- IAD is skin damage caused by exposure to urine and/or stool, and is exacerbated by the use of absorbent containment products. It affects 5.6-50% of long-term care residents and 10.9-54% of incontinent hospital patients. - Urine and stool impact the skin's moisture barrier, increasing pH and promoting bacterial/fungal growth. Absorbent products further overhydrate the skin. - IAD is diagnosed by inspecting the skin for redness,

1. Incontinence
Associated Dermatitis
Mikel Gray, PhD, FNP, PNP, CUNP, CCCN, FAAN
Professor & Nurse Practitioner
University of Virginia Department of Urology

2. 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

3. 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

4. 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.

5. 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.

6. 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
microcirculation
Ghadially R. American J Contact Dermatitis 1998; 9(3): 162.

7. 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.

8. 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

9. 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. JWOCN
34(1): 57-69.

10. 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

11. 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,

12. 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 injury
Junkin J, Selekof J. IAD prevalence in acute care. WOCN National Conference, June 2006 Minneapolis, MN.

13. 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 .

14. 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,

15. 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.

16. 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
infections2
1.Donskey, Clinical infectious Disease 2004; 39: 219.
2. Cunningham et al., J. Hospital Infection 2003; 36: 149.

17. 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.

18. 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 healing5
1. 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.

19. 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.

20. Pathophysiology

21. Normal skin
Epidermis
Dermis
Hypodermis

22. Irritants Perspiration
Urine
Stool (especially liquid)
Exudate / Effluent
Penetration
of irritants
Elevated
TEWL
Altered pH

23. Inflammation
Cracking of
skin
Redness
Swelling
Release of
cytokines
Inflammation

24. Denudation
Erosion
(denudation)
of skin

25. Screen for Redness, Inflammation

26. IAD: Diagnosis

27. 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?

28. 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

29. IAD: Diagnosis
 Look for erosion of
skin
 Partial thickness
erosion common
 Full thickness wound
implies pressure or
shear and pressure
ulceration

30. 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
inpatients1
1. Junkin J, Selekof J. IAD prevalence in acute care. WOCN National Conference, June 2006
Minneapolis, MN.

31. Differentiate MASD from
Pressure Ulceration
Gray M et al. JWOCN 2007; 34(2):.

32. What type of skin damage?

33. 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

34. Hospital Disposable
Washcloth Vs. Washcloth
Basin Sage

35. 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 patients1,2
1. Byers et al. JWOCN, 1995, 187.
2. Lewis-Byers et al. OWM, 2002, 44.

36. 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

37. Preventive Skin Care:
Perineal Skin Cleansers
Product Key Components Notes
Aloe-Vesta 2-n-1 Cleanser, moisturizer* (aloe 3-n-1 adds
and 3- n-1 vera), emollient emollient, lemon
scented
Sensi-care Cleanser, emollient, No scents, no
moisturizer preservatives
Cavilon 1-step Cleanser, moisturizer*, Labeled as “Skin
emollient, moisture barrier care lotion”
Cavilon Cleanser Cleanser, moisturizer, Humectant acts as
humectant moisture barrier

38. Preventive Skin Care:
Perineal Skin Cleansers
Product Key Components Notes
DermaRite 3 in 1 Cleanser, moisturizer Advocates use as
shampoo as well
Peri-Fresh Cleanser, moisturizer* “Fresh fruit” fragrance
Perigene Cleanser, moisturizer No alcohol, fragrances,
preservatives, dyes
Provon Perineal P Wash: cleanser, vit. E, Wash has “herbal”
Wash & moisturizer*, fragrance, AB has
Antibacterial antibacterial in one “deodorizer”
preparation

39. Preventive Skin Care:
Perineal Skin Cleansers
Product Key Components Notes
Restore Clean & Cleanser, moisturizer, 3-n-1 product
Moist emollient
Remedy 4-n-1 Cleanser, moisturizer, 3-n-1 product with
antimicrobial emollient, benzalkonium antimicrobial agent
cleanser chloride
Carafoam skin & Cleanser, moisturizer Dispensed as foam, mild
perineal cleanser fragrance
Peri-wash II Cleanser, benzethonium Antiseptic, fragrance
chloride (deodorizer)

40. Preventive Skin Care and
Contemporary Assessment
 Comfort Bath:
cleanser &
moisturizer
 Deodorant Comfort
Bath: cleanser,
moisturizer &
deodorizing agent
(Exopheryl™)

41. 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

42. 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

43. 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.4
1. 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 collecting
prevalence 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

44. 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 K
Long-Term Care Unit, Fulton County Medical Center, McConnellsburg, PA, Ostomy/Wound Management. Dec 2002;48(12):60-7.

45. “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.asp
Dieter L, Drolshagen C, Blum K, Cost-effective, quality care for the patient with incontinence. Research Poster Abstract presented at
WOCN , Minneapolis, MN June 2006

46. “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.asp
Gray DP, Developing a comprehensive fecal incontinence management program.
Practice Innovation Poster Abstract presented at WOCN, Minneapolis, MN June 2006.

48. 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

49. 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

50. Sluser Study – Consistent Treatment

51. Sluser Study – Consistent Treatment

52. Sluser Study – Consistent Treatment

53. 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

54. IAD: Treatment
 Inert Skin Barriers
– Deflect drainage and
provides moisture
barrier
 Most common
contain
– Petrolatum
– Dimethicone
– Zinc oxide

55. 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)

56. 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

57. 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

58. 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

59. 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

60. 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

61. 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/