Rare Operative Intervention for Urinary and Fecal Incontinence-Associated Dermatitis

Moisture-associated skin damage (MASD) can involve partial-thickness (PT) skin erosion and loss after extended exposure to urine, feces, perspiration, mucus, or saliva.¹ Urinary and fecal incontinence produces incontinence-associated dermatitis (IAD) due to an inflammatory response that injures the stratum corneum layer of the integument, favoring fungal and bacterial colonization as well as infection.^2-4 Urinary ammonia (produced by urease from urea) induces an alkalization of the skin layers, which are usually more acidic, thereby weakening the stratum corneum.⁵ Gastrointestinal lipolytic enzymes and proteases further damage the skin, including the deep layers of stratum lucidum and stratum granulosum.⁶ Pressure ulcers and injuries are usually the main differential diagnosis. If there is a persistence of skin redness without infection, other possible diagnoses include psoriasis inversa, seborrheic dermatitis, allergic contact dermatitis, acrodermatitis enteropathica, and autoimmune bullous skin diseases.⁷ In addition to age and comorbidities, risk factors for urinary and fecal or dual incontinence include the perineal environment, toileting ability, tissue tolerance, skin pH, absorbent products, lack of structured skin care, friction/shear, bacterial colonization, low albumin, poor nutrition, impaired cognition, and compromised mobility.^3,8 The present 2 cases illustrate the rare association of IAD presenting as a chemical burn, which may require debridement and skin grafting. This approach, albeit rare, does not differ significantly from typical partial-thickness and full-thickness burn treatment. 

Case 1

After being shuffled between several local emergency departments, a 65-year-old male was transferred to the authors’ emergency room. Bedridden without a caregiver for 1 week, he was found lying in urine and feces. The patient had 14 % total body surface area (TBSA) superficial to deep PT burn-like injuries from an unknown mechanism to the back, bilateral buttocks, posterolateral lower extremities, and perineum (Figure 1). There was no antecedent history involving scald or thermal burn injuries. Past medical history revealed alcohol misuse with alcoholic cirrhosis, chronic arthritis, type II diabetes with retinopathy, hypertension, cardiomyopathy, and depression. The patient underwent operative debridement using curettage to remove any burn-like eschar, and the wounds were dressed with a silver-impregnated foam dressing (Mepilex Ag; Mölnlycke Health Care). On postoperative day 1, treatment transitioned to MediHoney Gel (Integra LifeSciences).

The patient received tube feedings and intravenous fluid of half normal saline for the oliguria. Hyperglycemia was treated with subcutaneous insulin. To avoid urine and fecal contamination of the wounds, a Foley catheter and fecal management system were placed. On hospital day 12, the patient was discharged to a skilled nursing facility.

Case 2

An 85-year-old female presented with a 4% TBSA chemical burn to the left torso, flank, and thigh (Figure 2). After falling at home, the patient was unable to move, so she had laid in her urine and feces for an unknown length of time; the patient was found after neighbors requested a welfare check. A syncopal workup was negative; the patient had a urinary tract infection on admission. Comorbidities included Alzheimer’s disease and depression. After a 12-day hospitalization following debridement with curettage and silver-impregnated foam dressings, the patient was discharged to a psychiatric facility for treatment of the Alzheimer’s disease and depression. 

The patient was readmitted to the authors’ hospital 11 days later for operative management due to full-thickness conversion of the wounds, which required surgical excision. Urinary urgency and incontinence were present, necessitating vigorous toilet training. The patient underwent tangential excisional debridement and fascial excision with porcine xenograft placement (EZ Derm; Mölnlycke Health Care); 3 days later, the patient received a split-thickness skin graft. To promote the healing process, negative pressure wound therapy (V.A.C. Dressing System; 3M) was utilized. After this 17-day hospitalization, the patient was discharged in stable condition to a long-term care facility. 

Both patients required operative intervention and diligent wound care for management of IAD. Although infrequent for IAD, depending on the type of skin destruction, skin grafts may be necessary to reconstruct the cutaneous tissue in severe cases. Incontinence-associated dermatitis resembling chemical burn-like injuries are rarely reported. There is a report of a feces-induced chemical burn in an 84-year-old female with dementia who drank kerosene, thinking it was water.⁹ The buttocks healed with topical corticosteroid treatment.

Since the patients were alone at the time of injury, they were not aware of the time sequence for these chemical burns or a more complete exposure history. 

Prolonged urine and fecal exposure may result in partial-thickness or full-thickness chemical burns to the affected body areas. Key factors in successful IAD prevention and management are careful patient assessment, good continence care, and clear evidence-based skincare protocols, all of which can improve the patient experience and clinical outcomes.

Authors: Samantha Delapena, MD¹; Philomene Spadafore, RN, MHA¹; Stephanie E. Bollenbach, MD¹; Areta Kowal-Vern, MD^2,3; Kevin N. Foster, MD, MBA, FACS²; and Marc R. Matthews, MD, FASC²

Affiliations: ¹Department of Surgery, Valleywise Health Medical Center, Phoenix, AZ; ²Arizona Burn Center, Phoenix, AZ; ³Department of Research, Valleywise Medical Center, Phoenix, AZ

Correspondence: Marc R. Matthews, MD, FACS, Arizona Burn Center, 2601 E. Roosevelt Street, Phoenix, AZ 85008; azmrmltc@gmail.com 

Disclosure: The authors disclose no financial or other conflicts of interest.