Incontinence Associated Dermatitis by Prof Dr Mikel Gray
IncontinenceAssociated Dermatitis Mikel Gray, PhD, FNP, PNP, CUNP, CCCN, FAAN Professor & Nurse Practitioner University of Virginia Department of Urology
Anatomy & Physiology Largest organ (6 pounds or 3,000 sq inches); its thickness varies from 0.5mm – 6 mm Functions: – Barrier: against toxins in external environment and for the prevention of excessive fluid & electrolyte loss from internal environment – Thermoregulation – Sensory organ/ communication – Immune functions – Vitamin D metabolism Burns T et al. Textbook of Dermatology, 2004. Mass: Blackwell Science
Moisture barrier of the skin– Stratum corneum: dead keratinocytes or corneocytes– Lipid matrix: slows movement of water & electrolytes– Water: hydrates corneocytes– pH: (usually 5.0-5.9) forms an acid mantle– Bacterial flora: competes with pathogens to prevent infection– Temperature: regulates permeability
How do Clinicians & Researchers Measure the skin’s Moisture Barrier? No clinical test for measuring moisture barrier Researchers measure Transepidermal water loss (TEWL); which is the rate of passive diffusion of H20 from internal environment to external environment (differs from perspiration) The perineal skin and scrotum have the highest TEWL os any surfaces of the body, skin over back is the lowest Loffler H, Hautarzt. 50(11):769-78, 1999 Hautarzt.
Perineal Skin at the Extremes of Life Barrier function in the neonate – Less robust than adults, particularly premature infants Higher TEWL Higher rates of percutaneous absorption Greater risk for erosion, stripping, pressure injury – Cornification of skin begins about GW 20 – Vernix contains FFA, cholesterol & ceramides, thus acting as proxy while skin develops – Full-term skin contains 10-20 layers of stratum corneum, skin in premature baby has 2-3 Lund C et al. JOGNN 1999; 28(3): 241.
Perineal Skin at the Extremes of Life Aging Skin: gradual decline in barrier function – ↑ TEWL – Overall thickness declines – ↓ Collagen & elastin – Local changes in capillary beds reflect systemic changes in microcirculationGhadially R. American J Contact Dermatitis 1998; 9(3): 162.
Searching for an appropriate name: Perineal Dermatitis? Perineum: region between the thighs, in the female between the vulva and the anus, in males, between the scrotum and the anus1 Dermatitis: inflammation of the skin1, itself a broad term may be divided into2 – Atopic (eczema) – Allergic – Irritant – Multiple other terms used, dermatoses used to describe “well defined endogenous skin dysfunction”2 1. Online Medical Dictionary, http://cancerweb.ncl.ac.uk/cgi-bin/omd?action=Home&query http://cancerweb.ncl.ac.uk/cgi-bin/omd?action= 2. Burns T et al. Textbook of Dermatology, 2004. Mass: Blackwell Science.
Searching for an appropriate name: Diaper or Nappy Dermatitis? Strengths – Clearly associated with incontinence and use of one type of containment device, infant diaper (often called nappy in UK) or adult containment brief Limitations – Unfairly blames one type of containment device as cause of the problem itself – Possible pejorative interpretation when applied to adults
Searching for an appropriate name: Incontinence Associated Dermatitis Name selected from alternatives at consensus conference held in Chicago, IL summer of 2005, results of conference published in JWOCN, 20071 Describes etiology and outcome of condition* Supported by unrestricted educational grand from SAGE, Inc.1. Gray M, Bliss DZ, Doughty DB< Ermer-Seltun K, Kennedy-Evans KL, Palmer MH. JWOCN34(1): 57-69.
Moisture Associated Skin Damage (MASD) IAD is part of larger etiological framework called MASD – Intertrigo: inflammation in skin folds related to perspiration, friction and bacterial/ fungal bioburden – Periwound maceration: skin breakdown from wound exudate, related to volume, constituents or exudate & bacterial bioburden – IAD: urine, stool, containment device, secondary cutaneous infection – typically fungal
Epidemiology of IAD Long-term care literature reports – Prevalence of 5.6%-50% – Incidence of 3.4%-25% Acute-care – Incontinence prevalence: 20% – IAD prevalence was 10.9% of the general hospital population – IAD prevalence was 54% in incontinent patients in 3 acute-care hospitals Lyder, et al., 1992; Bale, et al., 2004; Bliss, et al., 2005; Junkin, More-Lisi, Selekof, 2005 Selekof,
2005 IAD Prevalence Study 976 Total number of patients surveyed • 27% had IAD 20.3% (198) 35% had • 33% had a pressure prevalence of Foley catheter ulcer incontinence(deemed continent) • 18% had a probable urine or stool fungal Infection 21% had more than 1 type of injuryJunkin J, Selekof J. IAD prevalence in acute care. WOCN National Conference, June 2006 Minneapolis, MN.
IAD: Effect of Urine on Skin Water: decreases skin hardness, renders it more susceptible to friction and erosion Ammonia: raises pH, promotes pathogenic growth, disrupts acid mantle, activates fecal enzymes, alters normal flora of skin Gray M. Journal of WOC Nursing 2004; 31(1 Suppl):S2-9 .
Impact of Stool on Skin Intestinal colonization acts as a reservoir for potential pathogenic substances1 – VRE – MRSA – Clostridium difficile – Antibiotic resistant Staphylococcus aureus – Multiple other antimicrobial resistant gram- negative bacilli Steifel & Doskey, 2004; Current Infectious Disease Report 2004; 6:420. Doskey,
Impact of Stool on Skin Disruption of the usual microflora provides opportunity for pathogenic colonization1 – Normal colon: 1012 CFU per Gm with obligate anaerobe counts exceeding parasitic organisms ~1000:1; important defense against pathogens – Antimicrobials that are excreted into the intestinal tract disrupt this balance – Result in skin contamination in 83% and environmental surface contamination in 67%, diarrhea and fecal incontinence magnify risk2 1. Steifel & Doskey, 2004; Current Infectious Disease Report 2004; 6:420. Doskey, 2. Donskey et al. NEJM 2000; 343: 1925.
Impact of Stool on Skin Disruption of gastric acid content in stomach – Healthy individual: >99% of coliform bacteria ingested killed within 30 minutes because of gastric acid secretion1 – Use of medications that inhibit stomach acid production associated with C. difficile, S. aureus, VRE and antibiotic resistant gam negative infections21.Donskey, Clinical infectious Disease 2004; 39: 219.2. Cunningham et al., J. Hospital Infection 2003; 36: 149.
Pathophysiology Use of absorptive containment devices – Exacerbate overhydration by promoting perspiration & retaining urine and stool; with padding alone: TEWL increases 3-4 fold within days CO2 emission increases > 4 fold pH increases from 4.4 to 7.1 (without incontinence) – Emerging data supports direct role in PU risk… 1. Grove GL et al. Clinical Problems in Dermatology 1998; 26:183 2. Zimmerer RE et al. Pediatric Dermatology 1986; 3: 95. 3. Zhai H et al. Skin Research & Technology 2002; 8:13.
IAD & Pressure Ulceration Precise nature of association not understood Fecal incontinence strongly associated with PU risk, UI is not1-4 Analysis rarely based on PU stage, few articles that use stage associate FI/ UI with stage I & II3 Both FI & UI associated with increased time and cost to wound healing51. Maklebust J & Magnan MA Advances in Wound Care 1994; 7(6): 25.2. Gunninberg L. Journal of Wound Care 2004; 13(7): 286.3. Fader M et al. Journal of Clinical Nursing 2003; 12(3):374.4. Berlowitz DR et al. Journal of the American Geriatrics Society 2001; 49(7):866-71.5. Narayan S et al. Jounal of WOCN 2005; 32(3): 163.
IAD & Pressure Ulceration Does FI or UI indirectly contribute to pressure ulcer risk? – Skin wetted with synthetic urine or water shows a significant decrease in hardness, temperature, and blood flow during pressure load when compared to dry sites1 – Absorbent products may enhance the risk for pressure ulceration by creating areas of increased interface pressure, even when used in conjunction with a pressure reducing or relieving device2 1. Mayrovitz HN, Sims N Adv Skin Wound Care 2001;14(6):302. 2. Fader M et al. Journal of Advanced Nursing 2004; 48(6): 569.
IAD: Diagnosis Inspect the skin for erythema, redness, cracking, swelling, vesicles Determine location of skin damage – does it lie in skin fold or over bony prominence, underneath containment device?
IAD: Diagnosis Look in Skin Folds – Opposing skin surfaces trap moisture – Warm moist environment encourages bacterial and fungal colonization, overgrowth and infection – Friction created as skin folds rub against one another
IAD: Diagnosis Look for erosion of skin Partial thickness erosion common Full thickness wound implies pressure or shear and pressure ulceration
IAD: Diagnosis Look for secondary cutaneous infection, especially candidiasis – Opportunistic infection with candida albicans – Thrives in warm, moist environment & damages stratum corneum – Seen in 18% of one group of 976 acute care inpatients11. Junkin J, Selekof J. IAD prevalence in acute care. WOCN National Conference, June 2006Minneapolis, MN.
Differentiate MASD fromPressure Ulceration Gray M et al. JWOCN 2007; 34(2):.
IAD: Prevention Principles of Prevention: 1) cleanse, 2) moisturize, 3) protect – Gentle cleansing: NO scrubbing – Select a cleanser with acceptable pH & no irritants – Moisturize dried areas to maximize lipid barrier – Apply moisture barrier as indicated
Hospital DisposableWashcloth Vs. Washcloth Basin Sage
Preventive Skin Care: Cleanse Soap & Water – What is the clinical evidence for soap & water as a perineal skin cleanser alkaline pH raises pH more than cleansing with pH ‘balanced’ cleansers; alkaline pH associated with skin irritation and severity of IAD1 cleansing requires significantly more time than with cleansers1,2 2 small RCT have not demonstrated greater risk for dermatitis in frail elder patients1,21. Byers et al. JWOCN, 1995, 187.2. Lewis-Byers et al. OWM, 2002, 44.
Preventive Skin Care: Cleanse Incontinence skin cleansers – ‘pH Balanced’ designed to maintain the acid mantle of perineal skin – Many described as “no rinse” (no water required) – Require significantly less time than traditional cleansing with soap and water – Many contain emollients (skin softeners) or moisturizers to preserve lipid barrier, thus combining 2 steps into a single action
Preventive Skin Care: Perineal Skin CleansersProduct Key Components NotesAloe-Vesta 2-n-1 Cleanser, moisturizer* (aloe 3-n-1 addsand 3- n-1 vera), emollient emollient, lemon scentedSensi-care Cleanser, emollient, No scents, no moisturizer preservativesCavilon 1-step Cleanser, moisturizer*, Labeled as “Skin emollient, moisture barrier care lotion”Cavilon Cleanser Cleanser, moisturizer, Humectant acts as humectant moisture barrier
Preventive Skin Care: Perineal Skin CleansersProduct Key Components NotesDermaRite 3 in 1 Cleanser, moisturizer Advocates use as shampoo as wellPeri-Fresh Cleanser, moisturizer* “Fresh fruit” fragrancePerigene Cleanser, moisturizer No alcohol, fragrances, preservatives, dyesProvon Perineal P Wash: cleanser, vit. E, Wash has “herbal”Wash & moisturizer*, fragrance, AB hasAntibacterial antibacterial in one “deodorizer” preparation
Preventive Skin Care Typical Protocol – Routine daily cleansing for everyone – Cleanse & moisturize with each major incontinent episode – Apply moisture barrier for significant UI, fecal or double incontinence – Comfort Shield: cleanser, moisturizer, 3% dimethicone skin protectant
Risk Factors for Pressure Ulcer Development “…The odds of having a pressure ulcer were 22 times greater for hospitalized adult patients with fecal incontinence compared to hospitalized patients without fecal incontinence…and 37.5 times greater in patients who had both impaired mobility and fecal incontinence”JoAnn Maklebust, MSN, RN, CS, NP and Morris A. Magnan, MSN, RN,“Risk Factors Associated with Having a Pressure Ulcer: A Secondary Data Analysis”, Advances in Wound Care, November 1994
Facts About Pressure Ulcers 80% of pressure ulcers in hospital are Stage I or Stage II.1 Almost half of all pressure ulcers form on the sacrum (36.9%) and ischium (8.0%).2 A healthcare facility will spend between $400K and $700K annually on pressure ulcer treatment.3 JACHO lists prevention of health care associated pressure ulcers as a patient safety goal.41. Whittington KT, Briones R, “National Prevalence and Incidence Study: 6-Year Sequential Acute Care Data,” Adv Skin Wound Care.2004 Nov/Dec;17(9):490-4. 2. Amlung SR, Miller WL, Bosley LM, Adv. Skin Wound Care. 2001 Nov/Dec; 14(6): 297-301. 3.Robinson, C; Gioekner, M; Bush, S; Copas, J; et al. Determining the efficacy of a pressure ulcer prevention program by collectingprevalence and incidence data: a unit-based effort. Ostomy Wound Manage. 2003. May: 49(5):44-6. 48-51. 4.http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_ltc_npsgs.htm
Clever et al. - Pressure Ulcer Study “Evaluating the Efficacy of a Uniquely Delivered Skin Protectant and Its Effect on the Formation of Sacral/Buttock Pressure Ulcers”* Average Monthly Incidence of Sacral/Buttock Pressure Ulcers Old standard of care vs. 4.7% using Comfort Shield® as preventative in new Reduction in Incidence standard of care Of sacral/buttock pressure 0.5% ulcers Old Standard of Care New Standard of Care 7/00 – 3/01 5/01 – 7/01 2/02 – 4/02*Comfort Shield® was used on all incontinent patients and was the only variable changed from the control period.Clever K, Smith G, Bowser C, Monroe KLong-Term Care Unit, Fulton County Medical Center, McConnellsburg, PA, Ostomy/Wound Management. Dec 2002;48(12):60-7.
“The Development of Cost-Effective Quality Care for the Patient with Incontinence” Group A = Cleansing spray, washcloths, skin barrier (multi- step process and the current practice). Group B = Shield Barrier Cloths. Group C = Disposable washcloth without dimethicone. Results: • Group A = $6.13 per patient per day; 10% skin breakdown. • Group B = $5.40 per patient per day; 8% skin breakdown. • Group C = Discontinued in week 4 due to 29% skin breakdown. • 2003 72 consults due to IAD and 2004 10 consults due to IAD. http://www.sageproducts.com/education/shSymposiaPres.aspDieter L, Drolshagen C, Blum K, Cost-effective, quality care for the patient with incontinence. Research Poster Abstract presented atWOCN , Minneapolis, MN June 2006
“Developing a Comprehensive Fecal Incontinence Management Program… (for IAD)” Program, guidelines and algorithm for clinical decision making to include: Protection, Treatment and Containment devices. 33% of hospitalized patients have fecal incontinence. Fecal Incontinence increases PU risk 22 times and 30% if immobile. Shield Barrier cloths for prevention of IAD; Xenaderm for Treatment of IAD and guidelines for external and internal fecal containment devices. http://www.sageproducts.com/education/shSymposiaPres.aspGray DP, Developing a comprehensive fecal incontinence management program.Practice Innovation Poster Abstract presented at WOCN, Minneapolis, MN June 2006.
Treat Underlying Incontinence Consider Diversion of Stool When Indicated Anal Pouch – Synthetic, adhesive skin barrier attached to pouch Bowel Management System – Zassi BMS or Flexiseal Nasal Trumpet – Off label use
Treat Underlying Incontinence Temporary Diversion for UI: Indwelling Catheter – Indications UI complicated by urinary retention, obstruction & only when CIC not feasible Stage 3-4 PU for transient diversion only – Selection criteria Siliconeor Lubricath Smaller French size
IAD: Treatment Goals – Establish or continue cleansing/ moisturization/ skin barrier program – Restore epidermal integrity – Minimize exposure to irritants (Manage UI or Fecal incontinence) – Treat secondary cutaneous infections – Create environment for wound healing
IAD: Treatment Inert Skin Barriers – Deflect drainage and provides moisture barrier Most common contain – Petrolatum – Dimethicone – Zinc oxide
IAD: Treatment Inert moisture barriers – No evidence base could be identified supporting efficacy for existing IAD – Ample anecdotal evidence supports role in mild to moderate cases in outpatient/ home setting – Disadvantages include removal (zinc oxide in particular)
IAD: Treatment Topical Dressings – Hydrocolloids – Thin film dressings Act as barrier to urine & stool Promote moist environment for wound healing Can be combined with topical treatments
IAD: Treatment Topical Dressings – Maintaining adherence significant challenge – Skin surfaces complex – Borders often roll when ointments or moisturizing products have been applied – Undermining of urine or stool may occur
IAD: Treatment BCT agents BCT Ointment (Xenaderm) – Balsam Peru, Castor Oil, Trypsin in ointment base – Applied to dermatitis twice daily or with major cleansing BCT gel (Optase) NOTE: FDA has ruled out further reimbursement pending documentation of efficacy
IAD Treatment: Secondary Complications Candidiasis – Topical antifungals are effective for the treatment of cutaneous infections – Effective agents include the polyene antibiotics, azoles and the allylamines1 – Resistance to antifungals is emerging, careful monitoring of research literature is essential 1. Evans & Gray, JWOCN, 30(1), 2003
IAD and IHI as it relates to Sage Facilities need to follow the Six Elements of Pressure Ulcer Prevention (from IHI) – Asssess the skin upon admission – Reassess the skin daily – Inspect the skin daily – Manage moisture – Optimize nutrition and hydration – Minimize pressure
Summary: Manage Moisture: Keep the Patient Dry and Moisturize Skin Provide supplies at the bedside of each at-risk patient who is incontinent. This provides the staff with the supplies that they need to immediately clean, dry, and protect the patient’s 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 pre-moistened, disposable barrier wipes to help cleanse, moisturize, deodorize, and protect patients from perineal dermatitis due to incontinence.http://www.ihi.org/IHI/Programs/Campaign/