How much do you know about incontinence-related dermatitis?

Incontinence-associated dermatitis (IAD) refers to inflammation of the skin around the anus, buttocks, groin or thighs caused by contact with irritants in feces and/or urine. IAD is a type of moisture-related skin damage, an irritant dermatitis caused by skin exposure to urine and feces. IAD also includes perineal dermatitis, moist dermatitis, irritant dermatitis, contact dermatitis and diaper dermatitis, and is mainly defined based on the location and cause of the dermatitis.

IAD is a common nursing problem for incontinence patients and a global health problem. It not only brings discomfort and pain to patients, but also increases the economic burden on patients and the workload of caregivers. If IAD can be identified early and treated scientifically, the severity of IAD can be reduced, the patient's pain can be alleviated, the length of hospital stay can be shortened, and the patient can recover sooner. Let's learn about it together!

01 Causes of IAD

The occurrence of IAD is mainly composed of three aspects: tissue tolerance, perineal environment and toileting ability. The nutritional status of the patient in tissue tolerance is an important factor in determining the occurrence of IAD. The perineal environment includes: the type, frequency, and skin contact time of incontinence. The incidence of fecal incontinence is higher than that of simple fecal or urinary incontinence, and the frequency of incontinence and skin contact time are proportional to the incidence of IAD.

In addition, diabetic patients and people with a high body mass index are more likely to develop incontinence dermatitis, so more skin care interventions are needed for these patients.

02 IAD Features

IAD, as a new concept in clinical nursing, has attracted widespread attention from medical staff. In clinical practice, IAD and pressure sores often coexist. The two must be distinguished in order to truly eliminate the cause and prescribe the right medicine to help patients recover as soon as possible.

IAD is mainly caused by moisture and friction, manifested by erythema, edema, maceration, and damage to the skin in the relevant parts. The boundaries of the wound are usually unclear and diffuse, accompanied by itching and pain, with or without secondary fungal infection.

03 IAD prevention measures

Regarding IAD, it is generally believed that prevention is better than cure. The primary task of nursing work is to take effective preventive measures before the problem occurs.

1. Avoid long-term skin contact with irritants : Early detection of patients at risk of IAD, and adequate attention to them, to improve the awareness and attention of patients and their families to IAD. Strengthen observation and inspection to promptly detect and eliminate skin irritation caused by excrement: such as choosing a suitable drainage device; timely replacing contaminated diapers and bed sheets, etc. Keep the skin clean and dry, and reduce the time the skin is exposed to irritants.

2. Skin cleaning: Skin cleaning is essential for incontinent patients. Pay attention to the cleaning of the perineum and perianal area after each bowel movement. Trim the nails before cleaning the patient to avoid scratching the patient's skin. Use appropriate water temperature (around 37°C) and be gentle. Pat or wipe with a cotton swab to avoid secondary damage caused by excessive wiping. You can choose a rinse-free cleaning solution. When choosing a cleaning solution, it is best to use a cleaning solution close to the skin's pH value (5.4-5.9), and avoid using alkaline skin cleansers such as soap. This will not destroy the normal acidic environment of the skin.

3. Moisturizing/protecting the skin: Proper selection of moisturizers can promote skin repair. Moisturizers keep the skin moisturized, increase the skin's water content, and strengthen the skin's moisturizing barrier. Use your fingers to spread the skin at the wrinkles and apply moisturizer. Skin protectants can form a breathable and watertight semi-permeable membrane on the skin, such as: 3M Skin Protective Film, Sefurun, Vaseline, zinc oxide, etc. It can isolate urine and feces, protect the skin from irritation, and reduce the incidence of IAD.

04 IAD rehabilitation care

For patients with urinary and fecal incontinence, we should properly manage the intestines and bladder, which can fundamentally reduce the incidence of IAD.

1. Patients with fecal incontinence:

(1) Symptoms can be improved by adjusting the patient's eating habits, fluid intake, and bowel habits. Patients can use bowel movement diaries to self-assess their eating and living habits to further understand the daily eating and living habits that induce or aggravate the condition, and then adjust or eliminate them.

(2) Depending on the cause of incontinence, appropriate Western medicine or traditional Chinese medicine can be selected for treatment under the guidance of a doctor.

(3) When patients fail to respond to simple dietary adjustments, drug therapy, and other nursing measures, they can be given perianal stimulation to exercise the perianal sphincter by restoring the defecation muscles and related nerve functions; guide pelvic floor muscle training; intermittent defecation stimulation to cultivate the habit of regular defecation to keep the rectum and anus empty. During rehabilitation training, the cause of the patient's incontinence and rectal type need to be fully assessed so that personalized rehabilitation care can be given.

2. Patients with urinary incontinence:

(1) Lifestyle guidance: Provide targeted lifestyle guidance for patients with urinary incontinence, including weight loss, smoking cessation, healthy diet (high dietary fiber, low salt, low caffeine), limiting alcohol and beverage intake, and reducing or avoiding actions that increase abdominal pressure.

(2) Develop a training plan based on the bladder function assessment results and the urination interval, and provide targeted rehabilitation nursing guidance, such as bladder function training and pelvic floor muscle training.

(3) Urinary incontinence products and assistive devices: When choosing collection products, patients with urinary incontinence who are bedridden for a long time should consider their gender and choose the appropriate model: women should use urine collectors and men should use urine sheaths. It is generally not recommended for patients with urinary incontinence to place a urinary catheter to avoid complications such as urinary tract infections.

(4) Intermittent catheterization: refers to not leaving the catheter in the bladder, but inserting it into the bladder only when needed and removing it after emptying. Before implementing intermittent catheterization, it is necessary to fully evaluate the patient's bladder type and develop a detailed drinking plan and intermittent catheterization plan. This greatly reduces the incidence of urinary incontinence, thereby reducing the incidence of IAD and improving the patient's daily quality of life.

【References】

[1] Huang Haiyan, Mi Yuanyuan, Yu Jiaohua, et al. Summary of the best evidence for the prevention and care of incontinence-related dermatitis in critically ill hospitalized patients[J]. Journal of Nursing, 2017, 32(21): 50-53. DOI: 10.3870/j.issn.1001-4152.2017.21.050.

[2] Wang Ling, Zheng Xiaowei, Ma Rui, Liu Xiaoli. Interpretation of the expert consensus on nursing practice of incontinence-related dermatitis at home and abroad[J]. Chinese Journal of Nursing Management, 2018, 18(01): 3-6.

[3] Xu Yuanyuan, Shi Guangling, Zhang Yanhong, Xu Jianzhen, Liu Juan, Jiang Xuejuan, Du Haiyan. Evidence-based practice for preventing fecal incontinence dermatitis in ICU patients[J]. Chinese Journal of Nursing, 2021, 56(6): 811-817. DOI: 10.3761/j.issn.0254-1769.2021.06.002.

[4] Beele H, Smet S, Van Damme N, et al. Incontinence-Associated Dermatitis: Pathogenesis, Contributing Factors, Prevention and Management Options[J]. Drugs Aging, 2018, 35(1): 1-10.DOI:10.1007/s40266-017-0507-1.

[5] Wang Shuilian, Yang Zhen, Zhang Baozhen, Tang Liping, Xie Zhiqin, Yang Lina, Du Yunyu. Construction of evidence-based protection strategy for incontinence-related dermatitis[J]. Evidence-Based Nursing, 2021, 7(11): 1475-1479.

[6] Chinese Medical Association Anorectal Physicians Branch, Anorectal Disease Expert Committee of Chinese Medical Association Anorectal Physicians Branch, Clinical Guidelines Working Committee of Chinese Medical Association Anorectal Physicians Branch. Chinese expert consensus on clinical diagnosis and treatment of fecal incontinence (2022 edition) [J]. Chinese Journal of Gastrointestinal Surgery, 2022, 25(12): 1065-1072. DOI: 10.3760/cma.j.cn441530-20221012-00409.

[7] Urology Management Branch of Guangdong Medical Industry Association. Expert consensus on nursing care for elderly patients with urinary incontinence [J/CD]. Chinese Journal of Laparoscopic Urology (Electronic Edition), 2022, 16(5): 389-393.

Author: Wu Fang, Gao Caiping, Tongji University Affiliated Yangzhi Rehabilitation Hospital

Chief Judge: Zhai Hua, Vice Chairman of the Science Popularization Working Committee of the Chinese Rehabilitation Medicine Association,

Secretary of the Party Committee of Yangzhi Rehabilitation Hospital Affiliated to Tongji University

The popular science content of this platform has been funded by the China Association for Science and Technology's Science Popularization Department's 2022 National Science Literacy Action Project "National Society Science Popularization Capacity Improvement Project-Rehabilitation Science Popularization Service Capacity Improvement Action Plan"