The year 2007 went down in health care history as a defining year in wound care. In case you were too busy working to keep up on the latest news, here's a quick recap. In January 2007, the condition commonly known as “diaper rash” was relabeled as “incontinence-associated dermatitis” by Mikel Gray, PhD, FNP, PNP, CUNP, CCCN, FAAN, and a panel of wound care thought and content leaders. Any health care practitioner working at the bedside with persons in need of assistance with activities of daily living knows that skin damage resulting from urine or fecal exposure is a common problem. The best solution for this is to treat the cause of the incontinence and stop the exposure.1,2 Addressing this issue, which has been covered extensively in the literature, is beyond the scope of this article.
As we work together to find the best solution for skin damage from incontinence that has resisted resolution, we should use a term that doesn't insult adults. “Peri-rash” is one term used instead of diaper rash. The perineum is the small area of skin between the anus and the external genitalia. Because an area larger than the perineum is affected, we suggest using the term from Gray, et al.'s white paper, incontinence-associated dermatitis, and its acronym, IAD.1
In February 2007, the National Pressure Ulcer Advisory Panel (NPUAP) culminated a 5-year process by reaching a consensus to improve the Pressure Ulcer Definition and Staging System.3 The Panel lists as a goal that staff use the new definitions to better differentiate between pressure ulcers (PrUs) and IAD.3 The document makes it clear that the system isn't meant to be used for other skin injuries, such as IAD. As we better define these 2 major types of skin injury, the nursing profession has the opportunity to respond by making a change in practice.
We've made strides in the past decade to standardize practice and reduce the incidence of PrUs. You can request from nearly any facility in the United States, and many abroad, to see their protocol for preventing PrUs. The standard protocol includes a risk assessment system and interventions to prevent skin breakdown. Confusion remains, however, about how these interventions are to be accomplished. One major area of focus to prevent PrUs is a protocol for keeping incontinent persons clean and dry.
Until we better define the skin damage that results from exposure to urine or feces, we can't define the best protocol. It's difficult to determine which process works the best (that's what clinical research does for us as we test interventions with real patients or residents) when we can't even agree on what to call the problem. IAD is often associated with PrUs and distinguishing between the two conditions in the buttock area isn't easy.1 Yet making the distinction is particularly important because prevention and treatment differ for each condition.
Building on Gray, et al.'s published “white paper” on naming and defining the problem of dermatitis due to incontinence, let's explore together a system proposed to help identify and treat cases of IAD.
Incontinence-associated dermatitis has been defined by Gray, et al.1 as “skin inflammation manifested as redness with or without blistering, erosion, or loss of the skin barrier function that occurs as a consequence of chronic or repeated exposure of the skin to urine or fecal matter” (Figures 1 and 2). The condition begins with simple maceration, but inflammation develops if exposure continues.1 In someone with darker skin tones, the inflammation may not look red but be a different color than surrounding skin— possibly yellow, white, or dark red/purple. For these persons, palpation can help you identify injured skin. Palpation may reveal induration, or firmness of the area as compared to surrounding tissue. A person who can communicate sensation may report burning, itching, or tingling. It is important to note this description is similar to that of the NPUAP stage I PrU, but the condition of IAD occurs as a result of exposure to urine or fecal matter. Therefore IAD injuries will not be confined to an area over a bony prominence. The injured area will have more irregular, diffuse margins in the locations exposed to the output. Another difference between IAD and PrUs is that IAD will not cause a full-thickness skin injury (unless complicated by infection). When palpating injured skin, pain usually worsens. Someone who can't speak may communicate this pain by withdrawing from touch or frowning. For persons who can speak but may not communicate the pain clearly, such as those with dementia, consider using a pain assessment tool such as that available from the Hartford Institute for Geriatric Nursing (http://www.hartfordign.org/).4
IAD is a vicious cycle of pain and increased disruption of barrier function. When the skin is overhydrated from exposure to moisture, it's no longer an effective barrier against further insults and is more likely to be damaged. The problem can be further aggravated by infection with fungus, such as Candida, or skin bacteria, such as Corynebacterium.1
The connection between IAD and PrU risk was made clear by Maklebust and Magnan,5 who showed that patients who are incontinent and immobile have a 37.5% greater risk of developing a PrU. The development of IAD also increases the risk of infection, the length of hospital stay, and morbidity. The injured skin in a commonly moist, dark area is a breeding ground for bacteria and fungus that can later spread to incisions or invasive lines.6,7 To avoid these complications, the cause of incontinence must be identified and treated. Until incontinence is resolved, the excrement must be contained when possible, and the skin must be consistently cared for and protected.8 Although many efforts are being made to reduce PrU rates, bedside practice in the area of incontinence care has been slow to change despite the growing body of knowledge that IAD prevention is an effective way to reduce PrU incidence.2
The Centers for Medicare & Medicaid Services (CMS) has revised hospital payment systems to deny reimbursement for expenses associated with high cost, preventable complications that develop during hospitalization. The CMS has selected PrUs as one of the initial preventable complications, and will not reimburse if the PrU is hospital-acquired.9 This new regulation took effect October 1, 2008. Identifying IAD and distinguishing it from a pressure injury can determine whether a facility is reimbursed by CMS. For example, a person admitted from a long-term–care (LTC) facility for surgery may have denudement on the buttocks because of IAD. If the admitting hospital provider codes the skin injury as a Stage III or IV PrU, the hospital will receive money to help care for that injury because it was present at admission.
Two possible scenarios, however, may constitute fraud in this situation. The first is that the LTC facility erred and the wound is actually a Stage III PrU over a bony prominence, not IAD. This means the LTC facility has wrongly entered data in the Minimum Data Set from which reimbursements are made. The other possibility is that the hospital provider wrongly believes the ulcer is a Stage III PrU, when it is actually IAD. The hospital would be billing CMS for a condition that isn't reimbursable. It's always been important to correctly identify these two injuries in order to care for them correctly, but now the stakes are even higher.
The overall economic costs of IAD are unknown, but the costs of preventive care have been estimated. The staff costs associated with the use of a soap and water method are higher than those associated with the use of no-rinse and combination products.10-12 Most soaps raise the pH level of the skin, defeating the “acid mantle” that is needed to protect skin against pathogens and fungal overgrowth. An all-in-one cleanser, moisturizer, and protectant offers a reasonable alternative to more labor-intensive methods of cleaning that must include separate application of a protective agent.11 By using a 1-step product, staff can more easily and effectively comply with skin-care recommendations, because the protectant is automatically included. According to the literature, consistency is the key to preventing IAD. Applying protectants may also assist in preventing other skin injuries such as PrUs and skin tears.
This intervention has been recommended in a national effort to reduce harm to patients. The 5 Million Lives Campaign sponsored by the Institute for Healthcare Improvement (IHI) targeted 2007 and 2008 as the years to tackle PrUs.13 In the IHI's “Getting Started Tool Kit,” one of the interventions recommended is the use of the all-in-one cloth to cleanse, moisturize, and protect the skin of incontinent patients.13 No-rinse skin cleansers are preferable to soap and water because many soaps are harsh, and the all-in-one products are made to be gentle to skin that is at-risk for injury.14,15
Providing the no-rinse cleanser in a disposable cloth is recommended because the cloths are softly woven to reduce the friction that can further harm skin that may be more fragile because of repeated exposure to moisture.
Protecting persons from harm is the most compelling reason to tackle IAD aggressively, and there are other reasons. For a manager, one focus may be the costs associated with staff time, prevention or treatment products, and laundry. The high cost of pain and suffering to persons with IAD is well known to any caring clinician at the bedside. IAD is painful, and each episode of incontinence necessitates a clean-up that can be excruciating. The pain of IAD is likened to that of burns on an individual's buttocks and thighs. Imagine a small burn on your finger from touching the edge of the oven or a hot pan and multiply this pain a hundred times to get an idea what someone with IAD experiences. The pain often increases morbidity and possibly the length of hospital stay because progress toward activity is impeded.6,7 Because of pain, the person may be uncooperative if asked to ambulate or to sit up in a chair. Yet, when refusing to get out of bed, the person is more vulnerable to the well-documented hazards of immobility.
Significance of the problem
IAD presents a group of signs and symptoms that registered nurses report as part of an assessment, just as PrUs are named and staged. Early skin changes of IAD such as color change, induration or tenderness should be documented so interventions can be planned based on findings. If the problem worsens, causing weeping, denudement of skin or a skin infection, for example, contact the individual's primary care provider to collaborate on the treatment plan of care.
Urinary and/or fecal incontinence has been reported in 19.7% of patients in acute care hospitals2 and in up to 78.6% of nursing home residents.16 Of the incontinent patients in acute care settings, as many as 42.7% have some associated skin injury. In a study conducted in 3 acute care facilities, exposure to stool was linked with a higher prevalence of skin injury (45.8%) than was exposure to urine (29.7%).2 As many as 5.6% to 50% of residents in long-term settings will develop IAD.1
Does the nursing staff in your organization truly know the difference between a PrU and IAD if the person's skin damage is in the buttocks area? Clearly defining IAD and using consistent language when charting and reporting skin injuries differentiates PrUs from IAD, which can result in better skin health outcomes and cost savings through more focused problem-specific care. For example, a person with IAD may not need the time-intensive repositioning and more costly pressure-redistributing devices required by someone with a PrU.
Having a skin split in the gluteal cleft (Figure 3) related to moisture exposure doesn't necessitate a specialty mattress if it is not located over a bony prominence, but this type of injury is often classified as a Stage II PrU and the PrU care plan will be implemented. More correct naming of the injury will also result in more accurate reporting of statistics for related skin problems, especially the prevalence and incidence of PrUs.
One step toward differentiating between the 2 types of skin injury is recommended by one of the authors, Ms. Junkin. An organization can define in its policies a pressure ulcer as a skin injury over a bony prominence. Using this method, a nurse can palpate for a bony prominence even when lighting is poor and visualization is difficult. This would narrow the definition currently in place from the NPUAP which adds the word “usually” over a bony prominence. The NPUAP has included the word usually because it is true that there are other pressure-related ulcers, such as those caused by devices. The advantage in separating device-associated ulcers, such as damage from lying on a catheter or ischemic injury to a nare from a nasogastric tube, is that an organization can ensure that appropriate interventions are used. For example, a device-associated ulcer care plan would address manipulation of the device to avoid pressure and possibly application of a hydrocolloid to protect skin from friction at the edge of a cast or boot. But if the person's Braden Scale for Predicting Pressure Sore Risk17 score doesn't indicate high risk for a PrU over a bony prominence, there is no need for a specialty bed or turning 30 degrees every 2 to 4 hours as recommended in the WOCN Pressure Ulcer Prevention and Treatment Guidelines.18
Another injury that involves pressure occurs in adipose tissue in a person who is obese. Ischemia of adipose tissue in a pannus or any other area can result in necrotic tissue and deep injury. Caregivers won't be able to palpate a bony prominence, but pressure on the adipose tissue from a bed or wheelchair that's too narrow may be what caused the injury. However, the care plan for adipose tissue folds should be different in some ways than the regular PrU care plan because of the bariatric needs to be met.
This method of separating the types of skin injury more clearly would be similar to the way neuropathic injuries are defined. Although it is true that pressure (and shear) over a bony prominence definitely causes a diabetic foot ulcer, if the person is diabetic with neuropathy, the injury is called a neuropathic ulcer because there are different interventions needed. In this case, there must be a method of removing the pressure (off-loading) from the bony prominence, but it is also essential to control the serum glucose levels and debride the callus at the edges that is characteristic of neuropathic ulcers.
Health care providers must do more with less in the current economic environment. There are only so many hours in a shift. Defining issues very clearly will help save time by helping focus the interventions most effective for that specific problem. If staff is busy turning people every 2 hours even though their pressure ulcer might be related to devices, not bony prominences, they certainly have less time to give to other needs. Saving time by choosing interventions specific to the problem allows staff to focus on persons with urgent needs; for instance, more quickly caring for those who are fecally incontinent—a condition that has been shown to increase the risk of PrUs by 22 times.5
IAD risk assessment
The risk of IAD is higher in some persons than in others. Fecal incontinence, frequent incontinence, poor skin condition (for example, changes due to aging or steroid use), pain, poor skin oxygenation, fever, constant exposure to moisture, the use of products to contain incontinence that do not allow the skin to breathe, and decreased mobility all put the person at a higher risk.1 Of these intrinsic and extrinsic factors, fecal incontinence appears to be the factor most strongly associated with IAD.2
Consistent skin care following a protocol for the prevention or treatment of IAD may reduce the incidence of IAD.1 Accurately identifying persons at risk of IAD allows caretakers to take the appropriate steps for prevention. The assessment tool should specifically address the risks that lead to IAD, not one proven for use in predicting PrU development such as the Braden Scale for Predicting Pressure Sore Risk.
The Perineal Assessment tool (PAT) described by Nix19 is a 4-item tool that specifically assesses the risks that lead to IAD on the basis of factors known to lead to skin damage (Table 1).19 The duration of exposure to an irritant such as urine or feces, the intensity or type of irritant, the perineal skin condition, and factors that can cause diarrhea (for example, antibiotic treatment) are all taken into account. Each of the 4 items evaluated with this tool is rated with a score ranging from 1 to 3, which results in total scores of 4 (least at risk) to 12 (most at risk).19 A score of 4–6 is considered low risk, a score of 7–12 is considered high risk. Wound specialty nurses have tested this tool and found it to be a valid way of measuring IAD risk.19 However, it needs to be tested further to establish its reliability when used by staff nurses and to ensure that it is quick and easy to use before recommended for bedside use. Also, the tool isn't intended to instruct clinicians how to respond to the risk levels.
The presence and severity of IAD needs to be determined with a standardized tool that accurately and reliably assesses skin injury in persons who are incontinent. The Perirectal Skin Assessment Tool (PSAT)20 is an example of such a tool and is described in Table 2. This tool uses descriptions of skin color and skin integrity to estimate the amount of skin damage caused by the incontinence.
The rating scale developed by Kennedy and Lutz21 is a tool that can be used to categorize IAD according to a cumulative score based on points given in each of 3 categories (Table 3). The categories of assessment are the area of skin breakdown, skin redness, and skin erosion.21 This tool involves the use of assessments that measure the amount of skin affected and asks the user to determine whether the damage affects only the epidermis or both the epidermis and the dermis.
The PSAT and the Kennedy and Lutz score have the advantage of being specifically designed to classify skin injury due to incontinence. They're based on information in the literature describing the physiologic and clinical conditions that contribute to skin injury in incontinent persons and don't depend on descriptions that were originally intended to describe PrUs. These tools are especially useful in research applications for which the most precise measurement is needed. They haven't been used extensively in clinical settings, however, possibly because they involve measurements of the affected skin, which are often inaccurate and time consuming. Because changes in the skin due to incontinence can occur within hours of exposure, clinicians may be concerned that the measuring would need to be done quite frequently to be accurate. Clinicians may also be concerned about whether they can differentiate between injury to the epidermis and injury to the dermal layers of the skin. Regular assessments of the skin based on a general description of the skin should be documented until a tool to assess IAD is developed and proven to be valid and clinically useful. Many of the terms used in the scales discussed are useful for charting, such as red and dry or red and weepy. Keep in mind that IAD should be categorized as a superficial wound because the NPUAP PrU staging system is not to be used for other skin injuries.
New scale proposed to classify and treat IAD
The authors propose a new IAD classification scale that builds on the work that has been done in this area. This scale involves the use of descriptions of the condition of the skin to determine which incontinent persons have developed IAD (see IAD Intervention Tool that accompanies the article.). The system doesn't require measurements or extensive training to use, so it's appropriate for all staff, licensed and unlicensed, to use. Although an unlicensed staff member doesn't assess and diagnose conditions, he can be taught through use of the visual cues to alert the licensed professional of a potential break in skin, such as IAD.
The main measures of this scale are a change in the color of the skin compared to surrounding skin (or feeling for induration/hardness in darker-skinned individuals), the presence or absence of blisters or weeping, and the presence or absence of symptoms in areas exposed to incontinence. These factors are used to determine whether the person has intact at-risk skin or mild, moderate, or severe IAD. These measures are similar to those used in other scales. What's different about this scale is that each of the categories is associated with suggested interventions, which guide nursing in developing a care plan to prevent further damage and heal the skin (see IAD Intervention Tool that accompanies the article.). This tool builds on the work already reported in the literature and offers the advantage of being quick and simple to use. It can be used each time the person is changed or cleaned because of an incontinent episode. The more frequently such tools are used, the more likely it is that clinicians or possibly even lay caregivers in the home will recognize the early onset of IAD and alert nurses to get a plan in place to prevent further damage.
What do we know so far?
Interventions for treating buttock or perineal skin breakdown have long been provided.3 Some of the previously accepted interventions have been questioned. Some of you may remember using heat lamps, or putting povidone-iodine and sugar onto the buttocks to help heal skin. Many of us thought that we were treating PrUs and still remember that many times they healed. Could it be that the skin healed because we were often treating IAD, not PrUs, and anything that helped keep the skin dry would promote healing because excess external moisture is the skin's enemy?
The dermal layer of skin must be moist, but the outer layer, the epidermis must remain dry. Hydration from the inside is essential, but when the epidermis is in contact with external moisture for too long, skin damage occurs as in the case of IAD. This type of skin damage, often termed “moisture-associated skin damage” is easily recognized when we spend too long soaking in the tub and note the white look, or maceration of the skin which then is shed. Persons with healthy skin have no trouble replacing this layer in the normal regeneration that occurs continuously, but for those with less ability to regenerate, such as the elderly, this represents yet another challenge.
We will continue our efforts to improve the prevention and treatment of IAD until the research identifying the ideal methods to use is conclusive. Until such time, the best known methods for preventing contact dermatitis to the skin from exposure to urine or feces are as follows:
1. Identify and treat the cause of incontinence— this is the best way to prevent IAD and improve the life of a person with incontinence. The following interventions are needed only in those cases where incontinence hasn't yet been resolved.
2. After determining that IAD is present or that the patient is at risk for IAD, regularly check the skin, especially if the skin color has already changed from the person's normal skin tones. Watch for skin color or integrity changes each time care is provided, such as turning or skin cleansing.
3. For someone who's incontinent, gently cleanse the skin with a product that has an acidic pH (close to the 5.5 pH of normal skin). The pH isn't provided on the packaging of most products, but can be determined by checking the Material Safety Data Sheet or by calling the manufacturer. Don't scrub while cleansing. Rather, take a couple of minutes to soak the skin clean by laying a cloth gently on the soiled skin and softly patting if needed. Avoid friction. The smoothly woven disposable cloths are preferred over a washcloth with loops that provide friction.
4. Use emollients and skin agents that soften and soothe the skin but that don't add excess water to the skin, which has already been damaged from excess moisture. Avoid products with strong concentrations of humectants (chemicals such as urea, glycerin, alpha hydroxyl acids, and lactic acid that retain water in the skin) because for persons who are frequently incontinent, the skin is already overhydrated or macerated from exposure to urine or feces and possibly sweat as well.
5. Position the high-risk person semi-prone 30 minutes 2 or 3 times a day, covered only by a sheet, to expose the skin to air. If the person is also high risk for PrU, continue the 30 degree turn every 2 to 4 hours on a pressure-redistributing surface for prevention of PrU injuries, but that doesn't take the place of the semi-prone position to get air to the buttocks.
6. Finally, apply a protectant to the skin (for example, dimethicone, liquid clear film barrier, petrolatum, or zinc oxide) to prevent injury from future episodes of incontinence. You can use a 1-step system for cleaning and adding emollients to the skin and applying a skin protectant to save time.1 This method is recommended as one of the steps for reducing harm to patients in the IHI 5 Million Lives Campaign.13 Despite the availability of an “all-in-one” product and research supporting the cost benefits and better skin health outcomes associated with this approach, some facilities continue to use a basin, soap, and water.22 This is an example of the disconnect between research and practice that is frequently seen in health care.
Improving comfort and skin health
IAD is a serious and common problem that must be addressed to improve skin health in every health care setting. The authors have proposed the use of the IAD Intervention Tool, which is based on simple descriptions of the skin's condition and associated photos as a means to make it easier to detect and treat IAD (see IAD Intervention Tool that accompanies the article.). Ultimately, the goal of the proposed tool is to improve comfort and skin health and to reduce the frequency and severity of IAD by identifying persons at risk.
1. Gray M, Bliss DZ, Doughty DB, Ermer-Seltun J, Kennedy-Evans KL, Palmer MH. Incontinence-associated dermatitis: a consensus. J Wound Ostomy Continence Nurs 2007;34(1):45–54.
2. Junkin J, Selekof JL. Prevalence of incontinence and associated skin injury in the acute care inpatient. J Wound Ostomy Continence Nurs 2007;34:260–9.
3. National Pressure Ulcer Advisory Panel. Pressure Ulcer Stages Revised by NPUAP. Available at: http://www.npuap.org/pr2.htm
. Accessed on September 16, 2008
5. Maklebust JA, Magnan MA. Risk factors associated with having a pressure ulcer: a secondary data analysis. Adv Wound Care 1994;7:25, 27–28, 31–34 passim.
6. Wishin J, Gallagher TJ, McCann E. Emerging options for the management of fecal incontinence in hospitalized patients. J Wound Ostomy Continence Nurs 2008;35:104–10.
7. Farage MA, Miller KW, Berardesca E, Maibach HI. Incontinence in the aged: contact dermatitis and other cutaneous consequences. Contact Dermatitis 2007;57:211–7.
8. Beitz JM. Fecal incontinence in acutely and critically ill patients: options in management. Ostomy Wound Manage 2006;52(12):56–58, 60, 62–66.
9. The Centers for Medicare & Medicaid Services. CMS guidelines. Baltimore, MD: CMS; 2007:47201, 47205.
10. Bale S, Tebble N, Jones V, Price P. The benefits of implementing a new skin care protocol in nursing homes. J Tissue Viability 2004;14(2):44–50.
11. Clever K, Smith G, Browser C, Munroe K. Evaluating the efficacy of a uniquely delivered skin protectant and its effect on the formation of sacral/buttock pressure ulcers. Ostomy Wound Manage 2002;48(12):60–7.
12. Narayanan S, Van Vleet J, Strunk B, Ross RN, Gray M. Comparison of pressure ulcer treatments in long-term care facilities: clinical outcomes and impact on cost. J Wound Ostomy Continence Nurs 2005;32:163–70.
14. Hodgkinson B, Nay R, Wilson J. A systematic review of topical skin care in aged care facilities. J Clin Nurs 2007;16(1):129–36.
15. Zimmaro Bliss D, Zehrer C, Savik K, Thayer D, Smith G. Incontinence-associated skin damage in nursing home residents: a secondary analysis of a prospective, multicenter study. Ostomy Wound Manage 2006;52(12):46–55.
16. Bliss DZ, Zehrer C, Savik K, Smith G, Hedblom E. An economic evaluation of four skin damage prevention regimens in nursing home residents with incontinence: economics of skin damage prevention. J Wound Ostomy Continence Nurs 2007;34:143–52.
18. Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for prevention and management of pressure ulcers. Glenview, IL: Wound, Ostomy, and Continence Nurses Society (WOCN); 2003. 52 p. (WOCN clinical practice guideline; no. 2).
19. Nix DH. Validity and reliability of the Perineal Assessment Tool. Ostomy Wound Manage 2002;48(2):43–9.
20. Brown DS. Perineal dermatitis: can we measure it? Ostomy Wound Manage 1993;39(7):28–31.
21. Kennedy KL, Lutz J. Comparison of the efficacy and cost-effectiveness of three skin protectants in the management of incontinent dermatitis. Proceedings of the European Conference on Advances in Wound Management; October 4, 1996; Amsterdam, Netherlands.
22. Larson EL, Ciliberti T, Chantler C, et al. Comparison of traditional and disposable bed baths in critically ill patients. Am J of Crit Care 2004;13(3):235–41.
© 2008 Lippincott Williams & Wilkins, Inc.