Incontinence-associated Dermatitis: Changing Practice, Improving Care

Incontinence-associated dermatitis (IAD) is increasingly recognized as a problematic and preventable form of skin injury. Exposure to stool and/or urine is the primary causative factor creating top-down injury through inflammation, often in combination with friction.

The type of incontinence is an important factor in determining risk for development of IAD; exposure to liquid stool or mixed urine and feces is considered to put individuals at the highest risk for skin injury and is more likely to result in severe skin damage.¹

Acute fecal incontinence with diarrhea² is a significant problem in health care settings and especially in critical care, occurring in approximately 12.9% to 38% of patients.³ With efforts to eliminate catheter-associated urinary tract infections, use of indwelling urinary catheters has decreased, but mixed urinary and fecal incontinence has become more common.  

Why should we think differently about IAD? IAD is associated with significant negative clinical outcomes, including pain, discomfort, depression, and poor quality of life.^1,4,5 Patients with IAD also are at risk for secondary fungal infections.⁶ Additionally, IAD has been identified as an independent risk factor for pressure injury/ulcer development⁷ — the risk of pressure injury is associated with an increase in IAD severity score.⁸ 

IAD also can present challenges for bedside clinicians. Many nurses have difficulty identifying IAD and distinguishing IAD from pressure injury. In 2015, an international expert working group advanced the IAD Severity Categorization Tool¹ in an effort to simplify IAD assessment and help clinicians better identify and document skin damage. In this tool, moderate to severe damage, identified as Category 2, is characterized by erythema with skin breakdown that can include denudation. 

Why should we think differently about IAD management? In the acute care setting, there is a 43% incidence of moderate to severe IAD (Category 2); it is present in 35% of patients.⁹ Bliss¹⁰ reported 81% of patients had IAD at discharge from the ICU. These data suggest that common, traditional approaches to IAD prevention and management are less than effective.

In contrast to the nearly continuous innovation seen in wound care over the past 30 years, products for management of Category 2 IAD have relied on semi-solid moisture barrier products formulated with traditional ingredients such as zinc oxide and petrolatum. A 2016 Cochrane review¹¹ concluded: “Little evidence, of very low to moderate quality, exists on the interventions for preventing and treating IAD in adults.” Application of products “seems to be more effective” than no products, and “performance of products depends on formulation and usage.”

When the epidermis is severely damaged or absent with the dermal layer exposed (denudement), essentially 2 approaches are available for treatment.  In the first, an ostomy powder is applied to the wet tissue to create a dry surface. An alcohol-free barrier film then is sprayed or blotted onto the powder. This crusting process is repeated 2 to 3 times to build layers of protection. Although this process can be effective, it is time-consuming and can be difficult for bedside staff to replicate.

A more common approach to protect denuded skin involves application of a moisture barrier paste. Pastes evolved from the early practice of wound ostomy continence (WOC) nurses (or pharmacists) compounding a barrier in an effort to manage severely damaged skin. Powder was added to zinc oxide ointment until the mixture was essentially a semi-solid, with the intent to attach it to the wet, damaged surface and provide absorption of serous fluid while protecting the surface from liquid stool. Commercially available products now typically contain 15% to 30% zinc oxide (and sometimes petrolatum), thickened with carboxymethylcellulose, corn starch, or gums. Although readily available and relatively easy to apply, pastes can have significant limitations for both patients and clinician because they impact:

1. Protective ability. Formulations vary and pastes do not always create a continuous protective coating that can repel caustic, corrosive irritants (such as enzyme-rich liquid stool) over time. In part, this is because they are not able to attach effectively to the underlying wet, damaged surface and remain in place. This necessitates frequent reapplication.

2. Patient comfort. Absorbent ingredients in many pastes impart a gritty texture that can make the product painful to apply and wear. Pastes also tend to dehydrate once in place, leading to cracking, clumping, and caking. To avoid patient pain and discomfort associated with removal, some clinicians advocate removing only the soil on the surface of the paste. The success of this approach relies on fecal material aligning neatly on the surface of the paste. In practice, it is more likely that stool will embed into the barrier, necessitating thorough cleansing. 

3. Friction and shear. The stickiness causes many semi-solid barriers to adhere skin to contact surfaces such as briefs and linens. This will increase frictional force and could increase the risk for damage from shearing over the sacrococcygeal area and buttocks. 

4. Breathability. Pastes are usually occlusive. This prevents normal evaporative moisture loss from the skin and can create or exacerbate moisture-associated skin damage. 

5. Skin assessment. Because semi-solid moisture barriers are opaque, nurses are unable to visualize skin through the barrier. This necessitates complete cleansing in order to assess the skin.

6. Nursing time. Cleansing and removal of pastes can be difficult and time-consuming for staff. Available data have shown incontinence cleansing with barrier removal can take 13–20 minutes per episode.^2,12  

7. Infection control. During clean-up of large-volume diarrheal episodes, the multi-use tube may become contaminated and pathogens may be inadvertently spread within the environment. This is of special concern when diarrhea is due to infections such as Clostridium difficile or norovirus. 

What is the alternative to pastes or crusting? Clinicians articulated the need for a better approach to severe IAD. The  extensive experience of 3M (St. Paul, MN) in coatings and medical polymers led to the development of an innovative barrier technology. 3M™ Cavilon™ Advanced Skin Protectant is designed to provide skin protection under the most challenging conditions of irritant exposure. The polymer-based barrier creates a highly protective coating on the skin, with exceptional durability that allows the barrier film to elongate and stretch during wear; this elastomeric property ensures integrity even when exposed to caustic, corrosive irritants such as liquid stool and gastric fluid. Durability also allows for extended wear, with only 2 to 3 applications needed.

In addition, a barrier must be able to attach to the underlying skin surface to effectively protect skin. The vast majority of moisture barrier pastes and ointments cannot reliably attach to an underlying surface that is wet; they are mobile and transfer off the affected area between applications. To enable adhesion to wet or weepy, damaged skin surfaces, a form of cyanoacrylate was blended into the polymer.

The polymer and cyanoacrylate are dissolved in a non-stinging solvent that enables comfortable delivery of the liquid barrier system. The solvent evaporates off, leaving an ultra-thin, breathable protective coating. This novel formulation creates an environment that supports healing and has been shown to reduce pain associated with IAD and IAD care.¹³ Beyond IAD, it can be used to protect skin around stomas, fistulas, and tubes where moderate to severe skin damage is present or risk of breakdown is significant. 

Cavilon^™ Advanced Skin Protectant gives clinicians the power to stop, end, and reverse IAD. The innovative technology has the potential to change practice, not only by helping improve clinical outcomes for the severe injury of Category 2 IAD, but also by making incontinence skin care easier for clinicians.

Practical Perspectives is made possible through the support of 3M, St. Paul, MN. The opinions and statements of the clinicians providing Practical Perspectives are specific to the respective authors and are not necessarily those of 3M, Ostomy Wound Management, or HMP Communications. This article was not subject to the Ostomy Wound Management peer-review process.