You’re performing a routine skin examination on a patient. Or maybe you’re changing their incontinence brief. Either way – you see it. Patches of red or raw skin, right on the buttocks or the sacrum: prime territory for pressure injuries.
You categorize it as a superficial pressure injury, maybe Stage 1. You avoid as much pressure as possible at the site of the injury, with dressings when appropriate to soothe and heal the damaged skin.
If it is really a pressure injury, that’s a great approach.
Sometimes, however, the above scenario is NOT a pressure injury.
What is it?
Different Causes
IAD – incontinence associated dermatitis – is a trickster, reveals Prof. Dimitri Beeckman of Ghent University. It looks like a pressure injury; it occurs in the same places as a pressure injury; it shares risk factors with pressure injuries – and yet the cause is completely different.
Just look at your hands. As a caregiver who is constantly washing her hands, the skin on your hands is likely red, cracked, raw or otherwise damaged. If it’s not, you’re probably VERY careful with drying your hands and/or with applying moisturizer.
Moisturizer is good for your hands; moisture is not. Even when the moisture consists just of water, the skin can become macerated and break down. That’s all the more so when the moisture is not just water, but contains the acidity of urine and the bacteria and digestive enzymes of fecal matter. The skin of incontinent patients is constantly exposed to moisture from urine or fecal matter, irritating and eroding the surface of their skin.
In order to understand incontinence associated dermatitis even better, caretakers should draw on their personal experience as parents (or other close relatives of a baby). Young children are at risk for developing diaper rash because the skin of their buttocks and genital area is constantly in contact with moisture from urine and stool.
Geriatric patients with the same level of exposure - but fragile skin and a low skin cell replacement rate – are obviously at a much higher level of risk.
Treating IAD Effectively
The key to treating – and preventing – incontinence associated dermatitis has nothing to do with pressure, and everything to do with dryness and dressings.
Dryness
It may seem like stating the obvious, but: if the cause of IAD is exposure to urine and fecal matter, you want to significantly minimize the patient’s exposure to urine and fecal matter.
It’s not easy.
If your sum total responsibilities would be managing one communicative patient and keeping him dry, it would be easy. But that’s never the case. As a caregiver, you’re usually responsible for several patients and many other tasks as well. Many patients aren’t aware enough or communicative enough to tell you when they’ve relieved themselves.
For high-risk patients, however, the benefits of creating and implementing a process to check and maximize dryness can be enormous. Even a few minutes in a brief with liquid stool can cause a minor case of redness to turn into raw, broken and bleeding skin.
When you cleanse the area, never use traditional soaps which will irritate the skin, create change in the lipid structure of the skin and increase the pH of the skin. Instead, utilize pH-neutral no-rinse skin cleansers. Or just avoid soap completely and use baby oil instead. Baby oil has an added advantage because it will add extra fatty acids to the skin to keep it smooth and resilient.
Be careful that the surface you use to clean the patient in that area (i.e. a washcloth) is not abrasive at all. Rubbing an already sensitive surface can scrape off layers of skin and cause or exacerbate an IAD condition.
After cleansing, and before moving on to the dressings, make sure the skin is patted dry first. It’s a simple step but often overlooked, and the benefit to patient care is significant.
Dressings
Caretakers should moisturize the skin and put a protective layer between the skin and the brief. Sometimes moisturizing elements are contained in the cleanser or protective layer. If not, apply a separate moisturizer.
There are different categories of protection:
| Vaseline | Zinc Oxide-based ointment | Dimeticome | Acrylateterpolymer based products | |
| Ability to observe skin underneath? | Yes | No – white, opaque | Yes | Yes |
| Interacts with the absorbent surface? | Yes | Yes | No | No |
| Cons | Greasy and decreases brief absorbency | Can’t see skin underneath | Don’t know what percentage in formula to optimally protect | No moisturization |
Dozens of studies were conducted to determine which protective layer is the most effective, but it remains to be seen.
Your patients with incontinence are at risk for incontinence associated dermatitis – even if they’re mobile, get proper nutrition, and share few of the other risk factors for pressure injuries. IAD can be prevented or minimized, however – with your awareness and effort.