As humans age, their skin becomes more susceptible to breakdown due to the effects of the ageing process. An older adult has thinner, more fragile skin, and the risk of skin damage occurring due to external factors, such as moisture or pressure, is increased in this section of the population. The author (2018) acknowledged that the role of skin (the body's largest organ) is one of a functional barrier, providing protection from the outside world, and damage to this barrier increases the risk of infection (Beeckman, 2016). All skin damage requires timely and appropriate diagnosis, management and intervention.
Moisture-associated skin damage (MASD) is an overarching term used to capture all skin damage occurring due to moisture. MASD significantly affects the skin, decreasing its ability to act as a functional barrier. It can present as persistent redness or broken skin. Additionally, it can both increase the risk of pressure ulcers and occur alongside pressure ulcers (Beeckman et al, 2009). Under the umbrella term of MASD, sit four sub-categories, further identifying the cause of moisture damage. Incontinence-associated dermatitis (IAD) is one of these four categories. IAD occurs due to excessive moisture (from urine and/or faeces) and poses the greatest risk to the sacrum, buttocks and groin areas (Beeckman, 2017). NHS England (2015) estimated that around 14 million adults suffer from incontinence.
Understanding MASD and IAD
Beeckman (2017) identified the following four conditions under MASD: IAD; intertriginous dermatitis (ITD; related to perspiration); periwound MASD (due to wound exudate); and peristomal MASD (occurring due to leakage from stoma edges).
IAD is defined as ‘reactive responses of the skin to chronic exposure to urine and faecal matter, which could be observed as an inflammation and erythema with or without erosion of the epidermis and dermis’ (Gray et al, 2007). This definition summarises how IAD occurs on the skin surface and can present as intact or broken skin. Previously, healthcare staff referred to IAD as ‘moisture lesions’; IAD now replaces this terminology. Campbell et al (2016) reached a consensus opinion that while urinary or faecal (liquid stool) incontinence does not always result in IAD, it significantly increases the risk of IAD. Further, as mentioned above, the risk of pressure ulcer development increases with the presence of IAD. Accurate diagnosis is not only essential for effective management and treatment regimes to be implemented, but also ensures accurate data reporting. Gray et al (2012) described how diagnosis is reliant upon both a focused history and a visual assessment. Bright red areas are present in patients with light skin tones, while darker skin tones present with a more red hue (Gray, 2014). Damage to the dermal and epidermal layers will occur in severe cases of IAD, with an absence of necrosis.
In 2018, NHS Improvement produced a comprehensive document entitled Pressure ulcers: revised definition and measurement (NHS Improvement, 2018); this included 30 recommendations designed for national implementation by 2019. Two of these recommendations refer directly to the reporting of MASD (IAD is, therefore, required to follow this guidance, as it falls within the overarching term). Points 25 and 26 of the document refer to MASD and require it to be counted and reported in addition to pressure ulcers (whether existing alone or in conjunction with pressure damage). The aim of this document is to focus on identifying and addressing the causative factors, while ensuring consistent reporting to allow the extent of damage to be fully understood (Lumbers, 2019).
How moisture affects the skin
Understanding the process of how the skin works provides greater insight into when it stops functioning. The external layer of the skin is the epidermis, with the stratum corneum, which adjusts to the environment and traps moisture to prevent it from drying out while additionally acting as a physical barrier to prevent the entry of microbes, foreign irritants and allergens (Flanagan, 2013). Voegeli (2016) described how the stratum corneum is often referred to as the ‘bricks and mortar’; the ‘bricks’ refer to the flattened keratinocytes, which hold and attract moisture, with the lipid-rich ‘mortar’ creating a protective layer that supports the epidermal permeability layer function.
Water loss is regulated within the epidermis through a process known as trans-epidermal water loss (TEWL). Preventing excessive fluid gain or loss ensures the effective working of the skin's barrier function (Voegeli, 2016). The skin struggles to cope with too much moisture, and the skin barrier becomes weakened by over-hydration, resulting in a high TEWL.
Effects of a high TEWL
The effects of a high TEWL can be summarised as follows:
Effects of the ageing process on skin
As the skin ages, the epidermis thins and loses some of its elasticity, cell turnover is reduced and the skin becomes more fragile (Cowdell, 2010). Young (2012) accepted that the damage due to alterations in pH levels and the effects of chemical irritants that come into contact with the skin through incontinence further damage the barrier function of the skin.
Beeckman et al (2015) identified the following risk factors associated with IAD: pre-existing skin conditions, cognitive impairment, poor dexterity, critical illness, pain, poor nutrition and raised body temperature.
IAD and pressure ulcers
The National Institute for Health and Care Excellence (2014) issued clinical guidance, which identified the same risk factors for both IAD and pressure ulcers, with both these conditions simultaneously occurring in patients experiencing problems such as poor health and mobility issues (Demarre et al, 2015). These risk factors may impact on one another, for example, poor mobility could result in an incontinent episode and a delay in cleaning, resulting in skin barrier function issues and an increased risk of pressure damage.
The difficulties in diagnosing superficial damage to the sacrum with a combination of possible causes were identified in 2014 by the National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. However, correctly identifying the cause of the damage, will ensure appropriate and timely response to treatment and implementation of a management regime. General guidance dictates that pressure damage will usually occur over a bony prominence, due to unrelieved pressure or friction (NPUAP, 2019). Generally, a pressure ulcer will display a regular or circular shape with distinct edges. IAD is usually widespread, due to the spread of moisture and presents a shiny appearance (Defloor et al, 2005).
Beeckman et al (2014) identified the probable association between pressure ulcers and IAD to be the associated risks of damage to over-hydrated skin. The anus is particularly susceptible to this coexisting damage. Faecal leakage causes skin damage (IAD), and this over-hydrated skin has a more alkaline pH, making it more susceptible to the risks of friction from incontinence aids. Thus, pressure damage occurs on the anus alongside IAD (Beeckman et al, 2013).
Management, treatment and prevention of IAD
Careful patient assessment will identify not only the source, or potential source of the damage, but will also clarify the severity, location, type of moisture and any other irritants. Young (2012) supported the ongoing need for regular skin assessments to be undertaken and recorded. Thorough assessments ensure that appropriate personalised care can be delivered.
Cleanse, protect, restore
The acronym ‘CPR’ (standing for cleanse, protect, restore) was developed by Beeckman et al (2015) to act as an aide memoire to support best practice in IAD management, reminding health professionals to cleanse, protect and restore the skin.
Cleanse
Whether the skin is intact or broken, care should be undertaken when cleansing it. The overall aim is to maintain (or achieve) a pH of 5.5, ensuring a slightly acidic mantle to discourage bacteria colonisation while removing any debris (Beeckman et al, 2014). Ideally, the episode of incontinence should be cleansed and carefully dried as soon after the event as possible (Beeckman, 2016). Early intervention can prevent fluid being absorbed into the skin. Careful drying should reduce friction to the skin, minimising the risk of pressure-associated damage occurring.
Protect and restore
The skin should be protected with a product designed to repel excess moisture that also offers protection from further damage. Voegeli (2016) acknowledged the beneficial use of various barrier products in creating a physical barrier between the moisture source and the skin. Skin barriers are available in various formats, from creams and films to sprays; the choice of product should be led by the location and severity of damage, in addition to the overall health needs of the patient. The components of barrier products usually serve a dual purpose: allowing the skin to be protected by repelling moisture and repairing damaged skin while moisturising intact skin (the latter is the function of the emollient within barrier products) (Penzer, 2013).
Both Stephen-Haynes and Stephens (2013) and Voegeli (2016) identified concerns over some barrier products adversely affecting the absorption ability of fluid into incontinence aids. Some products may block the pores on the incontinence pads, preventing the fluid being absorbed and locked away, resulting in a potential for the patient to suffer leakage and remain in a wet environment, which contributes to further damage. This aspect should be taken into consideration while selecting an appropriate product.
Address causative factors
First-line management for IAD should involve a review of the patient's toilet techniques. Needs should be addressed by first accessing non-invasive approaches. For male patients, the use of a sheath may be considered. Types of incontinence pad should be selected based upon patients' identified needs. While urinary or faecal catheters carry benefits of allowing the body to recover from an overload of moisture, they should be used with caution due to the associated risk of infection (Voegeli, 2017).
Educate staff, patients and carers
Bianchi (2012) stressed the importance of involving all people concerned with care, highlighting that healthcare staff, patients and carers should be educated on the various aspects of IAD prevention and care to support timely intervention and treatment. When patients, staff and carers take ownership of a problem, they not only address issues but are well placed to help prevent recurrence.
Conclusion
With many older adults at risk of painful skin damage through IAD, which also places them at increased risk of pressure ulcer development, it is essential that clinicians have a good understanding of treatment, prevention and management of IAD to ensure that this problem can be addressed in a timely and evidence-based manner.
Understanding how damage occurs through the over-hydrated epidermis to trigger a chemical or inflammatory response, allows appropriate and timely interventions to be implemented. This can prevent worsening of the IAD, infections and pressure ulcer development. Further, frequent skin assessment will support the implementation of evidence-based management in addition to support management of and preventing IAD in those with vulnerable skin.