How important is your skin to take care of when you have incontinence?

Incontinence and Dermatitis

The Problem

Incontinence associated dermatitis is a result and consequence of moisture-associated skin damage common in patients with bowel and/or urinary incontinence.

Among hospitalised patients, the prevalence rate has been found to be as high as 30%.

Incontinence-associated dermatitis (IAD), sometimes referred to as perineal dermatitis, is an inflammation of the skin associated with exposure to urine or stool over a sustained period of time.

Older patients may be often unaware of the discomfort they are experiencing and the injury may worsen before medical staff or carers become aware of the skin breakdown.

Some of the contributing factors to exacerbate skin breakdown are: the frequency of bowel and/or urinary incontinence, poor skin condition, pain, poor oxygenation percentage in the body, illnesses and lack of mobility.

Perineal dermatitis is an inflammatory condition of the skin in the perineal area and can also be localised around the upper parts of the thigh, the buttocks and areas affected by incontinence.

It will show up as a varying degree of skin injury from slight redness to areas to where the skin is badly damaged or no skin there at all. As mentioned earlier it can be without symptoms or with itching or tender or painful spots on the skin.

Why Does it Start?

Normal skin forms a barrier created by the individual skin cells. The normal pH of skin is acidic with an average pH of 5.7 and generally prevents all manner of infections and bacteria from entering the body through the skin surface.

When changes in the external pH of the skin occur it can affect the skin's ability to function as an effective barrier against whatever adverse chemical or infection is on the skin is causing this change.

This occurs when the skin is exposed to this pH change for a period of time so if a patient is exposed to moisture, fecal and urinary incontinence, an incontinence device, over a sustained period of time, the barrier cannot work properly and the skin begins to break down because its pH has changed dramatically enough to cause this to happen.

This allows infections and bacteria in to do their nasty work with microorganisms such as Staphylococcus and Candida.

The warm moist areas of the body are perfect breeding grounds for these microorganisms to rapidly grow and are greatly assisted by perspiration (alkaline) and urine and faeces.

Combine normal movement of the body such as friction with clothes or bedding and you have an ideal environment for skin to become chafed and break down very quickly because it is no longer robust enough to sustain everyday rigour in its rundown condition.

As an example: urinary incontinence will expose the skin to ammonia formed by the conversion of urea to ammonia raising the pH level.

Ammonia can have a pH of 10.0 or more, depending on the concentration hence the greater the amount of ammonia in the urine, the higher the pH of the urine.

Left unattended and untreated the skin deterioration breaks down even further with the possible onset of skin ulcers. Following is a general decline and worsening health status of the patient making recovery even harder and longer.

Even if attended to at an early stage the recovery can be a slow and time consuming process for the patient and carer.

All of this because the lack attending to and prevention of an incontinence issue weeks or months earlier.

IAD is common in homes, residential aged care facilities and even long stays hospitals–wherever people are suffering from incontinence.

It highlights the lack of emphasis and information available for not only patients but carers as well to appreciation to understand, diagnose and treat the symptoms of incontinence-associated dermatitis (IAD).

Prevention and Treatment

Treatment of incontinence associated dermatitis focuses on 3 main objectives:

1. Remove all the irritants of the affected skin areas-faeces, urine and any irritating chemicals.

2. Remove or eradicate all infections to be found in the area.

3. Ensure any incontinence material is kept off the skin as much as possible by the use of barrier ointments such as zinc oxide.

The clinical practice guidelines of the “Wound, Ostomy, and Continence Nurses Society “suggest keeping the skin clean and dry and applying an incontinence skin protectant after each episode of incontinence

Prevention of IAD comprises of a skin care regimen much like a military operation being carried out including: gentle cleansing, moisturising preferably with an emollient and application of a skin barrier, avoiding or minimising exposure to faeces or urine contact with the skin.

The management of irritant dermatitis caused by incontinence is not an easy problem to solve.

Many products are used to treat this type of dermatitis. Many contain perfumes and emollients to irritate the skin when applied so it is important to use the best ones available. Perineal skin cleansers typically are labeled for use as a perineal skin cleanser and if unsure ask your pharmacist or GP.

A cleanser specifically designed for perineal skin care is preferable to soap and water because soap will increases skin pH.

The use of skin protectants after cleaning is important as a mositure protectant (a moisture barrier) such as zinc oxide will reduce the incidence of perineal dermatitis by half.

Preventive cleansing and application of a protectant can reduce the incidence of pressure ulcers by up to half.

Caring for patients with fecal incontinence is a challenge for any carer.Patients with multi system organ failure often overlook the importance of the condition of the patient's skin -a living organ of its own. It only becomes noticeable after skin breakdown occurs.

Skin protectants are underused in hospital patients and some residential aged care facilities.

The morbidity rate associated with fecal incontinence is high.

Perineal dermatitis develops in a third of patients with fecal incontinence.

Skin breakdown can occur within bed stay not exceeding 14 days.

Be aware ,learn as much as you can about this condition and prevent these conditions happening to yourself and those around you.

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