and incontinence-associated dermatitis remain a perennial concern for people with all forms of incontinence. The pain and embarrassment of living with these conditions (not to mention their costly, time-consuming treatment at the expense of the NHS) can be avoided or mitigated by ensuring evidence-based skin management protocols, which include the application of a skin-protectant moisture barrier.
The case studies suggest Derma Protective Plus has significant efficacy in retaining moisture within the skin's layers and preventing damage to the skin from contact with urine and faeces.
Other barrier products are available, but their sticky or greasy consistency can be off-putting to use or seep into fabrics. Equally, other skin barrier products have been shown to impair the moisture-wicking properties of continence management products, which is not the case with Derma Protective Plus.
Given the large number of patients affected, the prevention and management of IAD presents a significant financial burden for healthcare systems. Therefore, it is important to use a competitively priced effective product, such as Derma Protective Plus. Derma Protective Plus has proven its effectiveness against MASD and IAD and provides a 60% cost saving to the NHS compared with the brand leader. The product is effective in promoting optimum skin integrity in the management of both urinary and faecal incontinence.
KEY POINTS
- Incontinence-associated dermatitis (IAD) presents a significant financial burden for healthcare systems
- Prolonged exposure of a patient's skin to excessive moisture is a major cause of skin breakdown but is often overlooked
- Introducing an effective and long-lasting moisture barrier can help prevent damage to skin vulnerable to IAD and moisture-associated skin damage (MASD)
- Early intervention can stop IAD and MASD occurring or worsening
- Skin damage from IAD and MASD can be reversed with the incorporation of an effective moisture barrier into the skin care regimen
- Derma Protective Plus has proven its effectiveness against MASD and IAD and provides a 60% cost saving to the NHS
CPD reflective questions
- What practices do you use to help prevent skin damage from incontinence in the patients for whom you care?
- Do you educate your patients regarding skin damage from incontinence?
- Do you know and understand the properties of the products you use and recommend for your patients?