Incontinence-associated dermatitis (IAD) is a vastly underestimated and under-researched problem that affects millions of people. Globally, urinary incontinence is estimated to affect 423 million people (Irwin et al, 2011), 3–6 million of whom reside in the UK (Irwin et al, 2006). Skin irritation and breakdown are common sequelae, where IAD resulting from urine leakage inflicts a further significant toll in terms of human suffering and economic burden.
So why doesn't IAD attract the same resources as pressure area care? The research, assessment tools and education are all at our disposal, and now is the time to galvanise our efforts for better skin care for those affected.
What is IAD?
IAD has been described by Gray et al (2011) as ‘… irritant dermatitis that develops from chronic exposure to urine … attributable to multiple factors, including chemical irritants within the moisture source, its pH, mechanical factors such as friction, and associated microorganisms’.
Skin changes from IAD share some characteristics with decubitus ulcers; however, the pathogenesis of each presentation differs greatly. Pressure ulcers occur from damage in the deeper layers of the epidermis, whereas IAD results from the exogenous irritant micro-environment affecting the superficial layers of the skin. The clinical features of IAD are presented in Box 1.
Who is at risk?
Much of the available research looks at IAD in inpatient and care home settings, but it can affect any person with incontinence, including otherwise ambulant and self-caring men, women and children living in the community.
Factors that predispose to skin breakdown include advanced age, illness, immobility, reduced nutritional, cognitive and immune status, and any impairment that prevents adequate hygiene (Box 2).
The same patient groups are also at risk of decubitus skin injury and the two conditions can often coexist and coalesce. The stages of erythema, bulla and epidermal erosion may become exacerbated by excoriation due to urticaria and altered skin sensation. Secondary infection may then occur by bacteria or fungi.
For some patients the cost of containment products can be prohibitive, with the result that they use each pad longer than advisable and/or supplement them with modifications using toilet paper or plastic bags, each of which can make humidity and skin breakdown worse. Such patients may not have qualified for pads provided on the NHS or have refused those offered because they are too bulky.
Similarly, women may purchase panty liners that are designed to absorb menstrual blood, but which cannot manage urine well enough to protect skin. Post-menopausal women may be at further risk due to the loss of the protective influence of oestrogen on skin integrity and pH balance.
Exacerbating factors
Ambulant self-caring patients may begin to use excess soap or ointments to ameliorate any inflammation and for fear of embarrassing odours. Frequently purchased agents include petroleum jelly and zinc cream, which may block the absorptive properties of the pad and, paradoxically, allow the urine to have greater contact with the skin, trapping moisture and humidity. See Box 3 for advice for such patients.
What nurses can do
Educating patients and nurses about the risks of IAD is the first step to prevention. Continence management should form part of regulated statutory mandatory training in every trust and is equivalent in importance to decubitus ulcer prevention. As such, continence care and prevention of IAD need to be promoted to the forefront of the nursing agenda. Indeed, Beeckman et al (2014) assert that only when IAD is included in the World Health Organization's International Classification of Diseases will it begin to gain the necessary standard definitions and focused research.
Prevention
Patients commonly suffer with urinary incontinence for many years before they approach health professionals. In addition, patients who have limited communication and functional abilities are not able to identify and seek treatment. Every contact with patients offers an opportunity to have conversations about incontinence so the person feels at liberty to fully discuss any problems they may be having, including skin and hygiene issues.
Any person with risk factors for IAD should have a timely and comprehensive continence assessment, including skin evaluation, which is clearly documented with a safety-net plan in place. Continence assessment should include honest estimates of pad usage and how these are obtained. Even at assessment stage, encouraging optimum pad use and promoting hygiene can prevent skin problems becoming established.
Accurate diagnosis of the type of urinary incontinence will allow any reversible cause to be identified and treated where possible. For patients for whom these measures are inappropriate, nurses should ensure that the individual is provided with adequate, well-fitting containment devices and that their incontinence is managed effectively.
Conclusion
The pathogenesis of urinary IAD is multifactorial and its epidemiology is influenced by a multitude of biological and societal modifiers. Holistic assessment at the earliest opportunity can prevent and limit the impact of this insidious problem.
The manifestation of IAD may be an indicator of reduced overall wellbeing and, when looking after vulnerable people, should be prioritised in terms of risk as highly as pressure area care. The aim of skin care in managing incontinence is to maintain healthy pH and moisture balance.