Skin Care and Incontinence Management
People who suffer from incontinence are at risk of skin damage. Skin areas most affected are near the buttocks, hips, genitals, and between the pelvis and rectum (perineum). Excess moisture in these areas causes skin problems such as redness, peeling, irritation, and yeast infections. The most common condition related to incontinence and skin care is moisture-associated skin damage (MASD).
MASD is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus. The skin is a brick and mortar structure with the cells as the bricks and intercellular lipid matrix as the mortar holding it together. The lipid matrix is responsible for slowing the movement of water, as well as electrolytes, yet storing the water needed for adequate hydration. When exposed to excessive amounts of moisture, the skin will soften, swell, and become wrinkled, making it more susceptible to damage. This can also be worsened by drying soaps and detergents, occlusive dressings, or containment devices.
Incontinence-associated dermatitis (IAD) is the most relevant type of MASD in regard to this topic. IAD is predominantly a chemical irritation resulting from urine or stool coming in contact with the skin. Ammonia from urine and enzymes from stool can disrupt the acid mantle of the skin and eventually cause the skin to break down.
Exposure to urine and feces is one of the most common causes of skin breakdown and makes the skin more susceptible to the following types of injuries:
Over-exposure to moisture can cause the skin to become macerated (waterlogged), which makes the skin very fragile. This added fragility puts the skin at greater risk for damage caused by friction, shear, and pressure. Once skin is macerated, even gentle rubbing by bed linens, diapers, and washcloths can cause injury.
A common condition related to incontinence is incontinence-associated dermatitis. Otherwise known as perineal dermatitis or diaper rash, this condition affects all age groups from infancy to old age. Perineal dermatitis involves the irritation and breakdown of the skin as a result of over-exposure to moisture and chemicals in urine and feces.
Another risk associated with incontinence is bacterial growth and infection. Incontinence allows the skin's surface to come in contact with bacteria from waste products. This is particularly dangerous for the elderly whose skin may be characteristically dry. Dry skin provides an opportune breeding ground for bacterial growth, as micro-organisms can be absorbed through skin cracks and fissures. When left unchecked, in a conducive environment, bacteria can double in number every 20 minutes!
Exposure to Caustic Agents
One of the caustic agents contained in urine is ammonia. Ammonia increases the pH of the skin, causing irritation. Ammonia is also used by bacteria as a source of nutrition, contributing to the reproduction of more micro-organisms. Without proper treatment, the cycle goes on and on. Individuals with fecal incontinence are at an even higher level of risk for bacterial colonization of the skin, as well as further deterioration of the skin by digestive enzymes in feces.
The damp, warm skin environment generally associated with incontinence is ideal for the proliferation of pathogenic fungi. A skin rash that is fiery red, itches, and burns is usually of fungal origin, and requires treatment with an antifungal agent in order to heal.
Taking Care of the Skin
Using adult diapers and other absorbent products may worsen the situation. Although they may keep bedding and clothing cleaner, these products allow urine or stool to be in constant contact with the skin. It is recommended to utilize underpads, which absorb urine and trap it away from the skin. Diapers worn in bed should be avoided unless absolutely necessary. A diaper free environment is optimal, however diapers may be necessary when patients are out of bed or if they are experiencing loose stools. Special care must be taken to keep the skin clean and dry.
The three essentials of IAD prevention are to cleanse, moisturize, and protect.
- Cleanse the skin with a mild soap that’s balanced to skin pH and contains gentle surfactants that lift stool and urine from the skin. Clean the skin routinely and at the time of soiling. Use warm (not hot) water, and avoid excess force and friction to avoid further skin damage.
- Moisturize the skin daily and as needed. Moisturizers may be applied alone or incorporated into a cleanser. Typically, they contain an emollient such as lanolin to replace lost lipids in the stratum corneum or silicones to provide a thin breathable barrier for the skin, as well as additional moisturization.
- Protect the skin by applying a moisture-barrier cream or spray if the patient has significant urinary or fecal incontinence (or both). The barrier may be zinc-based, petrolatum-based, dimethicone-based, an acrylic polymer, or another type.
Healthcare professionals agree that proper and consistent perineal care is essential when dealing with incontinence. Perineal refers to the area in front of the anus extending past the vagina in a female or the scrotum in a male. In order to maintain skin integrity, control odor and provide comfort, a three-step approach to incontinence care is recommended:
- Cleanse the perineal area by using gentle, but effective, cleansers to maintain skin integrity, control odor, and provide comfort and improved self-esteem. Appropriate cleansers for perineal skin care are non-irritating and non-drying and contain special ingredients to help gently remove dried fecal matter with minimal scrubbing.
- Condition and Protect perineal skin from continued exposure to moisture, irritating fluids, friction, dryness, and bacteria with barrier ointments and creams, and barrier sprays. Barrier ointments, creams and sprays are specifically designed to form a protective coating on the skin that minimizes skin contact with urine, feces and perspiration.
- Keep the Skin Dry by using products that have a soft top sheet next to the skin and an absorbent core which quickly wicks the moisture away and traps it.
Maintaining healthy skin in the face of incontinence is an important aspect to preventing further discomfort, and promoting a healthier, happier life. By taking the proper precautions and treating the conditions swiftly, patients and healthcare providers can manage the many skin care side effects associated with incontinence.
Beguin AM, Malaquin-Pavan E, Guihaire C, et al. Improving diaper design to address incontinence associated dermatitis. BMC Geriatr. 2010 Nov 22;10:86. doi: 10.1186/1471-2318-10-86.
Chatham N, Carls C. How to manage incontinence-associated dermatitis. Wound Care Advisor. https://woundcareadvisor.com/how-to-manage-incontinence-associated-derma.... Accessed November 17, 2017.
MedlinePlus. Skin care and incontinence. MedlinePlus. https://medlineplus.gov/ency/article/003976.htm. Updated November 6, 2017. Accessed November 17, 2017.
National Incontinence. How Incontinence Affects the Skin. National Incontinence. https://www.nationalincontinence.com/s/SkinCare. Accessed November 17, 2017.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of IncontinenceSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.