Incontinence Associated Dermatitis

Incontinence Associated Dermatitis Mikel Gray, PhD, FNP, PNP, CUNP, CCCN, FAAN Professor & Nurse Practitioner University of Virginia Department of Urology

Anatomy & Physiology Largest organ (6 pounds or 3,000 sq inches); its thickness varies from 0.5mm 6 mm Functions: Barrier: : against toxins in external environment and for the prevention of excessive fluid & electrolyte loss from internal environment Thermoregulation Sensory organ/ communication Immune functions Vitamin D metabolism Burns T et al. Textbook of Dermatology, 2004. Mass: Blackwell Science

Moisture barrier of the skin Stratum corneum: dead keratinocytes or corneocytes Lipid matrix: : slows movement of water & electrolytes Water: : hydrates corneocytes ph: : (usually 5.0-5.9) forms an acid mantle Bacterial flora: : competes with pathogens to prevent infection Temperature: : regulates permeability

How do Clinicians & Researchers Measure the skin s s Moisture Barrier? No clinical test for measuring moisture barrier Researchers measure Transepidermal water loss (TEWL); which is the rate of passive diffusion of H 2 0 from internal environment to external environment (differs from perspiration) The perineal skin and scrotum have the highest TEWL os any surfaces of the body, skin over back is the lowest Loffler H, Hautarzt.. 50(11):769-78, 1999

Perineal Skin at the Extremes of Life Barrier function in the neonate Less robust than adults, particularly premature infants Higher TEWL Higher rates of percutaneous absorption Greater risk for erosion, stripping, pressure injury Cornification of skin begins about GW 20 Vernix contains FFA, cholesterol & ceramides, thus acting as proxy while skin develops Full-term skin contains 10-20 layers of stratum corneum, skin in premature baby has 2-3 Lund C et al. JOGNN 1999; 28(3): 241.

Perineal Skin at the Extremes of Life Aging Skin: gradual decline in barrier function TEWL Overall thickness declines Collagen & elastin Local changes in capillary beds reflect systemic changes in microcirculation Ghadially R. American J Contact Dermatitis 1998; 9(3): 162.

Searching for an appropriate name: Perineal Dermatitis? Perineum: : region between the thighs, in the female between the vulva and the anus, in males, between the scrotum and the anus 1 Dermatitis: : inflammation of the skin 1, itself a broad term may be divided into 2 Atopic (eczema) Allergic Irritant Multiple other terms used, dermatoses used to describe well defined endogenous skin dysfunction 2 1. Online Medical Dictionary, http://cancerweb.ncl.ac.uk/cgi-bin/omd?action=home&query 2. Burns T et al. Textbook of Dermatology, 2004. Mass: Blackwell Science.

Searching for an appropriate name: Diaper or Nappy Dermatitis? Strengths Clearly associated with incontinence and use of one type of containment device, infant diaper (often called nappy in UK) or adult containment brief Limitations Unfairly blames one type of containment device as cause of the problem itself Possible pejorative interpretation when applied to adults

Searching for an appropriate name: Incontinence Associated Dermatitis Name selected from alternatives at consensus conference held in Chicago, IL summer of 2005, results of conference published in JWOCN, 2007 1 Describes etiology and outcome of condition * Supported by unrestricted educational grand from SAGE, Inc. 1. Gray M, Bliss DZ, Doughty DB< Ermer-Seltun K, Kennedy-Evans KL, Palmer MH. JWOCN 34(1): 57-69.

Moisture Associated Skin Damage (MASD) IAD is part of larger etiological framework called MASD Intertrigo: : inflammation in skin folds related to perspiration, friction and bacterial/ fungal bioburden Periwound maceration: : skin breakdown from wound exudate, related to volume, constituents or exudate & bacterial bioburden IAD: : urine, stool, containment device, secondary cutaneous infection typically fungal

Epidemiology of IAD Long-term care literature reports Prevalence of 5.6%-50% Incidence of 3.4%-25% Acute-care Incontinence prevalence: 20% IAD prevalence was 10.9% of the general hospital population IAD prevalence was 54% in incontinent patients in 3 acute-care hospitals Lyder, et al., 1992; Bale, et al., 2004; Bliss, et al., 2005; Junkin, More-Lisi, Selekof,, 2005

2005 IAD Prevalence Study 976 Total number of patients surveyed 35% had Foley catheter (deemed continent) 20.3% (198) prevalence of incontinence urine or stool 27% had IAD 33% had a pressure ulcer 18% had a probable fungal Infection 21% had more than 1 type of injury Junkin J, Selekof J. IAD prevalence in acute care. WOCN National Conference, June 2006 Minneapolis, MN.

IAD: Effect of Urine on Skin Water: : decreases skin hardness, renders it more susceptible to friction and erosion Ammonia: : raises ph, promotes pathogenic growth, disrupts acid mantle, activates fecal enzymes, alters normal flora of skin Gray M. Journal of WOC Nursing 2004; 31(1 Suppl):S2-9.

Impact of Stool on Skin Intestinal colonization acts as a reservoir for potential pathogenic substances 1 VRE MRSA Clostridium difficile Antibiotic resistant Staphylococcus aureus Multiple other antimicrobial resistant gram- negative bacilli Steifel & Doskey,, 2004; Current Infectious Disease Report 2004; 6:420.

Impact of Stool on Skin Disruption of the usual microflora provides opportunity for pathogenic colonization 1 Normal colon: 10 12 CFU per Gm with obligate anaerobe counts exceeding parasitic organisms ~1000:1; important defense against pathogens Antimicrobials that are excreted into the intestinal tract disrupt this balance Result in skin contamination in 83% and environmental surface contamination in 67%, diarrhea and fecal incontinence magnify risk 2 1. Steifel & Doskey,, 2004; Current Infectious Disease Report 2004; 6:420. 2. Donskey et al. NEJM 2000; 343: 1925.

Impact of Stool on Skin Disruption of gastric acid content in stomach Healthy individual: >99% of coliform bacteria ingested killed within 30 minutes because of gastric acid secretion 1 Use of medications that inhibit stomach acid production associated with C. difficile, S. aureus, VRE and antibiotic resistant gam negative infections 2 1.Donskey, Clinical infectious Disease 2004; 39: 219. 2. Cunningham et al., J. Hospital Infection 2003; 36: 149.

Pathophysiology Use of absorptive containment devices Exacerbate overhydration by promoting perspiration & retaining urine and stool; with padding alone: TEWL increases 3-4 fold within days CO 2 emission increases > 4 fold ph increases from 4.4 to 7.1 (without( incontinence) Emerging data supports direct role in PU risk 1. Grove GL et al. Clinical Problems in Dermatology 1998; 26:183 2. Zimmerer RE et al. Pediatric Dermatology 1986; 3: 95. 3. Zhai H et al. Skin Research & Technology 2002; 8:13.

IAD & Pressure Ulceration Precise nature of association not understood Fecal incontinence strongly associated with PU risk, UI is not 1-4 Analysis rarely based on PU stage, few articles that use stage associate FI/ UI with stage I & II 3 Both FI & UI associated with increased time and cost to wound healing 5 1. Maklebust J & Magnan MA Advances in Wound Care 1994; 7(6): 25. 2. Gunninberg L. Journal of Wound Care 2004; 13(7): 286. 3. Fader M et al. Journal of Clinical Nursing 2003; 12(3):374. 4. Berlowitz DR et al. Journal of the American Geriatrics Society 2001; 49(7):866-71. 5. Narayan S et al. Jounal of WOCN 2005; 32(3): 163.

IAD & Pressure Ulceration Does FI or UI indirectly contribute to pressure ulcer risk? Skin wetted with synthetic urine or water shows a significant decrease in hardness, temperature, and blood flow during pressure load when compared to dry sites 1 Absorbent products may enhance the risk for pressure ulceration by creating areas of increased interface pressure, even when used in conjunction with a pressure reducing or relieving device 2 1. Mayrovitz HN, Sims N Adv Skin Wound Care 2001;14(6):302. 2. Fader M et al. Journal of Advanced Nursing 2004; 48(6): 569.

Pathophysiology

Normal skin Epidermis Dermis Hypodermis

Irritants Perspiration Urine Stool (especially liquid) Exudate / Effluent Penetration of irritants Elevated TEWL Altered ph

Inflammation Cracking of skin Redness Swelling Release of cytokines Inflammation

Denudation Erosion (denudation) of skin

Screen for Redness, Inflammation

IAD: Diagnosis

IAD: Diagnosis Inspect the skin for erythema, redness, cracking, swelling, vesicles Determine location of skin damage does it lie in skin fold or over bony prominence, underneath containment device?

IAD: Diagnosis Look in Skin Folds Opposing skin surfaces trap moisture Warm moist environment encourages bacterial and fungal colonization, overgrowth and infection Friction created as skin folds rub against one another

IAD: Diagnosis Look for erosion of skin Partial thickness erosion common Full thickness wound implies pressure or shear and pressure ulceration

IAD: Diagnosis Look for secondary cutaneous infection, especially candidiasis Opportunistic infection with candida albicans Thrives in warm, moist environment & damages stratum corneum Seen in 18% of one group of 976 acute care inpatients 1 1. Junkin J, Selekof J. IAD prevalence in acute care. WOCN National Conference, June 2006 Minneapolis, MN.

Differentiate MASD from Pressure Ulceration Gray M et al. JWOCN 2007; 34(2):.

What type of skin damage?

IAD: Prevention Principles of Prevention: 1) cleanse, 2) moisturize, 3) protect Gentle cleansing: NO scrubbing Select a cleanser with acceptable ph & no irritants Moisturize dried areas to maximize lipid barrier Apply moisture barrier as indicated

Hospital Washcloth Vs. Disposable Washcloth Basin Sage

Preventive Skin Care: Cleanse Soap & Water What is the clinical evidence for soap & water as a perineal skin cleanser alkaline ph raises ph more than cleansing with ph balanced cleansers; alkaline ph associated with skin irritation and severity of IAD 1 cleansing requires significantly more time than with cleansers 1,2 2 small RCT have not demonstrated greater risk for dermatitis in frail elder patients 1,2 1. Byers et al. JWOCN, 1995, 187. 2. Lewis-Byers et al. OWM, 2002, 44.

Preventive Skin Care: Cleanse Incontinence skin cleansers ph Balanced designed to maintain the acid mantle of perineal skin Many described as no rinse (no water required) Require significantly less time than traditional cleansing with soap and water Many contain emollients (skin softeners) or moisturizers to preserve lipid barrier, thus combining 2 steps into a single action

Preventive Skin Care: Perineal Skin Cleansers Product Aloe-Vesta 2-n-1 and 3- n-1 Sensi-care Cavilon 1-step Key Components Cleanser, moisturizer* (aloe vera), emollient Cleanser, emollient, moisturizer Cleanser, moisturizer*, emollient, moisture barrier Notes 3-n-1 adds emollient, lemon scented No scents, no preservatives Labeled as Skin care lotion Cavilon Cleanser Cleanser, moisturizer, humectant Humectant acts as moisture barrier

Preventive Skin Care: Perineal Skin Cleansers Product Key Components Notes DermaRite 3 in 1 Peri-Fresh Cleanser, moisturizer Cleanser, moisturizer* Advocates use as shampoo as well Fresh fruit fragrance Perigene Cleanser, moisturizer No alcohol, fragrances, preservatives, dyes Provon Perineal Wash & Antibacterial P Wash: cleanser, vit. E, moisturizer*, antibacterial in one preparation Wash has herbal fragrance, AB has deodorizer

Preventive Skin Care: Perineal Skin Cleansers Product Restore Clean & Moist Remedy 4-n-1 antimicrobial cleanser Carafoam skin & perineal cleanser Peri-wash II Key Components Cleanser, moisturizer, emollient Cleanser, moisturizer, emollient, benzalkonium chloride Cleanser, moisturizer Cleanser, benzethonium chloride Notes 3-n-1 product 3-n-1 product with antimicrobial agent Dispensed as foam, mild fragrance Antiseptic, fragrance (deodorizer)

Preventive Skin Care and Contemporary Assessment Comfort Bath: cleanser & moisturizer Deodorant Comfort Bath: cleanser, moisturizer & deodorizing agent (Exopheryl )

Preventive Skin Care Typical Protocol Routine daily cleansing for everyone Cleanse & moisturize with each major incontinent episode Apply moisture barrier for significant UI, fecal or double incontinence Comfort Shield: cleanser, moisturizer, 3% dimethicone skin protectant

Risk Factors for Pressure Ulcer Development The odds of having a pressure ulcer were 22 times greater for hospitalized adult patients with fecal incontinence compared to hospitalized patients without fecal incontinence and 37.5 times greater in patients who had both impaired mobility and fecal incontinence JoAnn Maklebust, MSN, RN, CS, NP and Morris A. Magnan, MSN, RN, Risk Factors Associated with Having a Pressure Ulcer: A Secondary Data Analysis, Advances in Wound Care, November 1994

Facts About Pressure Ulcers 80% of pressure ulcers in hospital are Stage I or Stage II. 1 Almost half of all pressure ulcers form on the sacrum (36.9%) and ischium (8.0%). 2 A healthcare facility will spend between $400K and $700K annually on pressure ulcer treatment. 3 JACHO lists prevention of health care associated pressure ulcers as a patient safety goal. 4 1. Whittington KT, Briones R, National Prevalence and Incidence Study: 6-Year Sequential Acute Care Data, Adv Skin Wound Care. 2004 Nov/Dec;17(9):490-4. 2. Amlung SR, Miller WL, Bosley LM, Adv. Skin Wound Care. 2001 Nov/Dec; 14(6): 297-301. 3. Robinson, C; Gioekner, M; Bush, S; Copas, J; et al. Determining the efficacy of a pressure ulcer prevention program by collecting prevalence and incidence data: a unit-based effort. Ostomy Wound Manage. 2003. May: 49(5):44-6. 48-51. 4. http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/07_ltc_npsgs.htm

Clever et al. - Pressure Ulcer Study Evaluating the Efficacy of a Uniquely Delivered Skin Protectant and Its Effect on the Formation of Sacral/Buttock Pressure Ulcers * Average Monthly Incidence of Sacral/Buttock Pressure Ulcers Old standard of care vs. using Comfort Shield as preventative in new standard of care 4.7% 0.5% Reduction in Incidence Of sacral/buttock pressure ulcers Old Standard of Care 7/00 3/01 New Standard of Care 5/01 7/01 2/02 4/02 *Comfort Shield was used on all incontinent patients and was the only variable changed from the control period. Clever K, Smith G, Bowser C, Monroe K Long-Term Care Unit, Fulton County Medical Center, McConnellsburg, PA, Ostomy/Wound Management. Dec 2002;48(12):60-7.

The Development of Cost-Effective Quality Care for the Patient with Incontinence Group A = Cleansing spray, washcloths, skin barrier (multi- step process and the current practice). Group B = Shield Barrier Cloths. Group C = Disposable washcloth without dimethicone. Results: Group A = $6.13 per patient per day; 10% skin breakdown. Group B = $5.40 per patient per day; 8% skin breakdown. Group C = Discontinued in week 4 due to 29% skin breakdown. 2003 72 consults due to IAD and 2004 10 consults due to IAD. http://www.sageproducts.com/education/shsymposiapres.asp Dieter L, Drolshagen C, Blum K, Cost-effective, quality care for the patient with incontinence. Research Poster Abstract presented at WOCN, Minneapolis, MN June 2006

Developing a Comprehensive Fecal Incontinence Management Program (for IAD) Program, guidelines and algorithm for clinical decision making to include: Protection, Treatment and Containment devices. 33% of hospitalized patients have fecal incontinence. Fecal Incontinence increases PU risk 22 times and 30% if immobile. Shield Barrier cloths for prevention of IAD; Xenaderm for Treatment of IAD and guidelines for external and internal fecal containment devices. http://www.sageproducts.com/education/shsymposiapres.asp Gray DP, Developing a comprehensive fecal incontinence management program. Practice Innovation Poster Abstract presented at WOCN, Minneapolis, MN June 2006.

Treat Underlying Incontinence Consider Diversion of Stool When Indicated Anal Pouch Synthetic, adhesive skin barrier attached to pouch Bowel Management System Zassi BMS or Flexiseal Nasal Trumpet Off label use

Treat Underlying Incontinence Temporary Diversion for UI: Indwelling Catheter Indications UI complicated by urinary retention, obstruction & only when CIC not feasible Stage 3-4 PU for transient diversion only Selection criteria Silicone or Lubricath Smaller French size

Sluser Study Consistent Treatment

Sluser Study Consistent Treatment

Sluser Study Consistent Treatment

IAD: Treatment Goals Establish or continue cleansing/ moisturization/ skin barrier program Restore epidermal integrity Minimize exposure to irritants (Manage UI or Fecal incontinence) Treat secondary cutaneous infections Create environment for wound healing

IAD: Treatment Inert Skin Barriers Deflect drainage and provides moisture barrier Most common contain Petrolatum Dimethicone Zinc oxide

IAD: Treatment Inert moisture barriers No evidence base could be identified supporting efficacy for existing IAD Ample anecdotal evidence supports role in mild to moderate cases in outpatient/ home setting Disadvantages include removal (zinc oxide in particular)

IAD: Treatment Topical Dressings Hydrocolloids Thin film dressings Act as barrier to urine & stool Promote moist environment for wound healing Can be combined with topical treatments

IAD: Treatment Topical Dressings Maintaining adherence significant challenge Skin surfaces complex Borders often roll when ointments or moisturizing products have been applied Undermining of urine or stool may occur

IAD: Treatment BCT agents BCT Ointment (Xenaderm) Balsam Peru, Castor Oil, Trypsin in ointment base Applied to dermatitis twice daily or with major cleansing BCT gel (Optase( Optase) NOTE: : FDA has ruled out further reimbursement pending documentation of efficacy

IAD Treatment: Secondary Complications Candidiasis Topical antifungals are effective for the treatment of cutaneous infections Effective agents include the polyene antibiotics, azoles and the allylamines 1 Resistance to antifungals is emerging, careful monitoring of research literature is essential 1. Evans & Gray, JWOCN, 30(1), 2003

IAD and IHI as it relates to Sage Facilities need to follow the Six Elements of Pressure Ulcer Prevention (from IHI) Asssess the skin upon admission Reassess the skin daily Inspect the skin daily Manage moisture Optimize nutrition and hydration Minimize pressure

Summary: Manage Moisture: Keep the Patient Dry and Moisturize Skin Provide supplies at the bedside of each at-risk patient who is incontinent. This provides the staff with the supplies that they need to immediately clean, dry, and protect the patient s s skin after each episode of incontinence. Provide under-pads that pull the moisture away from the skin, and limit the use of disposable briefs or containment garments if at all possible. Provide pre-moistened, disposable barrier wipes to help cleanse, moisturize, deodorize, and protect patients from perineal dermatitis due to incontinence. http://www.ihi.org/ihi/programs/campaign/