Managing incontinence-associated dermatitis in the community: an overview

A significant portion of the community nurse's caseload will be occupied by moisture-associated skin damage (MASD), which is defined as inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture (Gray et al, 2011). The majority of the literature on the community nurse's role in the treatment and management of MASD is focused on the damage caused by wound exudate, but one of the clinical manifestations of MASD that receives less attention in research, but will often be encountered in practice, is incontinence-associated dermatitis (IAD). IAD is a common, under-recognised and painful skin condition caused by erosion of the skin from chronic exposure to urine, stool or both (Babino and Argenziano, 2023). Depending on the type of setting and population studied, prevalence of IAD ranges between 5.2–46.0% (Babino and Argenziano, 2023). However, it is estimated that 14 million people in the UK experience some degree of urinary incontinence, while over half a million adults experience regular faecal incontinence that impacts their quality of life (Lewis and Powell, 2023). Relatedly, one study has reported the prevalence of IAD among patients with incontinence to be 45.7% (1140/2492) (Gray and Giuliano, 2018), and another demonstrated that IAD occurred in 52.5% of a cohort of 189 community-living individuals with faecal incontinence (Rohwer et al, 2013). This would suggest that IAD presents an urgent challenge for community nurses.

This is especially the case when considering both the physiological and psychosocial impact of IAD. Patients with IAD experience considerable discomfort, with pain, burning and itching in the affected areas (buttocks, perineum and gluteal clefts), and can result in loss of independence, depression, sleep disruption and worsening of urinary and faecal soiling (Babino and Argenziano, 2023). IAD can also increase a person's risk of developing higher-stage pressure injuries: multivariate analyses of a population of 2492 incontinent individuals revealed that the presence of IAD and immobility was associated with a significantly increased likelihood of the development of both sacral pressure injuries (IAD: odds ratio [OR]: 4.56; 95% confidence interval [CI]: 3.68–5.65) and immobility (OR: 3.56; 95% CI: 2.73–4.63)) and full-thickness sacral pressure injuries (IAD: OR: 2.65; 95% CI: 1.74–4.03) and immobility (OR: 6.05; 95% CI: 3.14–11.64)) (Gray and Giuliano, 2018). These are severe and potentially life-threatening conditions; however, as Kayser et al (2021) have noted, incontinence and IAD continue to be treated as hygienic challenges, rather than serious comorbidities. More appropriate education on the management strategies specific to IAD is required, in order for personalised and effective care that reflects the critical nature of this condition to be provided.

Presentation

Typically, IAD presents as a form of irritant dermatitis, with inflammation of the skin surface characterised by erythema and, in extreme cases, swelling and blister formation (Babino and Argenziano, 2023). Erythema is considered a key clinical sign of IAD; bright red areas are present in patients with lighter skin tones, while darker skin tones present with a darker red hue (Lumbers, 2019). If lesions develop, they mostly occur in areas of the skin that are exposed to urine or faeces, such as the labia in women and the scrotum in men, as well as the inner thighs and buttocks in both sexes (Babino and Argenziano, 2023). IAD is often accompanied by discomfort, burning, tingling, itching and pain in the affected areas (Babino and Argenziano, 2023).

Prevention and management strategies

As moisture is the main cause of IAD, reducing exposure to excessive moisture will be pivotal in the management and prevention of IAD (Holroyd and Graham, 2014). The acronym ‘CPR’ (cleanse, protect, restore), developed by Beeckman et al (2014), supports best practice in IAD management and outlines the steps a community nurse should take to provide care for incontinent patients. When combined with a pressure ulcer prevention protocol, a structured care plan significantly lowers the incidence of IAD from around 25% to less than 5% (Holroyd and Graham, 2014).

Cleanse

The overall aim of this step is to maintain (or achieve) a pH of 5.5, ensuring a slightly acidic mantle to discourage bacteria colonisation while removing any debris, and minimising or eliminating moisture to prevent skin breakdown (Lumbers, 2019). The skin should be carefully cleansed and dried; a cleanser with a pH close to that of the skin and containing a moisturising agent, humectant or emollient to maintain skin integrity should then be applied (Holroyd and Graham, 2014).

Protect and restore

The skin should be protected with a product designed to repel excess moisture that also offers protection from further damage. Barrier products are an essential part of a protective skin care regime, ranging from creams to sprays; however, as with all interventions, patient assessment is key to ensure appropriateness of care (Holroyd and Graham, 2014). Many of the most commonly used barrier products contain certain key ingredients; the evidence does suggest that there is variability in the efficacy and ability of commercial products to protect the skin, prevent maceration and maintain adequate skin health (Holroyd and Graham, 2014), so the efficacy of a particular ingredient or solution for an individual patient will need to be carefully assessed (Table 1). Additionally, incorporating faecal collection devices or protective hydrocolloid dressings, in combination with or as alternatives to adult containment briefs, has proven effective in reducing the prevalence of IAD by minimising exposure to moisture, irritants and friction (Maskan Bermudez et al, 2023).

Conclusions

Community nurses, with their wide-ranging scope of practice and access to patients' daily lives, are well-placed to support individuals with a condition as intimate and personal as IAD. When the appropriate education, time and products are provided, effective treatment and management of IAD is achievable by the community nurse, helping patients attain a better quality of life.