Skin integrity is key when it comes to incontinence, and is increasingly considered in the development of healthcare solutions. We have requested Prof. Dimitri Beeckman’s expertise to inform us more on this essential topic.

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Prof. Dimitri Beeckman is a Professor of Skin Integrity and Clinical Nursing at Ghent University (Belgium) and Örebro University (Sweden). He is a Visiting Professor at the Royal College of Surgeons in Ireland, Monash University (Australia), and the University of Southern Denmark. He is President of the European Pressure Ulcer Advisory Panel (EPUAP) and the International Skin Tear Advisory Panel (ISTAP) and Council Member of the European Wound Management Association (EWMA). He specialises in skin integrity research, clinical trials, education, implementation and instrument development and psychometrics. He authored over 140 scientific publications and presented his research in > 60 countries. He is in the editorial board of the Journal of Wound, Ostomy and Continence Nursing, Journal of Tissue Viability, and BMC Geriatrics. He holds international Fellowships such as Sigma Theta Tau International Honour Society of Nursing and the European Academy of Nursing Science.

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Why is skin important when considering incontinence care?

Incontinence is any accidental or involuntary loss of urine from the bladder (urinary incontinence) or bowel motion, faeces or wind from the bowel (faecal incontinence). Population studies from numerous countries report that urinary incontinence prevalence ranges between 5% and 70%, with most studies reporting a prevalence in the range of 25-45%. Prevalence figures rise with increasing age and in women aged over 70 years more than 40% of the population is affected by urinary incontinence. Faecal incontinence is a hidden problem being under-diagnosed, underinvestigated and under-treated. Up to 10% of adults can experience an episode of faecal incontinence during the lifespan. Associated skin damage is the main physical health consequence of urinary and faecal incontinence. Skin irritation within the pad occlusion area is usually termed diaper dermatitis in infants. In adults, the terminology of perineal dermatitis has commonly been used, but more recently it has been proposed that incontinence-associated dermatitis (IAD) is a better term because affected skin areas are not confined to the perineum. Incontinence and its associated skin damage can have a considerable effect on the patients physical and psychological well-being. Patients with IAD can experience discomfort, pain, burning, itching or tingling in the affected areas. IAD can result in an undue burden of care, loss of independence, disruption in activities and/or sleep, and reduced quality of life, worsening with frequency and quantity of soiling.

Skin is more fragile when people are older, nevertheless, does this mean that there is no risk for younger people to suffer from skin problems associated with bladder control issues?

It is well known that alterations in skin integrity represent a serious and often preventable problem in pediatric care as well. Epidermal disruptions from skin contact with urine or stool, can leave a child’s skin susceptible to infection. Although children experience many of the same skin problems well described in adult patients, unique challenges do present in the young population. Irritant diaper dermatitis develops when skin is exposed to prolonged wetness, and a reaction to urine and/or faeces increases the skin pH, then resulting in breakdown of the stratum corneum, or outermost layer of the skin. This may be due to diarrhea, frequent stools, tight diapers, overexposure to ammonia, or even allergic reactions

Is there a correlation between the incontinence level and the potential skin damage? Are there other important factors?

Although the presence of incontinence is a prerequisite, not all incontinent patients develop skin damage. This indicates that many more factors and characteristics increase (risk factor) or decrease (protecting factor) the individual susceptibility for skin damage related to the incontinence. Risk prediction models that typically use a number of predictors based on patient characteristics to predict health outcomes are a cornerstone of patient care and guide clinical decision making. Even though, research into IAD risk factors and prognostic models is in its infancy. Merely based on expert opinion and cross-sectional studies the following variables have been associated with increased risk for skin damage related to incontinence: degree of permanence of the skin moisture, age, type of incontinence, increased body mass index, presence of diabetes mellitus, friction and shear problems during patient movement.

What is incontinence-associated dermatitis (IAD)? Is it a common problem?

Continuous exposure of the skin to urine and/or faeces causes skin breakdown, commonly defined as diaper dermatitis in neonates, babies and children and as Incontinence-Associated Dermatitis (IAD) in adults. IAD is a specific type of irritant contact dermatitis characterized by erythema of the skin around the buttocks, perineum, gluteal cleft and other areas where friction and moisture (from incontinence) is present between skin, incontinence materials, clothing and bed linen. Skin problems associated with incontinence are classified by the International Classification of Diseases (ICD)-11 coding as ‘Diseases of the skin’; more specifically under the subcategory ‘Irritant contact dermatitis due to friction, sweating or contact with body fluids’. Studies report prevalence figures of IAD between 5.6% to 50.0%, with incidence rates between 3.4% and 25.0%, depending on the type of clinical setting and population studied. A study of the prevalence of IAD among hospitalised acute care patients in the United States (n = 976) reported a prevalence of 27% (Gray & Giuliano 2018). A study using a large sample (n = 3713) of incontinent participants reported an overall IAD prevalence across different healthcare settings in two European countries of 6.1% (Kottner et al. 2014). Approximately one‐third of people with faecal incontinence develop IAD (Doughty et al. 2012).

How does IAD, incontinence-associated dermatitis, develop?

IAD is caused by the continuous interplay between skin surface ‘wetness’, increased skin surface pH, digestive intestinal enzymes, repeated skin cleansing activities, and an occlusive environment associated with diapers and incontinence pads. Prolonged exposure to these irritants leads to stratum corneum (SC) damage. Excessive skin surface moisture leads to hyperhydration of the corneocytes and to disruptions of the intercellular lipid bilayers. The corneocytes swell and the SC thickness increases (Kottner & Beeckman 2015). Lipases and proteases attack the SC proteins and lipids (Beeckman et al. 2009). This impaired skin barrier and occlusive skin conditions (e.g. caused by wearing diapers and the use of incontinence pads) may further facilitate the penetration of irritants and micro-organisms (e.g. Candida Albicans) in the SC. In addition, the recurrent use of water, skin cleansing agents and washcloths and towels lead to chemical and physical irritation of the skin (the latter defined as friction). Limited mobility and limited ability to move independently causes additional friction and shear loads in the SC and the epidermis in at risk areas, diminishing the strength of the epidermal barrier further (Kottner & Beeckman 2015).

How can IAD be prevented?

The first priority is to reduce or prevent incontinence if possible. If this is not possible, containment of the urine or stool will help reduce exposure of the skin to the wetness and pH changes associated with urinary and/or faecal incontinence and thus help prevent IAD. A Cochrane systematic review (Beeckman et al. 2016) concluded that soap and water perform poorly in the prevention of IAD. The application of leave-on products (such as skin protectants) and avoiding soap seems to be effective. The performance of leave-on products depends on the combination of ingredients, the overall formulation and the usage (e.g. amount applied). There is expert agreement that non-invasive methods for managing urinary incontinence are preferred over indwelling urinary catheters whenever possible to decrease the likelihood of catheter-associated urinary tract infections. Body-worn absorbent products, that improve moisture management thanks to a quick absorption and by keeping wetness away from the skin and thus contributing to keep a lower pH, may also be considered.

Can we guarantee that IAD or other skin rashes won’t happen?

No, people living with incontinence are always at risk to develop IAD; even if we provide them with the best possible care. Incontinence products approved by dermatologists through independent lab tests results, are limitating risks of allergy or irritation. There are many more (unknown) factors in or decreasing the probability to develop IAD. A scientifically solid IAD risk prediction model is lacking. Fully breathable pads could also offer a better solution as air flow could decrease the consequences of an occlusive environment. Breathable, microporous outer covers which keep the skin drier and have been shown to have a positive impact on the skin condition in the diapered area, particularly in terms of occlusion, diaper dermatitis and Candida albicans superinfections.

Once IAD is diagnosed, what are the main recommendations for treatment?

When IAD is diagnosed, treatment should reduce inflammation, promote healing and re-epithelialisation, and prevent infection. All of the above mentioned preventative interventions are applicable for treatment. A leave-on product can also be used to treat mild irritant contact dermatitis but in severe IAD cases, dressings may be used temporally to promote healing. In case of a fungal infection (e.g. Candida Albicans), an antifungal treatment should be used as a first-line therapy. It is recommended to treat the infection if present. The superimposed infection may alter the loco-regional clinical picture depending on the type of microorganism (bacteria, fungus or yeasts). Wound swabs and blood samples are indicated to confirm the infection and/or identify the micro-organism involved to target the treatment.

Are there studies proving the connection between IAD and pressure ulcers?

Yes, such research exists. Pressure ulcers are localized injuries to the skin and/or underlying tissue, usually over a bony prominence due to the impact of mechanical forces (pressure and shear). IAD and pressure ulcers have different etiologies but may co-exist: IAD is a ‘top down’ injury , i.e. damage is initiated on the surface of the skin, while pressure ulcers are believed to be ‘bottom up’ injuries , where damage is initiated by changes within soft tissues below and within the skin. In a systematic review and meta-analysis by Beeckman et al. incontinence and IAD were found to be risk factors for pressure ulcer development. This association is related to the prolonged exposure to skin surface moisture and irritants changing the mechanical skin properties of the skin and underlying tissue. We can link the associated risk for pressure ulcer development with the increase of the coefficient of friction and tissue stiffness changes. Additionally, local inflammation will increase the temperature of the skin leading to further diminishing of the cutaneous resistance against tissue deformation. Research points out that determining if the inflammation of the skin in the buttock and sacral areas is primarily due to pressure or irritation is difficult and confusing.

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[1] Beeckman D, Van Damme N, Schoonhoven L, et al. Interventions for preventing and treating incontinence
associated dermatitis in adults. Cochrane Database Syst Rev. 2016 Nov 10;11:CD011627.

[2] Doughty D, Junkin J, Kurz P, et al. Incontinence-associated dermatitis: consensus statements, evidence-based
guidelines for prevention and treatment, and current challenges. J Wound Ostomy Continence Nurs. 2012 May
Jun;39(3):303-15; quiz 316-7.

[3] Gray M, Giuliano KK. Incontinence-Associated Dermatitis, Characteristics and Relationship to Pressure Injury: A
Multisite Epidemiologic Analysis. J Wound Ostomy Continence Nurs. 2018 Jan/Feb;45(1):63-67.

[4]Kottner J, Blume-Peytavi U, Lohrmann C, et al. Associations between individual characteristics and incontinence
associated dermatitis: a secondary data analysis of a multi-centre prevalence study. Int J Nurs Stud. 2014
Oct;51(10):1373-80.

[5] Kottner J, Beeckman D. Incontinence-associated dermatitis and pressure ulcers in geriatric patients. G Ital Dermatol
Venereol. 2015 Dec;150(6):717-29.

[6] Edana Sustainability report D/2005/5705/2