Continence Coach: Intertrigo in the Obese Patient: Finding the Silver Lining

  The soaring prevalence of obesity in the past decade has forced healthcare providers to pay increasing attention to the unique needs of the obese patient.

Not the least of these needs is skin care and the risk of moisture-associated skin damage, most often diagnosed as intertriginous dermatitis (intertrigo). Obese patients are particularly vulnerable because the natural cooling mechanisms of their bodies are compromised, making perspiration a virtual constant. In addition, their body mass can limit mobility. As moisture accumulates and remains trapped within skin folds, bacterial, fungal, and viral growth inevitably leads to intertrigo and even skin breakdown.¹

  Intertrigo is first manifested by itching, burning, pain, odor, and erythema. If left undiagnosed or not addressed properly, the condition can progress to intense inflammation, erosion, and crusting. As skin becomes macerated with hyperhydration, skin-against-skin friction increases and weakens epidermal tissue, allowing invasion by external organisms. The ultimate insult of skin breakdown and secondary infection is similar to what occurs in the patient experiencing incontinence-associated dermatitis. Bariatric patients experiencing weight loss-redundant skin also are at risk.

  Nurses and aides must routinely inspect the skin inside skin folds. Particular attention should be paid to the axilla, pannus, area just below the breast, groin, gluteal folds and upper thighs, and back of the knee. Of course, the incontinent, obese patient is even more likely to encounter such skin problems, given the likelihood of both urine and perspiration becoming trapped in skin folds. Whether these patients are in acute care, rehab, extended-care facilities, or in home care or hospice, the nursing team responsible for hands-on care must inspect the skin down to the base of folds. Comprehensive nursing protocols for the bariatric patient should encompass bathing, toileting, skin fold management, odor, and genital care.²

  Over the years, many nurses assumed intertrigo inflammation is fungal in nature and best treated with antifungal or, in some cases, talcum powder. Increasingly, case studies are documenting a diverse number of organisms (eg, Escherichia coli, coagulase-negative Staphylococcus, Enterococcus faecalis, Proteus mirabilis, and Candida albicans) in skin folds. In a recent, hospital-based study,³ barely one in 10 infections (9.5%) was identified as a (frequently suspected) yeast-like fungus. Unfortunately, the costs of cultures can discourage clinicians to take the steps necessary to properly identify the organism at work. However, untimely and inappropriate treatment can lead to even greater expense, wasteful interventions, and more serious complications.

  One of the most promising medical products to appear on the scene to help alleviate the growing problem of moisture-associated skin damage aggravated by the prevalence of obesity is InterDry® Ag Textile (Coloplast, Minneapolis, MN), a 100% knitted polyester textile impregnated with an antimicrobial silver complex. Multifaceted in functionality, its specialty fabric wicks away and relocates excess moisture and its polyurethane coating helps keep the skin dry. The soft, knitted texture reduces skin-to-skin friction in folds. The ionic silver embedded in the fabric provides broad-spectrum antimicrobial action for up to 5 days,⁴ combating fungal and bacterial infections. The fabric is placed within the skin folds, simplifying care by eliminating the need for messy creams or powders. One sheet of fabric can be used for up to 5 days and typically does not require further replacement. Cost savings can be significant (more than 20-fold).

  This product, available in two sizes, is designed for managing the symptoms associated with intertrigo; it is not a wound dressing. It should not be placed directly onto an open wound or used on patients with a known sensitivity to silver, nor is it to be used as a barrier to urine and feces. If such soiling occurs, the textile should be changed immediately. Users should read the product packaging for warnings, cautions, and instructions for use. The product requires a prescription and should be used as directed by a licensed practitioner.

  Regardless of your practice setting, you are likely to encounter patients with skin fold complications. Acquaint yourself with this innovative, new product and discover where it is most successful for your patient population. And keep on the lookout for other such promising innovations!

 This article was not subject to the Ostomy Wound Management peer-review process.

1. Yosipovitch G, DeVore A, Dawn A. Obesity and the skin: skin physiology and skin manifestations of obesity. J Am Acad Dermatol. 2007;56(6):901–916.

2. Blackett A, Gallagher S, Dugan S, Gates JL, Henn T, Kennedy-Evans KL, Lutze JH. Caring for persons with bariatric health care issues: a primer for the WOC nurse. J WOCN. 2011;38(2):133–138.

3. Black J, Edwards K, Cuddigan J, Jizba T, Falcone L. Organisms cultured from sites of intertriginous dermatitis in hospitalized patients: a pilot study. J WOCN. 2011:In press.

4. Henn T, Kennedy-Evans KL, Smith D, Viggiano B. Unpublished case studies presented at the Clinical Symposium on Advances in Skin and Wound Care, April 2007, and the WOCN Society 39th Annual Conference, June 2007.