consensus statements, evidence-based guidelines for ... · incontinence-associated dermatitis...

Copyright © 2012 by the Wound, Ostomy and Continence Nurses Society™ J WOCN ■ May/June 2012 303

Copyright © 2012 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.

J Wound Ostomy Continence Nurs. 2012;39(3):303-315.Published by Lippincott Williams & Wilkins

CONTINENCE CARE

Incontinence-Associated DermatitisConsensus Statements, Evidence-Based Guidelines for Prevention and Treatment, and Current Challenges

Dorothy Doughty � Joan Junkin � Peter Kurz � Joan Selekof � Mikel Gray � Mandy Fader � Donna Z. Bliss � Dimitri Beeckman � Susan Logan

In 2010, an international consensus conference was held to re-view current evidence regarding the pathology, prevention, and management of incontinence-associated dermatitis (IAD). The results of this literature review were published in a previ-ous issue of this Journal. This article summarizes key consensus sta tements agreed upon by the panelists, evidence-based guidelines for prevention and management of IAD, and a dis-cussion of the major challenges currently faced by clinicians car-ing for these patients. The panelists concur that IAD is clinically and pathologically distinct from pressure ulcers and intertrigi-nous dermatitis, and that a consistently applied, structured, or defi ned skin care program is effective for prevention and man-agement of IAD. They also agreed that differential assessment of IAD versus pressure ulceration versus intertriginous dermati-tis remains a major challenge. Panel members also concur that evidence is lacking concerning which products and protocols provide the best outcomes for IAD prevention and treatment in individual patients. Issues related to differential assessment, product labeling and utilization, staff education, and cost of care are the primary focus of this article.

■ Report of Consensus Conference on Incontinence-Associated Dermatitis: Clinical Implications

In 2010, an international consensus conference was con-vened to review the current evidence base regarding prev-alence, pathology, prevention, and management of incontinence-associated dermatitis (IAD). The results of the literature review have been reported previously.1 Consensus statements from that article are summarized in Box 1. This article pro vides a summary of evidence-based guidelines for prevention and management of IAD, ad-dresses current challenges in the assessment and manage-ment of IAD, and reviews implications for practice and research.

IAD is a prevalent condition with signifi cant negative impact; it is painful, it places the patient at increased risk for secondary infection and for pressure ulcer develop-ment, and it can be costly and diffi cult to treat. Fortunately,

the increased recognition of IAD has led to additional re-search focusing on strategies for prevention and manage-ment, design and validation of assessment tools, and development of IAD-related products. While additional research is needed to determine specifi c elements of an evidence-based practice guideline for prevention and treatment of IAD, existing evidence supports implementa-tion of a defi ned or structured skin care regimen that in-corporates consistent and appropriate use of cleansers, moisturizers, and skin protectants.1,2

■ Evidence Gaps

Despite progress in recognition, prevention, and manage-ment of IAD, signifi cant gaps remain in both our evidence base and current practice that have implications for future

� Dorothy Doughty, MSN, Director of Emory University WOC Nursing Education, WOC Nursing Education Center, Emory University, Atlanta, Georgia.� Joan Junkin, MSN, RN, CWOCN, Wound Consultant at The Healing Touch, Bryan LGH Medical Center, Lincoln, Nebraska.� Peter Kurz, WPM Wund Pfl ege Management, Managing Director, Graduate Nurse for Wound Management, Vienna, Austria.� Joan Selekof, BSN, RN, CWOCN, Coordinator -Wound Ostomy Continence Nursing, University of Maryland Medical Center, Columbia.� Mikel Gray, PhD, FNP, PNP, CUNP, CCCN, FAANP, FAAN, Professor and Nurse Practitioner, University of Virginia Department of Urology and School of Nursing, Charlottesville.� Mandy Fader, PhD, Research Fellow, University College London, Centre for Clinical Technology & Science, London, England.� Donna Z. Bliss, PhD, RN, FAAN, Research Professor, University of Minnesota School of Nursing, Minneapolis.� Dimitri Beeckman, PhD, RN, SEANS, Assistant Professor, University of Ghent, King’s College London and Florence Nightingale School of Nursing & Midwifery, London, England.� Susan Logan, BSN, RN, CWS, FACCWS, Clinical Consultant, Kindred Healthcare, Inc, Louisville, Kentucky.The authors declare no confl ict of interest.Correspondence: Dorothy Doughty, MSN, Emory University WOC Nursing Education Program, 1762 Clifton Rd NE Ste 2200, Atlanta, GA 30322 ([email protected]).

DOI: 10.1097/WON.0b013e3182549118

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304 Doughty et al J WOCN ■ May/June 2012


research, caregiver education, and classifi cation and use of products for IAD prevention and management. Gaps iden-tifi ed during the consensus conference included (1) dif-ferential assessment of IAD, intertriginous dermatitis (ITD), and pressure ulcers; (2) appropriate classifi cation and use of products for prevention and management of IAD; (3) the critical importance of caregiver education, to include knowledge defi cits to be addressed and potential strategies for providing this education; and (4) direct and i ndirect costs of IAD treatment and prevention.

Differential AssessmentFor many years clinicians made no attempt to differentiate between lesions caused by moisture or moisture and fric-tion (top-down lesions) and those caused by pressure and shear (bottom-up injuries). As a result, moisture-related lesions were classifi ed as superfi cial (stage II) pressure ul-cers. In the last 2 revisions of the pressure ulcer staging system, the National Pressure Ulcer Advisory Panel (NPUAP) added a caveat to the defi nition of stage II ulcers: “This category should not be used to describe skin tears, tape burns, IAD, maceration, or excoriation.”3,4 This state-ment refl ects the growing consensus that differentiation between pressure ulcers and other types of lesions, such as moisture-related lesions, is clinically necessary.

One challenge in the assessment and management of IAD is the accurate differential classifi cation of IAD versus other forms of moisture-associated skin damage, specifi -cally intertriginous dermatitis, versus a stage 1 or stage II pressure ulcer.5-8 As noted in the literature review summa-rized by Gray and colleagues,1 IAD is frequently misclassi-fi ed as a pressure ulcer despite the fact that IAD is not caused

by ischemia; studies indicate poor agreement among clini-cians in terms of differential classifi cation of pressure ulcers and moisture lesions such as IAD. In 2006, DeFloor and col-leagues6 evaluated interrater reliability of nurses when cat-egorizing pressure ulcers and differentiation of pressure ulcers versus IAD based on photographs. Four hundred seventy-three nurses assessed 56 photographs and classifi ed each wound as “normal skin,” “blanchable erythema,” “pressure ulcer grade 1, 2, 3, or 4,” or “incontinence lesion.” The overall kappa was 0.37, and the investigators noted that incontinence lesions were frequently classifi ed incor-rectly.6 Beeckman and colleagues5 conducted a large study involving 1452 nurses in 5 European countries, using pho-tographs of normal skin, blanchable erythema, each grade/stage pressure ulcer, moisture lesions, and combined le-sions. They reported that only 22% of the moisture lesions were classifi ed accurately although accuracy was slightly higher among experienced nurses and those who had at-tended wound care training programs. In a separate study, Beeckman and associates9 evaluated baseline accuracy in pressure ulcer classifi cation and compared an e-learning program and a 1-hour lecture in terms of improved accu-racy. Their sample included 212 nurses and 214 senior nurs-ing stu dents. Preintervention scores revealed low accuracy in classifi cation; scores improved signifi cantly following educational intervention. The levels of agreement prior to the educational program are consistent with those of Mahoney’s group,10 who conducted a study in the United States evaluating the level of agreement among WOC nurses when asked to classify pressure, moisture and mix moisture, and pressure lesions based on photographs; they reported an overall kappa score of 0.1708.

BOX 1.

Summary of Consensus Statements From the Incontinence-Associated Dermatitis (IAD) Consensus Conferencea

IAD is now the accepted term for skin damage caused by exposure to stool or urine.Variability in reported prevalence and incidence rates of IAD may be attributable to differences in care setting, the prevalence and character of the underlying incontinence (urine, fecal double urinary, and fecal incontinence), and lack of a fully developed assessment tool to

measure IAD.Clinical observation and histopathologic analysis suggest that IAD is the result of “top-down” injury.The major etiologic factors for IAD are exposure to urine or stool, with liquid stool identifi ed as a particularly potent irritant.Factors contributing to the development and severity of IAD include high levels of Staphylococcus aureus or Candida albicans

The role of absorptive products in the pathogenesis of IAD is not well understood. The use of occlusive absorptive products has been associated with an increased likelihood of IAD; the use of modifi ed products that provide enhanced water vapor transmission may reduce

the risk of IAD.Differential assessment of IAD, pressure ulcers, and other forms of skin damage is diffi cult for both staff nurses and wound care nurses; accuracy in differential assessment is positively impacted by education and by the use of structured differential assessment tools.There is a dearth of evidence regarding best regimens for prevention and treatment of IAD, although most studies do support consistent use of a well-defi ned skin care regimen.Current clinical consensus supports the following as key components of an effective program for IAD prevention: Gentle cleansing with a no-rinse cleanser with pH range similar to normal skin. Moisturization to maintain normal levels of intercellular lipids and the skin’s normal barrier function. Application of moisture barrier product (petrolatum-based, dimethicone-based, zinc oxide–based, or liquid fi lm-forming acrylates).

a From Gray et al.1


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Houwing and associates11 suggest that a ccurate dis-tinction between IAD and pressure-induced ulcers is nei-ther feasible nor important. However, members of the IAD consensus document concur that misclassifi cation is a problem, for several reasons: (1) effective treatment of any type of skin breakdown must include correction of etiologic factors, and measures to protect against pro-longed pressure are quite different from those designed to correct exposure to urine and stool; (2) misclassifying IAD as a pressure ulcer increases the agency’s risk for litiga-tion, since pressure ulcers are now considered to be med-ical errors; (3) misclassifi cation of IAD lesions as pressure ulcers compromises the integrity and validity of preva-lence and incidence data and makes meaningful bench-marking impossible; and (4) incorporation of IAD lesions in pressure ulcer prevalence data prevents accurate mea-surement of the prevalence and incidence of both condi-tions and does not allow comparison of data for benchmarking purposes.10

Given differences in etiology and pathophysiology, ac-curate classifi cation of IAD versus pressure ulceration ap-pears straightforward on initial consideration. Pressure ulcers are ischemic lesions, caused by tissue and vessel de-formation that leads to progressive tissue hypoxia and death. Pressure ulcers are characterized as bottom-up inju-ries, because they originate in deep tissue layers and prog-ress toward the surface.10-12 They typically present as full-thickness wounds located over bony prominences or under medical devices, are characterized by signifi cant tis-sue necrosis and tissue loss, and are often associated with undermining and tunneling.3,13,14 In contrast, IAD is an infl ammatory response to prolonged exposure of the skin to stool and/or urine; the lesions are characterized as top-down injuries that initially present as erythema of intact skin but may progress to vesicle formation and epidermal

loss, especially when the area is also exposed to fric-tion.7,15,16 Thus the location, depth, and characteristics of pressure ulcers and IAD differ considerably; Table 1 high-lights these differences.

So why is accurate classifi cation of IAD lesions and pressure ulcers such a challenge? Several factors contribute to the diffi culty clinicians experience when classifying le-sions as IAD or pressure ulcer. Many patients who are at risk for IAD are also at risk for pressure ulcer development; indeed, some patients are very likely to have mixed etiol-ogy lesions. Another is the fact that both stage 1 pressure ulcers and mild to moderate IAD present clinically as ery-thema of intact skin, even though the underlying etio-logic factors differ. The erythema associated with stage 1 pressure ulcers represents an infl ammatory response to ischemic damage involving the subdermal tissues, while the erythema associated with IAD represents an infl amma-tory response to irritant exposure that is confi ned to the epidermis and dermis. A lesion that is exposed to both pressure and stool or urine presents a diagnostic dilemma, because visual inspection and palpation may not allow the clinician to accurately determine the depth of the injury and magnitude of infl ammation. In these cases, clinical experience suggests that assessment of the lesion’s blanch-ability may help clarify etiology. Wounds that are associ-ated with a pressure/shear etiology are characterized by nonblanchable erythema. Therefore, the clinician can be taught to gently press on the erythematous area to deter-mine whether or not it blanches. Lesions that do not and are located over a bony prominence should be classifi ed as a stage I pressure ulcer.3 Adequate environmental lighting and clear exposure of the involved area are critical to ac-curate assessment of erythema and determination of blanchability. Skin pigmentation also infl uences assess-ment accuracy; erythema is especially diffi cult to detect in

TABLE 1.

Differential Classifi cation of Pressure Ulcers, Incontinence-Associated Dermatitis (IAD), and Intertriginous Dermatitis (ITD)

Pressure Ulcer IAD ITD

Location Over bony prominence or under medical device

Perineum; perianal area; inner thighs; buttocks

Intergluteal cleft Groin creases

Associated factors Reduced mobility May have reduced sensory awareness

Urinary and/or fecal incontinence Diaphoresis

Depth Initially may present as stage I or sDTI; ultimately usually full

thickness (III/IV)

Usually partial thickness Usually partial thickness, at least initially

Shape/distribution Typically round; if shear involved, may be oval/elongated; distinct

borders

Irregular and indistinct borders common

Linear break in skin

Associated fi ndings May have necrotic tissue; may have undermining or tunneling

Surrounding skin typically macerated

Surrounding skin frequently macerated

Abbreviations: IAD, incontinence-associated dermatitis; ITD, intertriginous dermatitis.




darkly pigmented skin. In this case, accurate assessment requires palpation of the tissue to determine changes in fi rmness or temperature.

Partial-thickness skin loss also may result in confusion with differential classifi cation of IAD versus pressure ul-cers. Pressure ulcers are ischemic lesions that begin in the deep tissue layers and progress toward the surface, and partial-thickness lesions represent epidermal loss with preservation of deep dermal and underlying tissue layers. Therefore, it seems unlikely that partial-thickness lesions represent pressure-induced injuries. Nevertheless, stage II pressure ulcers are defi ned as “partial thickness loss of der-mis presenting as a shallow open ulcer with a red pink wound bed, without slough [that]… may also present as an intact or open/ruptured serum fi lled or serosanguinous fi lled blister.”3

Differentiation between IAD and intertriginous der-matitis also may lead to confusion in classifi cation. Intertriginous dermatitis is defi ned as skin damage caused by trapped perspiration and frictional forces between op-posing skin surfaces and typically presents as infl amma-tion and linear lesions occurring at the base of skin folds (eg, beneath the pannus, underneath pendulous breasts, or in the groin crease).16,17 It involves skin damage from internally produced moisture (perspiration); thus, preven-tion and management of these lesions involves strategies to wick moisture away from skin creases and to keep the skin dry and supple. In contrast, IAD involves skin damage caused by exposure to external moisture sources, specifi -cally stool and urine, and management involves the use of skin protectant products.15,17

Tools that may aid clinicians in the accurate classifi ca-tion of IAD and ITD versus pressure ulcers include diag-nostic instruments designed to detect early changes in the skin layers and soft tissues that correspond to superfi cial and deep tissue damage. Bates-Jensen and colleagues18 used electrical capacitance testing to evaluate subepider-mal moisture content (SEM) as a predictor of pressure ulcer development, especi ally in patients with darkly pig-mented skin. In their pilot testing, higher SEM levels were associated with PU development, but no instrument for clinical measurement of SEM measurement is currently available. Andersen and Karlsmark19 evaluated 4 diagnos-tic instruments for their ability to detect changes in the soft tissue characteristic of pressure ulcer development: (1) a handheld spectrometer for assessment of erythema, deemed especially useful in darkly pigmented skin; (2) a handheld infrared scanner capable of detecting small dif-ferences in skin temperature; (3) a device involving a suc-tion cup and photosensors that was designed to detect changes in skin elasticity; and (4) a 20-MHz ultrasonic scanner designed to detect changes in the soft tissue con-sistent with edema formation and/or tissue damage/ne-crosis. In their study of 11 patients with 15 pressure ulcers, they reported that the ultrasonic scanner provided the most defi nitive and consistent indicators of deep tissue

damage. Specifi c ultrasound fi ndings indicative of under-lying tissue damage included hypoechogenic layers or pockets consistent with edema formation, and loss of clear differentiation of the various skin layers.12,19,20 Aoi and col-leagues12 used a 10-MHz ultrasonic scanner and identifi ed discontinuity of the fascia layer as an additional indicator of deep tissue damage. Deprez and colleagues21 suggest that pressure ulcer development is characterized by stiff-ening of the involved tissue, and that this stiffening can be detected through anot her ultrasound measurement, tissue elastography. Further study is needed to elucidate the value and clinical utility of tissue elastography for dif-ferential assessment of pressure ulcers versus other lesions.

One ultrasound system is available for use in the clini-cal setting; the EpiScan I-200 (Longport Digital Scanner, Glen Mills, Pennsylvania) uses a 20-MHz probe to image the skin and 2 cm of underlying tissue. An observational study compared ultrasonic images of healthy volunteers with images of patients deemed at risk for pressure ulcer-ation. Fifty-fi ve percent of the ultrasonic images from pa-tients deemed at risk for pressure ulceration revealed fi ndings consistent with early pressure-induced changes in the soft tissues, whereas images from the healthy vol-unteers revealed only normal fi ndings. The investigators in this study also evaluated the ability of the Epi-Scan to determine differences in skin and soft tissues exposed to friction and those exposed to pressure. They found that friction lesions were associated with subepidermal edema but no changes in the deeper tissues. In contrast, pressure injury was associated with edema that extended into the subdermal tissues. These fi ndings suggest that ultrasonic imaging may hold signifi cant potential for improving our capacity for both early detection of skin and soft tissue injury and differential assessment of superfi cial and deep tissue damage.20 However, this device has not gained wide-spread clinical use and a literature search revealed no con-trolled studies verifying initial observations.

The Thermographic Imaging System (Wound Vision, Indianapolis, Indiana) has also been investigated for its ability to detect pressure damage to tissue before ulceration occurs. The device employs infrared thermography to visu-alize the skin and subcutaneous tissue. This instrument is newly available to clinicians but not yet widely used. Additional research is needed to determine its role in early detection of pressure injury to subcutaneous tissues.22

Despite progress in the development of technologic aids to early diagnosis, clinicians currently must rely on visual and palpatory assessment of damaged skin to deter-mine probable etiology. In addition, limited tools are available to aid clinicians in reliably differentiating pres-sure/shear injuries from moisture-related lesions such as IAD and ITD. The European Pressure Ulcer Advisory Panel (EPUAP) developed and published a guidance document titled “Pressure Ulcer Classifi cation: Differentiation Between Pressure Ulcers and Moisture Lesions.”15 This document provides a chart that compares pressure ulcers,




moisture lesions, and mixed lesions in terms of causative factors, location, shape of the lesion, anatomic depth of the lesion, presence of necrosis, edge characteristics, and color of the lesion and surrounding skin.

Guidelines for differential assessment and classifi ca-tion of IAD and pressure ulcers have been incorporated into EPUAP’s Pressure Ulcer Classifi cation Self-Assessment Tool (PUCLAS). This document provides instruction to the clinician along with a self-evaluation exercise designed to improve skills classifying (grading) pressure ulcers and dif-ferentiating pressure ulcers from moisture lesions. Beeckman and colleagues23 conducted a randomized con-trolled trial to evaluate the effi cacy of the PUCLAS tool in improving nurses’ ability to accurately differentiate be-tween pressure ulcers and IAD. They enrolled 1217 nurses from 4 European countries. Participants were asked to classify 20 photographs as either IAD, pressure ulcer, or mixed etiology wound; the etiology of the wounds in the photographs were determined by unanimous consensus from a panel of wound care experts. Participants received no feedback regarding the accuracy of their baseline clas-sifi cations. Following baseline data collection, participants allocated to the intervention group received education on differential assessment that included lecture, PowerPoint photos, video, and exercises. The control group received a 15-minute review of the various grades of pressure ulcers according to the EPUAP classifi cation system. Participants were then asked to classify 40 photographs for etiology. Baseline classifi cation accuracy was 44.5%, with no differ-ence between the control and intervention groups. Nurses’ ability to accurately differentiate between IAD and pres-sure ulcers was improved signifi cantly when results of the intervention group were compared to those of control subjects (70.7% vs 35.6%, P � .001).23 While the fi ndings of this study provide evidence that PUCLAS is effective for differentiation of IAD versus pressure ulcers, the tool has not been widely disseminated in the United States. Instead, the only tool available in the United States for improving accuracy in wound classifi cation is the NEOCS (N. E. One Can Stage, NE Solutionz, LLC, Las Vegas, Nevada). The effects of this tool were evaluated in a single pilot study that enrolled 101 clinicians who were asked to classify 10 wound photos accompanied by brief case de-scriptions.24 Young and colleagues24 reported that the NEOCS, combined with a 5-minute scripted education in-tervention, increased accuracy in pressure ulcer staging by 37.7%. The NEOCS is not yet widely available and its con-tribution to differentiating pressure ulcers from IAD has not been thoroughly evaluated.

■ Implications for Research and Practice

These observations clearly illustrate that differential diag-nosis of pressure ulcers, IAD, ITD, and mixed-etiology wounds has tremendous signifi cance for the clinician. The consensus panel, therefore, strongly supports utilization

of the PUCLAS tool or a comparable instrument to guide the clinician in differential assessment. Consistently ac-curate differential assessment requires agreement among clinicians regarding the pathology and presentation of pressure ulcers, IAD, ITD, and mixed lesions, and current data indicate that obtaining consensus on these issues will be a major challenge. Results of studies based in the United States and Europe5,6,9,10,25 consistently reveal that accurate classifi cation remains a challenge. A consensus session sponsored by the WOCN Society revealed that inclusion of partial-thickness lesions in the NPUAP staging system for pressure ulcers contributes signifi cantly to confusion among clinicians.25 Based on these fi ndings, consensus panel members recommend that the WOCN Society and NPUAP collaborate on a consensus statement regarding guidelines and tools for differential assessment of pressure ulcers, IAD, ITD, and mixed etiology lesions.

■ Product Selection and Classifi cation

Effective prevention or management of IAD requires the appropriate use of incontinence care products, which re-quires the clinician to be knowledgeable regarding the various products and the indications, contraindications, and guidelines for their use. Clinicians have access to a robust range of products, variously labeled as cleansers, moisturizers, moisture barriers, skin protectants, moisture barrier pastes, and antifungals. The variety of available products indicates the availability of a product for almost all of the skin care problems commonly encountered by clinicians seeking to prevent and manage IAD. However, this variety may render it diffi cult for the bedside nurse to select the optimal product for a given patient. This chal-lenge is exacerbated by a lack of consistency in product names and absence of a grading scale designed to aid clini-cians when selecting products based on severity of IAD, irritant source, and presence of complications. For exam-ple, patients with dry, fl aky, and rough-textured skin, those with macerated and overhydrated skin, persons with denuded skin, or patients with candidiasis require different products. The patient with very dry rough skin is best managed with a highly effective moisturizer that con-tains both emollients and humectants.26 Such a product would be inappropriate for a patient with macerated over-hydrated skin. In this case, the clinician should select a nonocclusive emollient that softens the skin; the addition of a humectant is contraindicated in this case because it attracts further moisture to the area, exacerbating rather than alleviating maceration. Emollients and humectants are also not indicated for the patient with damaged de-nuded skin; this person requires a skin protectant that adheres to the moist damaged skin, and provides absorp-tion of moisture. Finally, the patient with candidiasis re-quires a product with an effective antifungal agent. Selection of the best product in this case must be com-bined with the optimal delivery vehicle for the antifungal,




either a powder, cream, or ointment, depending on the presence of factors discussed earlier.

Consensus panel members identifi ed 4 primary prob-lems related to product labeling. Skin care products are classifi ed and regulated by the US Food and Drug Administration based on the following 3 categories: (1) prescription products, such as topical antifungal prepara-tions; (2) over-the-counter drugs such as zinc oxide protec-tant pastes; and (3) cosmetic products, including many of the moisturizing agents. The rules for labeling and the order in which ingredients are listed vary based on cate-gory. For example, inactive ingredients in over-the-coun-ter drugs must be listed alphabetically, while the ingredients in cosmetic products must be listed in de-scending order of predominance.27 This makes direct product comparisons diffi cult. While 2 products appear similar based on the list of inactive ingredients, the rela-tive amounts of these ingredients may signifi cantly differ owing to the Food and Drug Administration classifi cation and its effect on product labeling. In addition, many clini-cians select skin care products based on the category listed on the front of the tube (eg, moisturizer, moisture barrier, etc) rather than individual ingredients. Product labels pro-vide broad categories, but they may not provide suffi cient information for clinical decision making. For example, to many clinicians, the term moisturizer means that the product adds moisture (water) to the skin, and they reason that such products are unnecessary or even inappropriate for an incontinent patient with overhydrated skin. However, the term moisturizer describes products that provide oils or dimethicone to replace lost lipids and slow transepidermal water loss.28,29 Clinicians may not under-stand the importance of replacing lost intercellular lipids when the skin is overhydrated. This confusion is increased because moisturizers may contain emollients, humec-tants, or both. Consensus panel members noted that many clinicians may be unaware of the difference between emollients and humectants, because these terms are pri-marily used by dermatologists and manufacturers rather than by nurses who typically deliver this care.

Similarly, the product category skin protectant (some-times labeled moisture barriers) provides general guidance but does not substitute for consideration of individual in-gredients. Some moisture barriers are occlusive and there-fore contraindicated for overhydrated skin, while others (such as zinc oxide paste) are somewhat astringent and contraindicated for dry skin. Skin protectants also vary in the magnitude of protection from exposure to irritants, but we have inadequate evidence to rank these products based on their barrier function while preventing macera-tion of underlying skin. In addition, we have inadequate evidence to determine the effect of the concentration of active ingredients. For example, dimethicone is classifi ed as a nonocclusive emollient and skin protectant, but some products contain 1% dimethicone, while others contain 3% or 5% dimethicone.

Because of these defi cits in knowledge and clinical evi-dence, it is not surprising that product selection remains a challenge for clinicians when preventing and managing IAD. Failure to recognize IAD as a specifi c clinical diagno-sis, combined with absence of clear guidelines for manage-ment, may lead to ineffective or inappropriate application of a variety of topical agents. This confusion is refl ected in recommendations from multiple blogs and Web sites pro-moting a variety of questionable and unsubstantiated claims concerning the prevention and management of IAD or diaper dermatitis.30-32

■ General Recommendations

The consensus panel concurs that the solution to the chal-lenges associated with the appropriate use of skin care products should be addressed by changes in product label-ing and caregiver education. The panel recommends that industry leaders work together to standardize terminology and product classifi cation. There is precedence for this ap-proach; approximately 10 years ago, the NPUAP convened a task force charged with standardizing the language and criteria used to describe support surfaces such as overlays, mattresses, and chair cushions.33 Their work has revolu-tionized the way in which healthcare facilities evaluate and make product decisions related to support surfaces. More recently, the National Association for Continence has convened a task force to identify and defi ne key per-formance characterist ics for absorptive products.34 The panel believes that such an initiative could be equally ben-efi cial in the arena of incontinence-related skin products.

The consensus panel recommends creation of stan-dard defi nitions and performance characteristics for each skin care product category, including a pH-balanced no-rinse cleanser, emollient moisturizers, humectant mois-turizers, moisture barrier/skin protectant, skin barrier paste, and antifungal skin protectant. When applicable, members further recommend that products list the con-centration of key active ingredients (eg, dimethicone 3%) and pH range (eg, 5.5-6.0) on product labels.

Consensus panel members also advocate creation of educational materials that list commonly used ingredients in each category of products. It would be most benefi cial to clinicians if it clearly indicated the primary purpose of each category and individual ingredient. For example, the document should indicate that a humectant (hydrating) moisturizer is indicated for treatment of rough dry scaly skin (xerosis) while an emollient (softening) moisturizer is indicated for maintenance of an intact skin barrier. Ideally, panel members recommend that these recommendations are added to individual product labels. In addition, the panel encourages the WOCN Society to consider publica-tion of clinical guidelines for the use of various products that WOC nurses could use to educate their staff. The panel also asks that industry partners consider establishing a rat-ing scale for selected products, much like the SPF factor




used to indicate the level of protection provided by a spe-cifi c sunscreen product. For example, a moisture barrier that has been proven resistant to liquid stool and to re-petitive cleansing episodes might be rated as “5” on a scale of 1 to 5. A rating scale might also be used to indicate the relative effi cacy of various humectant moisturizers or as-tringent “paste” products. The panel acknowledges that promulgation of such a rating scale will require develop-ment of objective testing measures and individual product testing. In addition to the general recommendations listed earlier, specifi c recommendations pertaining to product categories are listed in Table 2.

Skin cleansersSoap and water cleansing using a washcloth and bath basin are associated with multiple infection control issues as well as increased risk of skin damage.36 Studies indicate that no-rinse cleansers are just as effective as soap and water in reducing bacterial counts on the skin, and clinical consensus now supports no-rinse nonionic “pH-balanced” cleansers and soft disposable washcloths as a preferred ap-proach to cleansing following an incontinent episode.37--39 However, the meaning of the term “pH-balanced” is am-biguous; it is meant to imply that the product has a pH consistent with the acid mantle of healthy skin (5.5), but some clinicians interpret the term as indicating a neutral pH (7.0) and others are unsure of the term’s meaning.40 Therefore, consensus panel members suggest a standard-ized defi nition of pH-balanced, coupled with a label that states the pH range of that product.

While the use of pH-balanced cleansers and soft washcloths is clearly preferable to soap and water cleansing, panel members acknowledged limitations to this approach. Specifi cally the clinician must fi rst cleanse the skin and then must apply a protectant prod-uct, which requires an additional product and cost. Consensus panel members also noted that while cleans-ing is consistently provided in clinical practice, applica-tion of moisturizers or a skin protectant product is not consistent,41 possibly due to lack of knowledge, access to appropriate products, or lack of time. Therefore, the panel recommends the use of a disposable cloth impreg-nated with both acidic no-rinse cleansers and with a protectant such as dimethicone. This recommendation is consistent with Institute for Healthcare Improvement guidelines for pressure ulcer prevention that advocate the use of a disposable cloth with cleansers and moistur-izers when caring for patients with urinary or fecal in-continence.42 This approach is also consistent with a Belgian study comparing the incidence of IAD among patients managed with soap and water cleansing and those managed with the impregnated disposable cloth containing both cleansers and protectants. In this study, the incidence among the soap and water group was 27.1% as compared to 8.1% in the treatment group (P � .003).43

MoisturizersProducts labeled as moisturizers typically contain emol-lients, which are designed to promote moisture barrier function by replacing intercellular lipids and slowing water loss from the skin. The water content of healthy epidermis is approximately 10%; when it falls below this level, the skin becomes rough and fl aky, rendering it more vulnerable to friction and penetration by irritants such as stool and/or urine.44 Moisturizers are available as “stand-alone” products, but they are also incorporated as ingredi-ents in most perineal and incontinence cleansers and disposable cleansing wipes. Since studies indicate that stand-alone moisturizers may not be used consistently, the panel recommends the use of products that combine a cleanser and a emollient-based moisturizer.41

Moisturizers may also contain humectants, which are designed to treat extremely dry skin by attracting and holding water within the skin cells. High concentrations of humectants are not appropriate for hyperhydrated skin; thus, the panel members recommend clear labeling of the level of humectant (hydrating) moisturizers to prevent in-appropriate use.

Skin protectantsSkin protectants, also referred to as moisture barriers or oc-clusive moisturizers, provide a protective fi lm that protects the skin against penetration by chemical irritants and pathogens contained in stool and urine. These combina-tion products are available either as stand-alone products or as an ingredient in disposable cleansing wipes. Evidence suggests that a disposable wipe that combines a cleanser, moisturizing agent, and skin protectant is more effective for prevention of IAD than a skin care regimen combining neutral soap and water.1,43 Therefore, the Consensus Panel recommends use of combination cleansing-moisturizing-protectant wipes for prevention of IAD when feasible. Because barrier products vary signifi cantly in the level of protection provided (based on the ingredients), the panel recommends that the industry consider labeling that indi-cates degree of effi cacy/protection.

■ Implications for Education

Education regarding prevention and management of IAD is a high priority; enhanced knowledge is key to accurate differential assessment of IAD and to implementation of appropriate preventive care and management protocols, including the appropriate use of available products. Thus, it is important to consider the current level of knowledge and education related to IAD, barriers to IAD care that must be overcome, aspects of IAD prevention and man-agement that represent “essential information,” and effec-tive strategies for providing the needed information.

While there are no available studies specifi cally ad-dressing nurses’ knowledge related to IAD, observations that both staff and wound care nurses frequently




TABLE 2.

Prevention and Treatment Incontinence-Associated Dermatitis (IAD) via a Defi ned Skin Care Regimen Product Selection

Recommendation SORT Strength of Recommendationa

A consistently applied, defi ned, or structured skin care regimen is recommended for prevention and treatment of IAD.

A

Product SelectionSkin care products used for prevention or treatment of IAD should be selected based on consideration of individual ingredients in addition to consideration of broad product categories

such as cleanser, moisturizer, or skin protectant.

C

Select a pH-balanced skin cleanser (one whose pH range approximates the acid mantle of healthy skin).

B

No rinse skin cleansers are preferred over towel drying. BGentle cleansing is preferred over scrubbing techniques; use a soft cloth to minimize friction damage.

C

Routine use of a moisturizer is recommended to replace intercellular lipids and promote moisture barrier function of the skin.

C

A moisturizer or combination product with a high concentration of humectants is not recommended for hyperhydrated skin.

C

A moisturizing product or combination product with an emollient moisturizer is recommended to prevent IAD in intact skin.

C

A product that combines a cleanser and emollient-based moisturizer ensures application of both products in a single step.

C

A skin protectant or disposable cloth that combines a cleanser, emollient-based moisturizer, and skin protectant is recommended for prevention of IAD in persons with urinary or fecal

incontinence and for treatment of IAD, especially when the skin is denuded.

B

Commercially available skin protectants vary in their ability to protect the skin from irritants, prevent maceration, and maintain skin health. Additional research is needed to establish a

benchmark for measuring various skin protectants’ ability to block exposure to a specifi c irritant, maintain hydration of underlying skin, and prevent maceration.

B

TimingCleansing should occur as soon as possible following an episode of incontinence to limit contact with urine and stool.

C

Timely cleansing, moisturizing, and application of a skin protectant are especially important following an episode of fecal incontinence.

C

TreatmentTreatment of IAD includes consistent application of a defi ned skin care regimen based on principles of cleansing, moisturizing, and application of a skin protectant similar to those advocated for

prevention of IAD.

B

Antifungal products should be used only when a cutaneous fungal rash is present; they are not recommended for routine treatment of IAD.

B

Steroidal-based topical anti-infl ammatory products should not be used for routine treatment of IAD.

C

Topical antimicrobials should not be used for the routine treatment of IAD. CPatients who do not respond to treatment within 2 weeks should be referred for additional evaluation.

C

Atypical presentations of IAD should be referred for additional evaluation and treatment. CSupporting interventions for prevention and treatmentWhen used correctly, absorptive or containment products may aid in the prevention of IAD. CIn selected cases, urine or stool may be transiently diverted from the skin via an indwelling device such as a urinary catheter or indwelling fecal diversion system to restore or maintain skin integrity.

C

Referral to a continence specialist should be considered for assessment and treatment of the underlying incontinence.

C

aStrength of Recommendation (SORT) grades are based on the following taxonomy35:A: recommendation based on consistent, good-quality patient-oriented evidence evaluating clinical outcomes, symptom improvement, impact on quality of life, and costs.B: recommendation based on inconsistent or limited-quality patient-oriented evidence.C: recommendation based on consensus among experts, disease-oriented evidence, or case series studies.




misclassify IAD as pressure ulcers and the confusion re-garding appropriate use of available products refl ect a clinically relevant knowledge defi cit.9,10 While inconti-nence management is included in most nursing texts, the focus on prevention and management of IAD is usually limited and frequently subsumed under pressure ulcer pre-vention. This is somewhat understandable since most edu-cation and focus on preventive skin care has been concentrated on pressure ulcers; IAD has sometimes been treated as a much lesser problem. However, there is in-creasing evidence that macerated skin and IAD signifi -cantly increase the risk for pressure ulcer development.45-47 In addition, IAD can be painful. Thus, we need to broaden clinicians’ focus on prevention to include all types of skin damage, including IAD.

For both professional and lay caregivers, incontinence is frequently a taboo subject, associated with embarrass-ment and disgust; this is particularly true of fecal inconti-nence. Thus, most caregivers try to minimize the time spent providing or focusing on management of inconti-nence; Consensus panel members speculate that this may contribute to the dearth of research and education related to IAD. Consensus panel members based in the Europe and the United Kingdom observed that this avoidance be-havior extends to specialty nurses; they note that nurses specializing in both stoma management and incontinence care prefer to focus on stoma care.

When considering care of the incontinent individual, many caregivers focus primarily on containment (a care-giver concern) and voice little awareness of the issues re-lated to skin protection until breakdown has already occurred. Even at that point, many caregivers are unaware that IAD is painful and that each incontinent and cleans-ing episode is associated with further pain and with em-barrassment. Thus, a very critical aspect of caregiver education is to sensitize them to the impact of inconti-nence and IAD on the patient. Statistics can be used to convey the prevalence and signifi cance of the problem, but it is also essential to educate caregivers more about the impact of IAD on comfort and dignity.48

When planning an educational intervention, Consensus panel members recognize the need to identify essential information that forms a framework for presenta-tions, handouts, and protocols. Unfortunately, a literature search retrieved no studies that identifi ed essential knowl-edge related to prevention and management of IAD. As a result, panel members’ recommendations are based on our collective experience as clinicians and educators. The con-sensus panel recognizes that clinical practice patterns and availability of continence care experts vary from country to country and from setting to setting. Thus, the panel has identifi ed educational content that we consider to be es-sential for all levels of caregivers, and a second level of content that is critical for continence care experts or for the clinical leaders in a setting where there is no conti-nence expert (Box 2).

The continence expert or clinical nursing leader obvi-ously must be knowledgeable in all of these areas; how-ever, this clinician must also be skilled in the differential assessment of pressure ulcers, IAD, and mixed etiology le-sions. In addition, the clinical expert/leader needs an in-depth understanding of the various products used for IAD prevention and management (in order to make appropri-ate product decisions for the agency, and also as a basis for developing guidance documents and protocols to be used by the bedside caregivers).

Although few studies focusing on IAD education were identifi ed, Consensus panel members concur that a pri-mary goal of education is to promote the integration of current best evidence into practice. Several studies have demonstrated that clearly defi ned evidence-based guide-lines and algorithms are effective in promoting appropriate clinical decision-making for a wide variety of clinical con-ditions.49-51 Beeckman and colleagues have demonstrated the effi cacy of the PUCLAS tool in improving accuracy in IAD assessment. Haslinger-Baumann an d colleagues52 re-port similar fi ndings in the area of IAD prevention and management; they developed a practice guideline based on a literature review and used this guideline as a basis for educating staff and advancing practice in both the acute care and long-term care settings.

A promising tool for educating staff and guiding prac-tice is the IAD-IT (Incontinence Associated Dermatitis Intervention Tool).53 This tool was designed by Junkin53 to promote accuracy in assessment and management; the tool provides a pictorial guide that allows clinicians to “match” their patients’ clinical presentation to photo-graphs depicting “early IAD,” “moderate IAD,” “severe IAD,” and “fungal appearing rash” (Figure 1). The tool then provides guidance to the clinician as to appropriate management. The panel believes that such a tool has the potential to assist clinicians to translate “evidence-based guidelines” into actual practice. Initial studies have been

BOX 2.

Essential Information for Educating Caregivers About Incontinence-Associated Dermatitis (IAD) Assessment, Prevention, and Treatment

Importance of intact skin barrier and characteristics of healthy skin (acidic, soft, dry)Overview of IAD: prevalence; impact on patient; impact on staff; link between IAD and increased risk of pressure ulcer developmentDefi nition, risk factors, and pathology of IADAssessment of IAD, including differential assessment of wounds with similar clinical appearance such as stage I and II pressure

ulcersPreventive care guidelines for cleansing, moisturizing, and protecting skin, to include basic discussion of product categories

and indications for eachTreatment of IAD using an established decision tree (and ideally a pictorial guide)




FIGURE 1. Incontinence-associated dermatitis intervention tool.




done in Europe, demonstrating reliability of this tool, and further study is underway.54 The Consensus panel recom-mends additional testing among US clinicians and in-creased utilization of the tool in educational programs regarding prevention and management of IAD.

Effective staff education requires innovative strategies as well as clinically relevant tools; in many settings, it is unrealistic to expect signifi cant numbers of staff nurses to attend a lecture-based educational event. Fortunately, fi nd-ings of several studies indicate that eLearning strategies are equally effective and are actually preferred by some subsets of learners.23,55 eLearning programs that utilize active ap-plication of content to case study scenarios may be particu-larly effective for clinical conditions such as IAD.

■ Cost

We have limited data regarding the cost of various proto-cols for prevention and management of IAD. However, the annual estimated cost for skin conditions related to incontinence in the United States was $136.3 million in 1995, so it is clear that IAD is a costly condition.56 Panel members agree that a focus on prevention of IAD is indi-cated, from both an economic and quality-of-care stand-point. Palese and Carniel57 reported on the impact of a multidimensional quality improvement program involv-ing both product modifi cations and intensive staff educa-tion on the incidence of IAD and the cost of care in a long-term care facility in Italy. The study involved 63 pa-tients with incontinence, all of whom had IAD at base-line. Following a data collection phase, the authors introduced a new line of absorbent products that were designed to minimize hyperhydration of the skin, and a structured skin care program that incorporated a pH-bal-anced no-rinse cleanser and moisture barrier creams. In addition, continence nurse advisors provided a 3.5-hour educational program for the fi rst-line caregivers (nursing assistants); they also provided input as to the best absor-bent product for each patient and strategies for preven-tion and management of IAD and met with the nursing assistants weekly to discuss continence care issues. The incidence of IAD decreased from 100% at baseline to 31.7% following introduction of the new skin care pro-gram and absorbent products; the addition of education and consultation provided by the continence nurse advi-sors resulted in a further reduction (from 31.7% to 3.1%). The estimated annual cost of care was reduced by almost 50% (from £653.35 to £354.05 per resident). Eigsti58 re-ported on a similar approach to quality improvement in the United States. Nurses in a critical care unit used evi-dence-based protocols for IAD prevention along with in-tensive staff education. Eigsti reported improved clinical outcomes and reductions in nursing time required for in-continence care. These studies underscore the positive impact of evidence-based protocols coupled with inten-sive staff education.

Two US studies compared the cost of soap and water cleansing versus the use of a pH-balanced, no-rinse cleanser and found that the no-rinse product saved an av-erage of 9 minutes per episode, resulting in a signifi cant reduction in staff time and labor costs.59,60 In addition, re-cent evidence supports the use of pH-balanced no-rinse cleansers as being preferable to soap and water for preven-tion of IAD.1,37

A limited number of studies have demonstrated both cost benefi ts and improved clinical outcomes related to simplifi ed protocols with fewer steps and product deci-sions. Bale and colleagues61 evaluated savings in product costs and labor when a structured 2-step skin care protocol was compared to a nonstructured protocol and demon-strated both a statistical ly signifi cant reduction in IAD in-cidence and associated costs. Warshaw and colleagues62 compared a 2-step skin care procedure (cleansing with ei-ther soap and water or an incontinence cleanser followed by application of a protective barrier) to a 1-step proce-dure, using a cleanser-protectant combination product. The 1-step procedure was associated with a reduction in nursing time and product costs as well as a reduction in skin pain and erythema. Clever and colleagues41 demon-strated similar outcomes; they found an 89% reduction in incidence of skin breakdown and an estimated annual sav-ings of $3700 with the use of a one-step skin protection program (Comfort Shield, Barrier Cream Cloths, Sage Products, Cary, Illinois), as opposed to a “multistep” inter-vention program. Several studies have addressed the eco-nomic and clinical effi cacy of a prevention protocol incorporating the use of a spray acrylate clear barrier fi lm applied 3 times weekly (Cavilon, 3M, St Paul, Minnesota) as the moisture barrier, as opposed to petrolatum or zinc oxide–based ointments applied after each incontinent episode. The barrier fi lm was found to be as clinically ef-fective and more cost-effective in all studies, due in part to the signifi cant difference in frequency of application.63,64

While more studies are needed in the area of cost-effec-tive IAD care, it seems evident that clearly defi ned proto-cols that minimize steps and time involved are both clinically effective and cost-effective. Additional research should focus on the comparative effi cacy and cost of 1-step and 2-step systems for both prevention and treat-ment of IAD.

■ Summary

IAD is recognized as a clinical entity that is distinct from pressure ulcers and other forms of moisture-associated skin damage. Current evidence strongly suggests that a defi ned or structured skin care program is benefi cial for prevention and management of IAD. Nevertheless, the ex-isting evidence base remains sparse, and Consensus panel members identifi ed a number of unresolved issues related to the assessment, prevention, and management of IAD. They include problems with differential assessment of IAD




versus pressure ulcers, challenges related to appropriate product utilization, a lack of effective education for all lev-els of caregivers, and the need for care protocols that are cost-effective as well as clinically appropriate. The Consensus panel recommends a conference jointly spon-sored by the WOCN Society and the NPUAP to develop consensus regarding parameters for differential assess-ment; wide dissemination and utilization of the PUCLAS tool or a similar instrument to guide differential assess-ment; clear labeling of continence care products to in-clude product category, indications for use, and concentration of active ingredients; increased education for all caregivers that includes sensitization to the impact of IAD as well as current guidelines for prevention and management; use of a photographic tool such as the IAD-IT to guide appropriate management of IAD; in-creased research on the cost-effectiveness of various proto-cols for prevention and management of IAD; and a focus on simple protocols (1-step or 2-step) that provide both cost savings and time savings.

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54. Steininger A, Jukic-Puntigam M, Urban W, Mueller G. A Delphi-study to validate the German Incontinence Asso ciated Dermatitis Intervention Tool (IADIT-D). Pfl egewissenschaft. In review.

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56. Wagner TH, Hu TW. Economic costs of urinary incontinence in 1995. Urology. 1998;51:355-361.

57. Palese A, Carniel G. The effects of a multi-intervention inconti-nence care program on clinical, economic, and environmental outcomes. J Wound Ostomy Continence Nurs. 2011;38(2):177-183.

58. Eigsti JE. Innovative solutions: beds, baths, and bottoms: a quality improvement initiative to standardize use of beds, bathing technique, and skin care in a general critical care unit. Dimens Crit Care Nurs. 2011;30(3):169-176.

59. Lewis-Byers K, Thayer D. An evaluation of two incontinence skin care protocols in a long-term care setting. Ostomy Wound Manag. 2002;48(12):44-51.

60. Byers PH, Ryan PA, Regan MB, Shields A, Carta SG. Effects of incontinence care cleansing regimens on skin integrity. J Wound Ostomy Continence Nurs. 1995;22:187-192.

61. Bale S, Tebble N, Jones V, Price P. The benefi ts of implementing a new skin care protocol in nursing homes. J Tissue Viabil. 2004;14(2):44-50.

62. Warshaw E, Nix D, Kula J, Markon C. Clinical and cost effec-tiveness of a cleanser protectant lotion for treatment of peri-neal skin breakdown in low-risk patients with incontinence. Ostomy Wound Manag. 2002;48(6):44-51.

63. Bliss DZ, Zehrer C, Savik K, Smith G, Hedblom E. An economic evaluation of four skin damage prevention regimens in nurs-ing home residents with incontinence: economics of skin dam-age prevention. J Wound Ostomy Continence Nurs. 2007;34(2):143-152.

64. Guest JF, Greener MJ, Vowden K, Vowden P. Clinical and eco-nomic evidence supporting a transparent barrier fi lm dressing in incontinence-associated dermatitis and peri-wound skin protection. J Wound Care. 2011;20(2):76, 78-84.

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