Incontinence, a condition common among older people, has a significant impact on wellbeing and quality of life. Although the prevalence of incontinence varies by the study population, the estimates for faecal incontinence range from 0.8% to 15% (Lazarescu et al, 2009) while those for urinary incontinence may be as high as 45% in populations of older adults in protected care (Du Moulin, 2008). A prevalent complication of both faecal and urinary incontinence is the associated breakdown of perineal skin (Gray, 2010) and ensuing dermatitis (Beeckman et al, 2016).
Incontinence-associated dermatitis (IAD) arises from chemical and physical irritation of the skin due to persistent exposure to moisture (Beeckman et al, 2010). Subsequent inflammation exacerbates injury to the skin. As nurses are regularly involved in care for people with incontinence, an important goal of nursing care is to prevent and manage IAD in many settings, from aged care to critical care (Van den Bussche et al, 2017). When IAD does occur, the symptoms include skin erythema, bullae, other lesions and infection (Beeckman et al, 2018). At present, innumerable products are available for both the prevention and treatment of IAD. These include cleaning agents and leave-on products, which may be used on their own or in combination (Beeckman et al, 2016).
Objective
The clinical question addressed in the review summarised here pertains to adults with incontinence in hospitals and nursing homes. The objective of Beeckman et al's review (2016) was to determine whether the application of topical skin care products and/or procedures is effective in preventing or treating IAD.
Intervention/methods
The evidence search and analysis identified 13 quasi-randomised control trials for inclusion in the review, comprising 1316 participants in hospital or aged-care settings, and these 13 studies were included in a qualitative analysis of the data. The primary analysis compared the efficacy of a topical skin care product with that of another skin care product in easing existing or residual symptoms of IAD or to prevent IAD (or its recurrence).
The topical products included in the review were divided into skin cleansers and leave-on products (e.g. moisturising products, protectants and barriers). Interventions included skin products to be left on (e.g., moisturisers, skin protectants and other skin products that were combined into a single product) and cleansing products (e.g., soap and water). Also included were skin care procedures, including methods and processes for the application of topical skin care products. Because of the variation in the topical products (n=15), methods of application (n=3) and frequency of application, the data from the studies were divided and reported separately. Overall, data regarding the primary outcome of IAD prevention were of low quality. This was because multiple products were reported in the included studies and different procedures were analysed, which precluded the pooling of data.
Results
Of the 13 studies included, only two studies provided clear evidence of skin regimens for people with IAD, and this evidence was of low to moderate quality and could not be combined because of heterogeneity. The evidence in one of these two studies indicated that skin cleansers are likely to be more effective than soap and water in preventing IAD (risk ratio (RR), 0.39; 95% confidence interval (CI), 0.17–0.87; low-quality evidence). Additionally, the second trial suggested that a structured program of intervention (including washing, cleansing, moisturising and protection) is more effective than soap and water in preventing IAD (RR, 0.31; 95% CI, 0.12–0.79; moderate-quality evidence). In the remaining trials, (n=11), the heterogeneity of the data prevented a pooled analysis.
Conclusions
The evidence ranges from low to moderate quality when examining interventions for treating or preventing IAD in adults with urinary and/or faecal incontinence. The inability to pool data for analysis prevented the authors of the summarised review from making substantive assertions about best practice. The review (Beeckman et al, 2016) did however state that soap and water did not perform adequately as an intervention for IAD and proposed cleansers, moisturisers, barriers and protectants as being more effective. It also found that a leave-on product such as a combination of moisturiser and protectant has a more desirable effect for IAD skin care than soap and water does. Despite the lack of quality evidence, it is safe to report that several products are available for clinicians to consider for preventing and treating IAD.
Implications for practice
From the review summarised here, it appears that research concerning treatments and prevention for IAD is not well developed. Beeckman et al (2016) remarked that there has been limited success regarding prevention and treatment of IAD even though it is a common clinical issue. Product-related research requires more development to reveal the range and type of products available, preferably with sponsorship plainly declared by industry. Additionally, further research around IAD management and its cost effectiveness is required to assist clinicians in making the best decisions concerning patient care.
Recommendations for the nursing care of skin to prevent and treat IAD include: