Incontinence-associated dermatitis: new insights into an old problem

Prolonged contact of the skin with urine or faeces leads to a specific form of moisture-associated skin damage, known as incontinence-associated dermatitis (IAD). While this is a common condition encountered in all areas of nursing practice, gaps remain in our understanding of the many contributing factors. A lack of standardised definitions of IAD, differences in terminology, and a bewildering increase in products available to prevent and manage IAD, make it difficult for nurses to deliver evidence-based care. However, it is an area where nursing research has made a considerable contribution over the past few years, culminating in the development and publication of a set of international best practice principles based on expert consensus.¹ This article explores the main principles developed and the implications for nursing practice.

IAD may be regarded as a type of contact dermatitis that occurs in patients who have urinary or faecal incontinence, often causing significant discomfort, and reduced quality of life.² Typically, IAD presents as inflammation of the skin surface characterised by redness and, in extreme cases, swelling and blister formation (Fig 1). In urinary incontinence this generally affects the labia in women, and the scrotum in men, as well as the inner thigh and buttocks in both sexes. If untreated this usually rapidly leads to excoriation and skin breakdown, which may subsequently become infected by the skin flora, leading to a vicious circle of increased inflammation and skin breakdown. It is generally agreed that urinary incontinence on its own does not necessarily lead to IAD, but combined with faecal incontinence or the passage of liquid stools significantly increases the risk. There is also the possibility that certain medications the patient might be taking also contribute, either by a direct action of drug metabolites excreted in the urine or faeces on the skin, or by drugs increasing the passage of liquid stools as a side effect, such as some antibiotics.³ The exact mechanisms that lead to IAD are not fully understood, although some significant insights have been achieved over the past few years, mainly driven by a continued interest in this area by nurse researchers. The main factors precipitating the skin inflammation are thought to be overhydration of the epidermis and an increase in the skin pH away from the protective acidic range, disrupting the normal skin barrier.⁴