Moisture-associated skin damage: causes and an overview of assessment, classification and management

Incontinence-associated dermatitis

An estimated 14 million adults experience incontinence in England alone, and this population is at a very high risk of developing IAD (Lumbers, 2019). IAD is the most common and widely recognised form of MASD, which is caused by prolonged or chronic exposure of urine and/or stool, particularly liquid stool, on the skin (Ousey and O'Connor, 2017). It can appear on the peri-anal area, scrotum, groin, buttocks, gluteal cleft and extend down to the inner and posterior thighs (Beeckman et al, 2015).

Urea in urine is converted to ammonia, resulting in a more alkaline environment; similarly, liquid faeces have higher levels of protein- and lipid-digesting enzymes, which can raise the pH further (making the enzymes even more active), increasing the risk of infection (Beeckman et al, 2015). Where both urine and faeces are in contact with the skin, skin damage can be expedited, causing maceration, microbial invasion and potential denudement or epidermal skin stripping (Browning et al, 2018). This manifestation not only causes pain but also predisposes the skin to prolonged erosion and the patient to subsequent infection. The impact of IAD on patients' wellbeing cannot be overestimated.

Periwound skin damage

In comparison with acute wound exudate during the process of normal wound healing, where it is deemed to be healthy and nurturing, chronic wound exudate is considered corrosive and has been proven to be destructive to the wound bed and surrounding skin because of the high levels of harmful proteolytic enzymes present (Voegli, 2012). If the volume of wound exudate cannot be contained within a wound dressing, there is a high likelihood of it leaking out on to the periwound skin (within 4 cm of the wound edges), causing the skin to become macerated and excoriated (Dowsett and Allen, 2013). This type of damage may be aggravated by vigorous removal of adhesive wound dressings.

Intertriginous dermatitis

Beeckman et al (2015) highlighted that ITD occurs when sweat is trapped in skin folds with minimal air circulation. Simply put, it is a perspiration rash, commonly occurring under the breasts, in the groin, on the inner thighs, in abdominal creases and in the armpits.

When sweat cannot evaporate, the stratum corneum becomes overhydrated and macerated. This facilitates friction damage, which, in turn, leads to localised inflammation and denudation of the skin, making the area more prone to bacterial and fungal infection. The damage often observed is typically mirrored on both sides of the fold (Dowsett and Allen, 2013).

Obesity raises the risk of ITD because of excessive skin folds, increased perspiration to regulate body temperature and a higher skin surface pH because of a decrease in sebum production (Man et al, 2009), a thinner dermal layer and decreased collagen content (Tobin, 2017). These make the acid mantle a less effective natural barrier against microbial invasion on the skin surface.

Peristomal moisture-associated dermatitis

This type of damage is a known complication of ostomies and is most commonly seen with colostomies and ileostomies (Ratliff, 2010; Gray et al, 2013). It is described as ‘inflammation and erosion of skin that begins at the stoma/skin junction and can extend outward in a 10 cm radius’ (Colwell et al, 2011). Damage occurs when alkaline output from the stoma comes into contact with the surrounding skin; it may occur soon after stoma formation surgery and reduces as patients become more competent at caring for their stoma. Alternatively, it may develop later if body shape changes because of weight loss or gain (Beeckman et al, 2015).

This form of dermatitis can happen rapidly, causing distress for the patient, resulting in pain, difficulty in obtaining a satisfactory seal from the appliance and huge embarrassment from leakages (Rae and Pridham, 2018). Management depends upon the correct choice and application of the containment device, along with a structured skin care routine (Gray et al, 2013).

Skin Moisture Alert Reporting Tool (S.M.A.R.T.)

In December 2019, the National Institute of Health and Care Excellence (2019) endorsed a new Skin Moisture Alert Reporting Tool (S.M.A.R.T.) (Figure 4).

This resource (Jones and Winterbottom, 2019) summarises and illustrates all four types of MASD. It also offers simple categorisation terminology regarding the extent of moisture damage, using the terms ‘mild’, ‘moderate’ or ‘severe’. Each category offers a clear definition as to what constitutes that level of damage and is supplemented with a general management plan. Feedback to the author and other practitioners has been encouraging, with a consensus that the tool is clear, concise and easily understood by any level of user. Further work is to be undertaken to quantify user feedback and measure its reliability and validity.

Skin cleansing

Skin cleansing is based on routine personal hygiene (Wounds UK, 2018) and failure to maintain this for patients could be considered clinically negligent (Nursing and Midwifery Council, 2018). Furthermore, a lack of effective skin cleansing increases the risk of fungal infection caused by Candida albicans with the potential for a secondary infection caused by Staphylococcus aureus (Flynn and Williams, 2011). Skin cleansing is an integral component of maintaining skin integrity (Wounds UK, 2018) and should be carried out after every episode of skin contamination from urinary or faecal incontinence (Ousey and O'Connor, 2017), peristomal effluent leakage and periwound exudate, and following episodes of profuse sweating (Dowsett and Allen, 2013).

Soap and water solution is alkaline, which alters the protective acidic mantle of skin and removes the natural sebum, resulting in drier skin, less protection from skin commensals and a greater risk of MASD (Beldon, 2008). Furthermore, cloths or towels used to wash and dry skin can be abrasive, and rubbing the skin dry can make the skin more susceptible to damage from shear forces (Beeckman et al, 2011). After washing, skin should be gently patted dry or allowed to air dry.

Non-rinse cleansers are advocated to effectively remove skin contaminants; they are pH-balanced soap substitutes, containing mild surfactants and provided in a spray foam for single patient use (Beldon, 2012). They are indicated because they not only maintain the skin's protective acidic mantle but also avoid the astringent effect soaps have on the skin (Payne, 2017). They also omit the need to dry the skin, so reduce the risks of shear damage and pain (Cooper et al, 2008).

In a recent comparative trial on tissue viability, Harries and Begg (2016) examined the effect of non-rinse cleansers on the incidence of IAD. Data were collated before and after the cleansing regime was introduced at five hospital wards over a period of 13 weeks by the lead continence advisor. Although patients were regularly assessed, which strengthens the reliability of the findings, a severity assessment tool was not used, which brings the validity of the study into question. Statistical significance was not tested but, nonetheless, the overall results show IAD fell by an average of 74% after the non-rinse cleansers were introduced, with a 91% inter-rater agreement. Therefore, the findings could be transferable to all types of MASD.

Barrier protection

Protective barrier products include creams, films and ointments. They are water repellent and commonly contain petrolatum, zinc oxide or dimethicone (Bardsley, 2013), and each product should be single patient use only to avoid cross-contamination (Payne, 2017).

Dimethicone products are silicone based and provide a protective film across a surface (Voegeli, 2016), without interfering with pad absorbency for patients with urinary or faecal incontinence (Southgate and Bradbury, 2016). They should be considered for all types of MASD where skin protection is required.

Films have the advantage of drying quickly on the skin surface and reducing the risk of skin stripping on dressing removal, creams are water based and are more likely to moisturise as well as act as a barrier, and ointments are thicker and therefore more occlusive (Fletcher, 2015). Protective films in the form of applicators, sprays and wipes for peristomal MASD are less likely to inhibit adherence of the stoma appliance than barrier creams (Metcalf, 2018).

Acton et al (2020) evaluated the effect of a topical film barrier on IAD using both a classification tool and a validated assessment tool. Eighteen patients were recruited with varying levels of IAD severity and five patients were excluded during the trial period because of adverse events. Most of the remaining patients (11 out of 13) had category 2 IAD (defined as skin loss or denudement); 85% were reported to have healed at the end of the evaluation period, which was an average of 13 days. However, two patients with category 2 IAD and infection did not heal, and it was not considered in the study whether this was as a result of fungal infection, which is a common complication of IAD. Although the sample size was relatively small and included only patients with IAD, the results are transferable to other types of MASD. It must be remembered that, although case series are relatively low in the nursing research hierarchy of evidence (Broomfield, 2011), they can provide invaluable real-life evidence towards advancing clinical practice. The findings support the efficacy of using skin protectants for patients with IAD. These findings are supported in the literature (Holroyd and Graham, 2014; Holroyd, 2015; Southgate and Bradbury, 2016; Callaghan et al, 2018).

An earlier study also highlighted the benefits of using protective barriers in 95 patients with MASD of differential aetiologies, including IAD, peristomal and periwound moisture damage and skin rashes from sweating (Stephen-Haynes and Stephens, 2013). What was less clear from the study was when it was appropriate to use either a barrier cream or a film.

Fundamental to effective MASD prevention and management are patient assessment, management of the underlying cause and implementation of a structured skin care regimen (Voegeli, 2016). Ongoing monitoring and assessment of progress provides the opportunity to step up or step down skin care regimens according to individual patient need to establish a cost-effective goal.

Case study 1

A 75-year-old patient lived at home with her husband and received support from carers. She was diagnosed with multiple sclerosis 50 years ago and was confined to a hospital bed on the ground floor. She had been known to the district nursing team since 2008 and was recently referred to the tissue viability team.

She developed IAD in July 2019, which was treated with a barrier film but did not resolve the skin problem. She refused to have a continence assessment or change the type of pads her husband was buying and, as a result, the IAD spread into the groins and creases in her lower abdomen. The MASD did not resolve with conventional products. Medi Derma-Pro Skin Protectant Ointment and Medi Derma-Pro Foam and Spray Incontinence Cleanser (Medicareplus) were started using the following regimen:

Healing was complete by week 7 and a clinical decision was made to step down to Medi Derma-S Total Barrier Cream to prevent recurrence in the long term.

Case study 2

The patient was a 71-year-old woman living in a residential care home, who was referred to the tissue viability service because the current treatment regimen of washing with warm wet flannels and a barrier cream was proving ineffective. Using the S.M.A.R.T. resource, the damage was classified as severe IAD. The skin care regimen began on 24 December as below and the S.M.A.R.T. tool was used to monitor progress:

Case study 3

The patient was an 83-year-old woman with a past history of cerebrovascular accident, myocardial infarction and type 2 diabetes. She was confined to bed and lived with her daughter, with support from carers. Recurrent UTIs were a problem, as well as burning pain associated with IAD to the groins and vulval region, with evidence of vulvular folliculitis. Previous treatments had been prescribed with little effect.

On 4 March, Medi Derma-Pro Skin Protectant Ointment and Foam and Spray Incontinence Cleanser was recommended after every episode of incontinence. There were significant reductions in erythema and pain by 31 March. The patient was stepped down to Medi Derma-S Total Barrier Cream.