What is Incontinence Associated Dermatitis(IAD)? How to Manage it

Incontinence Associated Dermatitis (IAD) is a skin condition characterized by inflammation, redness, and damage to the skin due to prolonged exposure to urine or faeces.

Causes of Incontinence Associated Dermatitis

This condition is directly related to incontinence. The skin, when exposed to urine or feces regularly, can become inflamed. The condition is worse for those with fecal incontinence, as stool can irritate the skin more than urine.

In many cases, IAD is caused by:

• an increase in the skin’s pH level
• the creation of ammonia by urinary and fecal incontinence
• skin erosion from bacteria breaking down protein in keratin-producing cells

Attempts to clean the area may result in IAD due to:

• overhydrating the skin
• friction caused by absorbent pads or other materials, including underwear and bed linens
• frequent cleaning of the affected area with soap and water

Ineffective or poor condition management can also lead to IAD. This includes:

• prolonged exposure to urine and feces
• inadequate cleaning of the exposed area
• the application of thick ointments
• the use of abrasive washcloths

Risk Factors:

1. Urinary or fecal incontinence
2. Immobility or limited mobility
3. Diabetes
4. Obesity
5. Skin fragility (e.g., elderly)
6. Neurological disorders (e.g., spinal cord injury)

Symptoms:

1. Redness and inflammation
2. Skin erosion or denudation
3. Ulceration or open sores
4. Pain or discomfort
5. Odor

Stages:

• Stage 1: Intact skin with a localized area of non-blanchable erythema.
• Stage 2: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red and moist. May appear as an intact or ruptured serum-filled blister.
• Stage 3: Full-thickness loss of skin. Fat is visible in the ulcer. Granulation tissue and rolled edges are often present. Slough and or eschar as well as undermining and tunneling may be present.
• Stage 4: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar (rolled edges), undermining and/or tunneling often occur.
• Unstageable: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.
• Suspected Deep Tissue Injury: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister⁵

Differential Diagnosis:

1. Pressure injuries
2. Skin tears
3. Intertriginous dermatitis
4. Folliculitis
5. Allergic contact dermatitis

How to Identify IAD

Healthy skin works as a barrier between the environments outside and inside your body. IAD can erode this barrier, causing severe and uncomfortable symptoms.

Symptoms of IAD include:

• redness, ranging from light pink to dark red, depending on skin tone
• patches of inflammation or a large, continuous area of inflammation
• warm and firm skin
• lesions
• pain or tenderness
• burning
• itching

IAD can affect skin on many parts of your body, including the:

• perineum
• labial folds (in women)
• groin (in men)
• buttocks
• gluteal cleft
• upper thighs
• lower abdomen

The severity of your symptoms depends on several factors, including:

• the condition of your skin tissue
• overall health and nutrition
• allergen exposure

If you have a form of incontinence that makes you more prone to leakage or accidents, you may also experience more severe IAD. This is because your skin is more frequently exposed to urine and stool.

Prevention and Management of IAD:

1. Skin cleansing and drying
2. Barrier creams and protectants
3. Incontinence products (e.g., diapers, pads)
4. Regular skin assessments
5. Pressure redistribution and mobility
6. Wound care and dressing changes (if necessary)

Implement a structured skin care regimen, key interventions:

• Cleansing the skin to remove urine and/or faeces, i.e. the
  source of irritants that cause IAD. This should be done
  prior to the application of a skin protectant as part of a
  routine process to remove urine and faeces
• Protecting the skin to avoid or minimise exposure to urine
  and/or faeces and friction.

Prevention Strategies for Incontinence-Associated Dermatitis (IAD):

1.Skin Care:

1. Cleanse skin promptly after incontinence episodes
2. Use gentle, pH-balanced cleansers
3. Avoid harsh soaps and abrasive products
4. Pat dry, don’t rub
5. Apply moisturizers and emollients

2.Barrier Protection:

1. Apply barrier creams or ointments (e.g., zinc oxide, dimethicone)
2. Use protective films or coatings (e.g., liquid film protectants)
3. Apply transparent dressings or hydrocolloid dressings

3.Incontinence Management:

1. Use absorbent incontinence products (e.g., diapers, pads)
2. Change products frequently
3. Consider catheterization or intermittent catheterization
4. Manage constipation and diarrhoea

4.Pressure Redistribution:

1. Reposition patients regularly
2. Use pressure-redistributing mattresses and cushions
3. Avoid prolonged sitting or lying

5.Education and Awareness:

1. Educate patients and caregivers on IAD prevention
2. Provide written instructions and visual aids
3. Encourage self-care and reporting of skin changes

6.Healthcare Setting Strategies:

1. Develop IAD prevention policies and protocols
2. Conduct regular skin assessments
3. Provide staff education and training
4. Monitor and report IAD incidence

7.Products for IAD Prevention:

1. Barrier creams (e.g., zinc oxide, dimethicone)
2. Protective films (e.g., liquid film protectants)
3. Moisturizers and emollients
4. Incontinence products (e.g., diapers, pads)
5. Pressure-redistributing mattresses and cushions

Treatment Options for Incontinence-Associated Dermatitis (IAD):

1.Topical Treatments:

1. Barrier creams (e.g., zinc oxide, petrolatum)
2. Moisturizers (e.g., hydrocortisone, urea)
3. Protectants (e.g., dimethicone, silicone)
4. Antimicrobial creams (e.g., antibiotic, antifungal)
5. Steroid creams (e.g., hydrocortisone, triamcinolone)

2.Wound Care:

1. Cleansing agents (e.g., saline, antibacterial)
2. Debridement (e.g., surgical, enzymatic)
3. Dressings (e.g., hydrocolloid, foam)
4. Pressure redistribution devices (e.g., mattresses, cushions)

3.Incontinence Management:

1. Absorbent products (e.g., diapers, pads)
2. Incontinence-associated dermatitis (IAD) cleansers
3. Skin-friendly incontinence products (e.g., breathable, moisture-wicking)

Pharmacological Interventions:

1. Antibiotics (e.g., oral, topical)
2. Antifungals (e.g., oral, topical)
3. Anti-inflammatory medications (e.g., oral, topical)
4. Pain management medications (e.g., analgesics, anaesthetics)

4.Other Interventions:

1. Skin assessments and monitoring
2. Nutrition and hydration support
3. Pressure redistribution and mobility
4. Bowel and bladder management
5. Psychological support and counselling

Best Practices:

1. Individualize treatment plans
2. Use multidisciplinary approach
3. Focus on prevention and early intervention
4. Monitor and adjust treatment as needed
5. Educate patients and caregivers

REFERENCES

1. Beeckman, D., Defloor, T., Verhaeghe, S.,Vanderwee, K., Demarre, L., & Schoonhoven, L. (2010, September 27). What is the most effective method of preventing and treating incontinence associated dermatitis? Nursing Times, 106(38).Retrieved from
   https://www.nursingtimes.net/clinical-archive/continence/what-is-the-most-effective-method-of-preventing-and-treating-incontinence-associated-dermatitis/5019714.article
2. Gray, M. (2014, Spring). Incontinence associated dermatitis in the elderly patient: Assessment, prevention, and management. Journal of Aging Life Care. Retrieved from http://www.aginglifecarejournal.org/incontinence-associated-dermatitis-in-the-elderly-patient-assessment-prevention-and-management/
3. Incontinence-associated dermatitis (IAD). https://members.nursingquality.org/ndnqipressureulcertraining/Module2/PerinealDermatitis1.aspx
4. Incontinence-associated dermatitis: Moving prevention forward. (2015) http://www.woundsinternational.com/media/other resources/_/1154/files/iad_web.pdf
5. Montague, M. (2013, April 12). Management of incontinence associated dermatitis https://my.clevelandclinic.org/ccf/media/Files/Digestive_Disease/woc-spring-symposium-2013/management-IAD.pdf?la=en
6. Wound, Ostomy and Continence Nurses (WOCN) Society
7. McNichol LL, Ayello EA, Phearman LA, et al (2018). Incontinence-Associated Dermatitis: State of the Science and Knowledge Translation. Adv Skin Wound Care. doi: 10.1097/01.ASW.0000546234.12260.611.

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