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Prevention and treatment of incontinence-associated dermatitis: literature review

Dimitri Beeckman, Lisette Schoonhoven, Soe Verhaeghe, Alexander Heyneman & Tom Deoor
Accepted for publication 28 January 2009

Correspondence to D. Beeckman: e-mail: dimitri.beeckman@ugent.be Dimitri Beeckman MA RN PhD Candidate Faculty of Medicine and Health Sciences, Ghent University, Belgium and Research Staff Department of Bachelor of Nursing, University College Arteveldehogeschool Ghent, Belgium Lisette Schoonhoven PhD RN Assistant Professor Nursing Science, IQ Healthcare, Radboud University Nijmegen Medical Centre, The Netherlands Soe Verhaeghe PhD RN Assistant Professor Nursing Science, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Belgium Alexander Heyneman MA RN PhD candidate Nursing Science, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Belgium Tom Deoor PhD RN Professor Nursing Science, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Belgium

BEECKMAN D., SCHOONHOVEN L., VERHAEGHE S., HEYNEMAN A. & D E F L O O R T . ( 2 0 0 9 ) Prevention and treatment of incontinence-associated dermatitis: literature review. Journal of Advanced Nursing 65(6), 11411154. doi: 10.1111/j.1365-2648.2009.04986.x

Abstract
Title. Prevention and treatment of incontinence-associated dermatitis: literature review. Aim. This paper is a report of a review conducted to describe the current evidence about the prevention and treatment of incontinence-associated dermatitis and to formulate recommendations for clinical practice and research. Background. Incontinence-associated dermatitis is a common problem in patients with incontinence. It is a daily challenge for healthcare professionals to maintain a healthy skin in patients with incontinence. Data sources. PubMed, Cochrane, Embase, the Cumulative Index to Nursing and Allied Health Literature, reference lists and conference proceedings were explored up to September 2008. Review methods. Publications were included if they reported research on the prevention and treatment of incontinence-associated dermatitis. As little consensus about terminology was found, a very sensitive lter was developed. Study design was not used as a selection criterion due to the explorative character of the review and the scarce literature. Results. Thirty-six publications, dealing with 25 different studies, were included. The implementation of a structured perineal skin care programme including skin cleansing and the use of a moisturizer is suggested. A skin protectant is recommended for patients considered at risk of incontinence-associated dermatitis development. Perineal skin cleansers are preferable to using water and soap. Skin care is suggested after each incontinence episode, particularly if faeces are present. The quality of methods in the included studies was low. Conclusions. Incontinence-associated dermatitis can be prevented and healed with timely and appropriate skin cleansing and skin protection. Prevention and treatment should also focus on a proper use of incontinence containment materials. Further research is required to evaluate the efcacy and effectiveness of various interventions. Keywords: dermatitis, incontinence, literature review, nursing, pressure ulcers, prevention, treatment

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Introduction
Incontinence-associated dermatitis (IAD), a clinical manifestation of moisture-associated skin damage, is a common problem in patients with faecal and/or urinary incontinence (Gray et al. 2007a). The lesions are characterized by erosion of the epidermis and a macerated appearance of the skin (Gray et al. 2007a). Incontinence and skin breakdown related to incontinence have a considerable effect on patients physical and psychological well-being (Sibbald et al. 2003, Newman et al. 2007). It is a daily challenge for healthcare professionals in hospitals, nursing homes and homecare to maintain a healthy skin in patients with incontinence.

The most common organisms are Candida albicans, from the gastrointestinal tract, and Staphylococcus, from the perineal skin. The skin is not only exposed to chemical irritation, but also to physical irritation (friction). Friction is dened by the National Pressure Ulcer Advisory Panel (NPUAP) as the resistance to motion in a parallel direction relative to the common boundary between two surfaces (NPUAP 2007). Friction increases when perineal skin rubs over containment materials, clothing and bed or chair surfaces (Newman et al. 2007). The combination of chemical and physical irritation results in a weakened skin status. If these mechanisms affect the integrity of the skin recurrently, IAD and further skin breakdown will develop (Figure 1).

Size of the problem

Up to 50% of nursing home residents and 1035% of community-dwelling adults are affected by urinary incontinence (Newman et al. 2007). Faecal incontinence has been reported in 2366% of nursing home residents (Newman et al. 2007). Combined urinary and faecal incontinence, also dened as double incontinence, occurs in 50% of long-term care residents (Newman et al. 2007). The prevalence of IAD has varied in different studies from 56% to 50%, and the incidence rates were between 34% and 25%, depending on the type of setting and population studied. Usually incidence rates were measured in small sample, single-centre and longterm care settings over periods of 4 weeks (Gray et al. 2007a).

Terminology and denitions

The terminology used to describe incontinence-associated skin problems is diverse, and more than 18 different terms occur. In the International Statistical Classication of Diseases and Related Health Problems (10th Revision Version for 2007) (ICD-10), the World Health Organization (WHO) classies incontinence-related skin problems as Diseases of the skin and subcutaneous tissue (Chapter XII, L00-L99) in subcategory Dermatitis and eczema (L20-L30). Terminology used is: diaper/napkin dermatitis, diaper/napkin erythema or diaper/napkin rash. The term used to classify incontinence-related skin problems used in the Medical Subject Heading Terms database of the US National Library of Medicine (MeSH database) is diaper rash. Diaper rash is dened as a type of irritant dermatitis localized to the area in contact with a diaper and occurring most often as a reaction to prolonged contact with urine, faeces, or retained soap or detergent. In the North American Nursing Diagnosis Association (NANDA) no single terminology describing IAD was found (NANDA 2008). In international literature, no common terminology is used to indicate the presence of incontinence-associated skin problems. The terminology focuses on a description of the skin (e.g. skin maceration), the cause of the irritation (e.g. incontinence lesion and incontinence dermatitis), the location of the skin problem (e.g. perineal dermatitis) or the material causing the skin problem (e.g. diaper dermatitis). Gray et al. (2007a) dene incontinence-associated skin problems as a reactive response of the skin to chronic exposure to urine and faecal material, which could be observed as an inammation and erythema with or without

Aetiology
An important function of the skin is to protect the body against pathogens. The stratum corneum, which is the outermost layer of the epidermis, provides this critical barrier by prohibiting the invasion of micro-organisms. The stratum corneum consists of 70% protein, 15% lipids and 15% water. Lipids and water are important components in the skins barrier function. In older patients, the volume of water decreases to <10% (Lekan-Rutledge 2006, Newman et al. 2007). The aetiology of IAD is complex and multifactorial (Jeter & Lutz 1996, Lekan-Rutledge 2006). When the skin is exposed to moisture (urine, faeces, double incontinence or frequent cleansing), its permeability increases and the barrier function reduces. Increased skin pH raises the risk of bacterial colonization. Colonization with microorganisms can lead to bacterial overgrowth, which may cause cutaneous infections.
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MOISTURE Urine Faeces

Double incontinence Urea-ammonia pH Faecal enzyme activity Microbes

Frequent cleansing Chemical irritation + Physical irritation

Urea-ammonia pH Microbes

Faecal enzyme activity pH Microbes

Permeability of the skin Barrier function Bacterial overgrowth Cutaneous infection

WEAKENED SKIN

INCONTINENCE ASSOCIATED DERMATITIS

Friction: rubbing perineal skin over containment devices, clothing and bed or chair surfaces

Figure 1 Aetiology of incontinence-associated dermatitis (based on Jeter & Lutz 1996 and Newman et al. 2007).
erosion or denudation. This denition was used to conduct the review reported in this paper.

The review
Aims

Current practice
Current prevention of IAD consists of cleansing, moisturization, and the application of skin protectants or moisture barriers. Treatment includes protecting the skin from further exposure to irritants, establishing a healing environment and eradicating skin infections (Gray et al. 2002). A wide range of skin care protocols, cleansers, moisturizers, moisture barriers, skin protectants and absorbents are available. Despite their widespread use in nursing practice, little is known about their efcacy and effectiveness (Gray et al. 2007a, Newman et al. 2007). A growing number of studies have been conducted to examine clinical and economic outcomes associated with prevention strategies, but little research exists on the efcacy of various treatments (Gray et al. 2007a).

The aims of this literature review were to assess the effectiveness of interventions for the prevention and treatment of IAD and to formulate recommendations for clinical practice and research.

Design
A literature search was performed using the databases PubMed, Embase, The Cochrane Library Central Register of Controlled Trials (CENTRAL) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL).

Search methods
The databases were searched for studies published in English, Dutch, French and German. There were no limitations
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concerning the year of publication, authors or participating institutions. To increase the sensitivity of the lter, all entry terms of the MeSH terms were added to the lter as [Text Word]. Only studies with patients over the age of 18 years were included using the MeSH term adult in the search lter. Randomized controlled trials, meta-analyses, reviews, controlled clinical trials, clinical trials, comparative studies, evaluation studies and validation studies were included. The MeSH terms of these publication types were added to the search lter. Study design was not used as a selection criterion due to the explorative character of the literature review and the scarce literature on this issue. A similar search lter was used in all databases. The literature search was completed in September 2008. Conference proceedings of the European Pressure Ulcer Advisory Panel (EPUAP), the European Wound Management Association, the European Tissue Repair Society and the International Continence Society of the years 20012008 were searched manually. The reference lists of all included publications were checked to identify additional studies not indexed in the databases or conference proceedings searched.

PubMed and CINAHL; two publications in PubMed and Cochrane Library; and 10 in PubMed. Subject areas of the publications in PubMed were: nursing (21), geriatrics (one) and dermatology (one). In 13 publications, the subject area was not stated, while in 30 the rst author was a nurse.

Quality appraisal
The full text of potentially eligible studies was examined to determine whether the publications met the above-mentioned criteria. Titles and abstracts of publications obtained through the search strategy were initially screened independently on the inclusion criteria by two reviewers. In case of different opinions, the reviewers made a decision based on discussion of the full text papers. The Research Appraisal Checklist (RAC) (Duffy 1985), which contains 51 assessment criteria ordered in 10 categories, was used to assess the scientic quality of the included studies. Categories included title, abstract, problem, review of literature, methods (subjects, instruments, design), data analysis, discussion, and form and style. The RAC was tested for reliability and validity, and showed a total Cronbachs a of 091 and good construct validity. Assessments using RAC were conducted by two independent reviewers. They used the six-point rating scale to indicate the extent to which each criterion item was met in the report being reviewed (1 or 2 = not met; 3 or 4 = partially met; 5 or 6 = completely met). An N/A (not applicable) option was available if the criterion was not applicable. In accordance with Duffy (1985), summated scores were computed for each of the 10 categories, after which the category scores were added to produce a total score. Reports with a score between 0 and 102 are considered below average, between 103 and 204 are considered average, and scores between 205 and 306 are considered superior.

Search outcome
All studies describing interventions to prevent or heal IAD were included. The search strategy revealed 2379 publications. Based on the inclusion criteria and after eliminating any overlap and screening of title, abstract and keywords by two independent reviewers, 28 publications were found to be useful. After checking the reference lists of all included publications, eight additional publications were included. Thirty-six publications were included in this review (Figure 2). Two publications were indexed in the databases PubMed, Cochrane Library and CINAHL; four appeared in

PubMed (1079) Cochrane Library(890) Embase (371) CINAHL (39)

2379

PubMed(18) Cochrane Library(4) Embase (0) CINAHL (6)

2351 excluded not meeting the inclusion criteria 28 8 included Handsearching journals Checking reference lists 36

Figure 2 Results of search strategy.

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Data abstraction and synthesis

Details of relevant studies were extracted and summarized using a prespecied standardized table of evidence. Apart from authors and year of publication, data concerning publication type, design, setting and number of participants, in- and exclusion criteria, duration in days, intervention studied, study outcome, baseline characteristics of the patients and results were also included in the evidence table. The occurrence and incidence of IAD and the skin condition were identied as the main outcome measures to assess the effectiveness of IAD preventive interventions. Healing rate and skin condition were dened as outcome measures to assess the effectiveness of IAD treatment interventions. Effect sizes could not be reported as they were not described in the publications. Cost-effectiveness was evaluated by reviewing the direct costs (product cost and nursing time), total costs (sum of direct costs and costs of supporting treatment-related products) and indirect costs (related to quality of life, assistance in completing activities of daily living, days lost from work and litigation) (Phillips 2007).

subjects, instruments and designs used in the studies were 154/36, 72/30 and 146/24 respectively. In nine studies, a randomized controlled trial was conducted. In 50% of the studies, a baseline comparison of patient characteristics was performed. In four studies, baseline evaluation was limited to a comparison of pressure ulcer risk assessment (Brown 1994a, Brown 1994b, Dealey 1995, Kennedy et al. 1996). In one study, the procedure for randomization was not described (Campbell et al. 2001). In ve studies, no control group was used (Dealey 1995, Hampton 1998, Campbell et al. 2000, 2001, Warshaw et al. 2002). A prospective power analysis was conducted in three studies (Brown 1994a, Brown 1994b, Baatenburg de Jong & Admiraal 2004). Thirteen different observational instruments were used in 10 studies. One study used an observation scale that was tested for content validity and inter-observer reliability (Warshaw et al. 2002). In 15 studies, no observation scale was specied.

Use of skin products

Skin protectants Zinc oxide-based products were evaluated in six studies. A topical zinc oxide preparation with antiseptic properties (Sudocrem) was found to be superior to traditional zinc cream for the treatment of IAD (Anthony et al. 1987). In eight studies, the use of a no-sting barrier lm was evaluated. Campbell et al. (2000) and Hampton (1998) observed a reduction of erythema, skin maceration and skin stripping when comparing a no-sting barrier lm and a petrolatumbased ointment in patients with IAD. Clever et al. (2002) observed a statistically signicant reduction of pressure ulcer incidence in patients with incontinence when a skin protectant (active ingredient: dimethicone 3%) was used, incorporated into a thick disposable washcloth that cleansed and moisturized the skin (Table 1). Moisturizers Draelos (2000) observed reduced erythema, roughness and desquamation of the skin when a hydrogel/barrier repair cream was compared to a petrolatum-based moisturizing cream for the treatment of IAD (Table 1). Perineal skin cleansers Skin cleansers were found to be more effective than water and soap for the prevention of incontinence-related skin problems (Byers et al. 1995, Cooper & Gray 2001). Reduced skin erythema was observed in four studies comparing the effect of combining a perineal skin cleanser and a skin protectant (Whittingham & May 1998, Warshaw et al. 2002, Hunter
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Results
All included publications were published in English between 1983 and 2007. In the 36 included publications, 25 studies were reported. The median study period, reported in 21 studies, was 420 days (IQR = 140900). The median number of patients included was 64 (IQR = 2901360). The patients were recruited from chronic care (14 studies) and acute care (six studies) settings. Two studies were conducted in both an acute and a chronic care setting (Leiby & Shanahan 1994, Dealey 1995). In three studies, the setting was not reported (Kennedy et al. 1996, Hampton 1998, Baatenburg de Jong & Admiraal 2004). Thirteen studies focused on treatment, eight focused on prevention and four on both treatment and prevention of IAD. An overview of the operational denitions of incontinence-related skin problems used in the studies is given in Tables 13. Economical evaluations were performed in 11 studies. An overview of these results is given in Table 4.

Scientic quality of the studies

The mean RAC score of the included studies was 208/306. Approximately one-fth (202%) of the criteria of the RAC were not applicable. The criteria for abstract, problem and review of literature could not be assessed in 323% of cases. The mean RAC scores for methods and analysis were 372/90 and 167/24 respectively (Tables 13). RAC scores for the

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Table 1 Description of studies concerning the use of skin products

RAC scores Methods Analysis Signicant outcomes

1146 Study design Operational denition Study period (days) Patients included/ analysed RCT double-blinded Dermatitis due to the physical stress of incontinence 14 67/57 20/90 11/24 Pre/post RCT Incontinent dermatitis Skin damage resulting from incontinence 10 14 16/14 39/29 21/90 35/90 5/24 19/24 RCT Perineal rash 12 40/ 30/90 20/24 Descriptive Pre/post Pressure ulcer Incontinence dermatitis 42 120 981/ 25/ 45/90 36/90 16/24 10/24 Observational Comperative Observational comperative Descriptive Incontinence dermatitis Incontinence dermatitis Incontinent dermatitis 90 42 183/ 78/ 33/ 53/90 53/90 21/90 20/24 20/24 14/24 Observational comparative Nappy rash 62/53 32/90 13/24 Reduced erythema, maceration, skin stripping when using barrier lm Skin improvement Retrospective pre/post Pressure ulcer 90 64/ 33/90 17/24 Reduced skin lesions RCT Diaper dermatitis 28 80/73 33/90 13/24 Reduced erythema, roughness and desquamation when using hydrogel barrier/repair cream

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Citation

Skin protectants Zinc oxide vs. Antiseptic topical cream Anthony et al. (1987)

Reduced erythema and bacterial counts when using antiseptic topical cream Reduced erythema and denudation when using barrier lm

vs. no-sting barrier lm Campbell et al. (2001) Baatenburg de Jong and Admiraal (2004)

vs. Petrolatum ointment vs. no sting barrier lm Kennedy et al. (1996) vs. No-sting barrier lm vs. ointment with 43% petrolatum vs. ointment with 98% petrolatum Bliss et al. (2007) +Skin cleanser Dealey (1995) No sting barrier lm vs. Petrolatum-based ointment Zehrer et al. (2004a) Frequency: 1/day vs. frequency: 3/week Zehrer et al. (2004a, 2004b) vs. Campbell et al. (2000)

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Hampton (1998) Skin protectant in disposable wash cloth that cleanses and moisturizes the skin (active ingredient: dimethicone 3%) vs. Clever et al. (2002) Moisturizers Hydrogel barrier/repair cream vs. Petrolatum-based moisturizing cream Draelos (2000)

Table 1 (Continued)
RAC scores Methods Analysis Signicant outcomes

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Citation

Study design

Operational denition

Study period (days)

Patients included/ analysed

Perineal skin cleansers Soap, water, moisture barrier vs. No-rinse cleanser with moisture barrier vs. no-rinse cleanser without moisture barrier Byers et al. (1995) Cross-over 21 12/10 36/90 19/24

Lewis-Byers and Thayer (2002) Foam cleanser vs. water, soap Cooper and Gray (2001) RCT Skin breakdown relating to incontinence 14 66/65 39/90

Prospective descriptive

Incontinence damaged skin

21

32/31

42/90

24/24 16/24

Reduced erythema when using no-rinse cleanser with moisture barrier Reduced erythema when using foam cleanser

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd Observational Comparative Excoriation due to incontinence 56 29/26 32/90 13/24 Post-test only Perineal skin breakdown 7 19/16 38/90 10/24 Reduced erythema and pain when using cleanser protectant lotion Pre/post Perineal dermatitis 420 136/ 42/90 15/24 Reduced perineal dermatitis RCT Skin problems 94/ 28/90 9/24 More skin problems when using disposable washcloth without dimethicone

Cleansing agent and barrier cream vs. aerosol mousse Whittingham and May (1998)

Cleanser protectant lotion vs. no-rinse cleanser spray + skin barrier paste or antifungal cream Warshaw et al. (2002)

Barrier ointment (lanoline, beeswax, petrolatum) + body wash (petrolatum) vs. Hunter et al. (2003)

Cleansing spray, washcloth, skin protectant vs. disposable washcloth with dimethicone vs. disposable washcloth without dimethicone Dieter et al. (2006)

Incontinence-associated dermatitis: literature review

RAC, Research Appraisal Checklist; pre/post, prepost-test design; RCT, randomized controlled trial; A, acute care; C, chronic care; , no result.

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D. Beeckman et al. Reduced incidence of IAD Reduced severity of skin lesions Reduced grade 1 PU when using structured protocol

et al. 2003, Dieter et al. 2006). In these studies, different formulae were compared (Table 1).

Use of a specic skin care and/or incontinence care regime

The implementation of a structured skin care protocol combined with a pressure ulcer prevention protocol caused a statistically signicantly lower IAD incidence (47% vs. 253%) and fewer grade 1 pressure ulcers (non-blanchable erythema of the intact skin). Use of the newly implemented skin care protocol resulted in a statistically signicant reduction of total costs when product costs were calculated together with staff time (Bale et al. 2004). Bates-Jensen et al. (2003)conducted a randomized controlled trial to examine health outcomes of an exercise and incontinence intervention. Intervention patients were statistically signicantly better in urinary and faecal incontinence and skin wetness outcome measures (limited to the back distal perineal area) than the control group (Table 2).
Signicant outcomes

Use of diapers and/or underpads

Brown (1994a, 1994b) found no statistical differences in the incidence of skin alteration (colour, integrity or symptoms) between patients wearing diapers and those managed with underpads. More patients in a non-polymer diaper and underpads group experienced alterations (skin colour change, tingling, itching, burning, pain) than those in a polymer group. Therefore, polymer products, whether diaper or underpads, appeared to be more effective in preventing skin breakdown than non-polymer products. Leiby and Shanahan (1994) observed improved skin condition when underpads with a more absorbent capacity and higher ability to keep the skin dry was used (Table 3).

Study design

Discussion
In general, the quality of methods found in the included studies was rather poor, especially for participants and instruments. The absence of power calculations, correct randomization procedures, blinded assessments, standardized measuring methods and intention-to-treat analyses were the most common methodological aws. Effect sizes were not reported. The number of patients included was small and the length of study periods was short. A wide range of different wound characteristics and observational instruments were used to classify and observe incontinenceassociated skin problems. These instruments were either not validated or validated only to a limited extent, which
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RAC, Research Appraisal Checklist; pre/post, prepost-test design; RCT, randomized controlled trial; IAD, incontinence-associated dermatitis; PU, pressure ulcer; , no result.

Analysis

21/24

24/24

RAC scores

Methods

46/90

64/90

Table 2 Description of studies concerning the use of a specic skin care regime and/or incontinence care regime

Patients included/analysed

Study period (days)

Incontinence care vs. usual care Bates-Jensen et al. (2003)

Structured protocol vs. unstructured protocol Bale et al. (2004)

Citation

Lyder et al. (1992)

RCT doubleblinded

Pre/post

Pre/post

Perineal skin wetness

Incontinence dermatitis

Operational denition

Perineal dermatitis

234

90

56

190/144

164/

15/

63/90

24/24

Reduced skin wetness and erythema

JAN: REVIEW PAPER Improvement of skin integrity when using underpads high absorbance Reduced skin irritation and odour

Incontinence-associated dermatitis: literature review

resulted in difculties in comparing the outcomes of the studies. Due to the explorative character of the review, the scarce literature found and the aim to provide an overview of current (limited) evidence, the methodological quality of each study is reported in this review but was not used as an exclusion criterion. This allows identication of potential areas for additional and rigorously conducted research.

Analysis

Signicant outcomes

18/24

Reduced skin breakdown when using polymer diaper/underpads

20/24

8/24

Prevalence and incidence

A wide variety in IAD prevalence and incidence was described in the literature. Only a few researchers reported prevalence or incidence data on IAD. Most studies were single-centred, conducted in chronic care settings and based on small samples. Prevalence proportions could not be compared, because no standardized method for determining prevalence was used. We suggest that the development of a uniform instrument and method to study IAD prevalence and management strategies across different patient groups are needed. Further research is also needed to obtain a clear picture of the prevalence and incidence in critical care units, in acute care and in community care settings.

RAC scores

Methods

54/90

38/90

Patients included/ analysed

139/107

166/

92/

19/90 RAC, Research Appraisal Checklist; RCT, randomized controlled trial; A, acute care; C, chronic care; , no result.

Study period (days)

84

42

Pathophysiology
Limited research was found focusing on the complex aetiology of IAD. Faecal incontinence and double urinary and faecal incontinence tend to appear more strongly associated with IAD than urinary incontinence alone (Jeter & Lutz 1996, Lekan-Rutledge 2006). Several components of faeces may contribute to this association, including faecal enzymes and bacteria, and excess moisture if the faeces are liquid (diarrhoea) (Jeter & Lutz 1996). The role of inuencing factors, such as the perineal environment and the nature of incontinence (urinary, faecal or double urinary and faecal incontinence), the volume and frequency of incontinence, friction, irritating agents, and factors that compromise the skins barrier function (hydration, pH, faecal enzymes, and fungal or bacterial pathogens) should be further investigated.

Perineal dermatitis

Table 3 Description of studies concerning the use of diapers and/or underpads

Moisture-related skin problems

Operational denition

RCT double-blinded

Non-polymer diaper/underpads vs. polymer diaper/underpads vs. cloth underpads Brown (1994a, 1994b)

Copper acetate-containing diaper Ha ggbom et al. (1983)

Underpads high absorbance vs. underpads low absorbance Leiby and Shanahan (1994)

Observational

Study design

RCT

Denition and observation

A clear denition and a validated observation instrument for IAD are important in communication and the acquisition of knowledge. The ability to describe the nature of IAD would allow the development and implementation of rational clinical actions. Furthermore, a clear denition and observation instrument would enable a more
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Citation

D. Beeckman et al.

Table 4 Overview of cost-reducing interventions

Cost-reducing intervention Zinc oxide vs. no-sting barrier lm Campbell et al. (2001) Baatenburg de Jong and Admiraal (2004) Kennedy et al. (1996) Bliss et al. (2007) Zinco oxide vs. petrolatum ointment Kennedy et al. (1996) Petrolatum ointment vs. no-sting barrier lm Zehrer et al. (2004a) Cleansing agent and barrier cream vs. aerosol mouse Whittingham and May (1998) Cleanser protectant lotion vs. no-rinse cleanser spray + skin barrier paste or antifungal cream Warshaw et al. (2002) Cleansing spray, washcloth, skin protectant vs. disposable washcloth with dimethicone vs. disposable washcloth without dimethicone Dieter et al. (2006) Structured protocol vs. unstructured protocol Bale et al. (2004) Non-polymer diaper/underpads vs. polymer diaper/underpads vs. cloth underpads Brown (1994a, 1994b) , no result; NE, not evaluated. Direct costs Product cost Nursing time Total cost Indirect costs

No sting barrier lm No sting barrier lm No sting barrier lm No sting barrier lm

Reduced Reduced Reduced Higher

Reduced Reduced NE Reduced

NE Reduced NE Reduced

NE NE NE NE

Petrolatum ointment

Reduced

NE

NE

NE

No sting barrier lm

Reduced

Reduced

NE

NE

Aerosol mouse

Reduced

Reduced

NE

NE

Cleanser protectant lotion

Reduced

Reduced

NE

NE

Disposable washcloth with dimethicone

Reduced

NE

NE

NE

Structured protocol

Higher

Reduced

NE

NE

Polymer diaper/underpads

Higher

Reduced

NE

NE

systematic observation of IAD and would probably improve research clarity and the applicability of results in practice. In the literature, a variety of terms was used to describe incontinence-associated skin problems. No predominant terminology was found. The use of the MeSH term diaper rash revealed 505 publications in PubMed, whereas the [Text Word] incontinence lesion revealed 1018. A variety of additional keywords was needed to increase the sensitivity of the search lter. In the ICD-10 (WHO 2008), different alternative terms (diaper/napkin dermatitis, diaper/ napkin erythema or diaper/napkin rash) were described. According to the NANDA (2008), incontinence-associated skin problems should be classied as (risk for) impaired skin integrity. Suggested assessment, therapeutic interventions and continuity of care were all focused on pressure
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ulcer prevention and treatment because the nursing diagnosis of impaired skin integrity focuses on pressure ulcers. Differentiation between IAD and pressure ulcers should be included in the widely used NANDA classication to create clear instructions for nurses caring for patients affected with IAD.

Diagnosis
In clinical and research settings, IAD is often combined with skin damage caused by pressure and shear or related factors, sometimes leading to confusion among clinicians about its aetiology and diagnosis. Also in pressure ulcer literature, incontinence is often referred to as a factor increasing the risk of pressure ulcer development (Jeter & Lutz 1996, Bates-Jensen 1997, Maklebust & Sieggreen

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Incontinence-associated dermatitis: literature review

2001, Houwing et al. 2007). Until recently, there was limited discussion about the differentiation between pressure ulcers and incontinence-related skin problems in the literature. Since 1999, a growing number of papers have been published on the issue (Deoor 1999, Deoor et al. 2005, Dealey & Lindholm 2006, Evans & Stephen-Haynes 2007, Gray et al. 2007b). A correct distinction between pressure ulcers and IAD is important in practice because the preventive measures to be taken are different. Based on this review, skin protection, hygiene and supporting interventions (incontinence training and use of containment materials) are suggested for IAD. Protection or repair of oxygen supply to the tissue is indicated for the prevention of pressure ulcers. Confusion between IAD and pressure ulcers will probably result in inadequate use of limited resources. Expensive and labour-intensive measures to prevent pressure ulcers will often be applied for patients affected with IAD. As a result, those needing pressure prevention will probably not receive optimal care because of limited resources. A clear consensus about the aetiology and the availability of unambiguous clinical descriptors of the distinction between IAD and pressure ulcers would probably avoid confusion and the inadequate application of preventive interventions. Efforts to clarify the difference between IAD and pressure ulcers are being made. In a recent position statement, EPUAP dened wound-related characteristics (causes, location, shape, depth, edges and colour) and patient-related characteristics to clarify the difference between a pressure ulcer and IAD (Deoor et al. 2005). These differential characteristics can help to distinguish both skin disorders. Healthcare professionals should be adequately educated about the principles behind the differentiation between IAD and pressure ulcers.

skin hygiene and management. However, it has not been found to be the most appropriate for skin care of patients with incontinence. The use of perineal skin cleansers was found to be more effective for the prevention and treatment of IAD. Another option is the use of a no-rinse cleansing foam. Based on the results of this review, it appears that optimal skin care following each major incontinence episode, particularly if faeces are present, is important. Optimal skin care should be provided by the development of a structured skin care regime (containing a skin cleanser and a skin protectant). In addition, a skin protectant should be applied more frequently in patients with highvolume or frequent episodes of incontinence. Combined products can be used to optimize time efciency and to encourage adherence to the skin care regime. Combined products include moisturizing cleansers, moisturizer skin protectant creams and disposable washcloths that incorporate cleansers, moisturizers and skin protectants into a single product.

Cost-effectiveness
In ve studies, reduced cost was reported when a no-sting barrier lm was used for the prevention and treatment of IAD. In a study by Zehrer et al. (2004a), a cost reduction was observed when a no-sting barrier lm was applied three times a week instead of once daily. The validity and reliability of cost-effectiveness analyses should be interpreted carefully. A nancial grant from the producer of the experimental intervention was mentioned in the studies. Another point of concern is that the cost-effectiveness analyses were limited to calculation of the direct costs [the product cost (cost per unit application rate) and nursing time (nursing time per application application rate)]. Total costs, dened as the sum of the product cost, nursing time and costs of treatment-related products (such as nonsterile gloves, spatulas, gauze, sweet oil, disposable material) was dened in only two studies (Baatenburg de Jong & Admiraal 2004, Bliss et al. 2007). Indirect costs were not taken into account. Caregivers and patients should be informed about direct costs as well as indirect costs so that they can choose the most cost-effective and appropriate intervention (Phillips 2007).

Management
Researchers tend to recommend a routine perineal skin-care programme that includes cleansing with a product with a pH as near as possible to that of normal skin. In a second step, a moisturizer, incorporated into a specially designed cleanser or cleansing system, can be applied. The use of a skin protectant is recommended for patients considered at risk of IAD, including those experiencing high volume or frequent incontinence or double urinary and faecal incontinence. The use of soap and water (applied with a washcloth) has traditionally been thought of as being the gold standard for

Conclusion
Incontinence-associated dermatitis is an important problem in both chronic and acute care. This literature review reveals limited evidence concerning various preventive and treatment
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D. Beeckman et al.

What is already known about this topic

Incontinence-associated dermatitis is a common problem in patients with incontinence. Faecal incontinence appears to be more strongly associated with incontinence-associated dermatitis development than urinary incontinence. A wide range of skin care products are available for prevention and treatment, but little is known about their efcacy and effectiveness.

Conict of interest
No conict of interest has been declared by the authors.

Funding
This research received no specic grant from any funding agency in the public, commercial or not-for-prot sectors.

Author contributions
LS and TD were responsible for the study conception and design. LS and TD performed the data collection. DB, LS and TD performed the data analysis. DB and TD were responsible for the drafting of the manuscript. DB, LS, SV, AH and TD made critical revisions to the paper for important intellectual content. TD supervised the study.

What this paper adds

The use of soap and water is not the most appropriate method for skin care of patients with incontinence. Structured perineal skin care, including cleansing with a product of which the pH is near to that of normal skin, is suggested. A skin protectant is recommended for patients with incontinence who are at risk of developing incontinence-associated dermatitis.

References
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Implications for practice and/or policy

Further research is needed to ascertain the safety and effectiveness of commonly used products and procedures. Caregivers and patients should be informed about direct and indirect costs so that they can choose the most appropriate intervention. Observation of incontinence-associated dermatitis should be more objective to improve the clarity of research results and applicability in practice.

skin regimes. Additional research is needed to identify and evaluate the efcacy and effectiveness of various interventions for IAD, and larger sample studies are needed to ascertain the safety and effectiveness of commonly used products and procedures. This will require long-term data collection in multicentre studies. In view of the limited validation of observation instruments for IAD, additional research is recommended.

Acknowledgements
The authors would like to express their thanks to Ann Van Hecke MA RN and Lien Proost MA RN (Research Staff, Nursing Science, Ghent University), for their valuable support during this study.

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