IAD prevention and management - the goal

The goal of the ‘prevention and management’ of IAD is to maintain and restore optimal skin condition and function. An important feature of this is to eliminate or minimize the cause—which in this case is incontinence. Incontinence management is a course unto itself—so let me be brief about the best treatment methodology.

 

The promotion of continence and the successful management of ongoing incontinence should be a central feature of the prevention and treatment plans for IAD.

Detailed assessments should provide the basis of a standardized and tailored treatment plan. The correct usage of products, including continence devices, absorbent pads, and urinary sheaths or stool-diversion systems, can reduce the risk for IAD. Look for our new course on ‘Continence Management’ which will be presented in April for more in-depth information and strategies.

 

Skin Care Principles

Now we will discuss the general principles of skin care to prevent and treat IAD.

·Skin cleansing ·Skin protection and restoration ·Skin loss restoration

Currently there is little evidence to support an optimum frequency for skin cleansing. However, it is recommended that skin should be cleansed daily and after any episode of fecal incontinence. It is important to balance the frequency of skin cleansing to assure that it does not strip the surface of its protective barriers. In general, soap and water should be avoided for cleansing after an incontinence episode because of the ability for soap to increase the skin’s pH, damaging the protective acid mantel that can lead to skin damage. Soap can also strip dirt and lipids from the skin, allowing it to dry out and become itchy—which can lead to an itch-scratch cycle that causes excoriation then provides a path for the entry of irritants and pathogens. Itchiness may be reduced with the application of emollients to help in building intradermal lipids, rehydrating skin, and reducing irritation to the sensory nerve endings. It is recommended to use perineal skin cleansers that may be available in liquid, lotion, foams, or in an impregnated cloth, that can gently remove skin irritants, and help to maintain an optimal skin pH level, thereby reducing skin damage. The last form I mentioned, the impregnated cloths, should be used very carefully, and only on patients with more intact skin, because their use can sometimes cause more injury.

As for the rest, many of these are not rinsed off after use because they contain helpful moisturizing factors to help maintain and restore the skin’s barrier function. Use of these cleansers can reduce the friction element of manual drying. If the skin must be manually dried, care should be taken to avoid mechanical injury. Specifically designed continence care wipes are impregnated with products that cleans, moisturize, deodorize, and help to seal out moisture.

 

Skin protection and restoration

In addition to cleansing, skin protection to support the restoration of the skin’s barrier function is the central focus of treatment for IAD. We will explore some products under the categories of emollient and moisturizer as topical treatments.

First, let’s differentiate between these products. Emollients are used to occlude the epidermis and prevent water loss, dehydration, and the risk for damage when in contact with urinary and fecal incontinence. Moisturizers, on the other hand, are used for their humectant properties that bond with water molecules and increase the water content on the skin surface to improve overall hydration. In these products, collagen, glycerin, and sugars draw water from a humid environment to enhance water absorption. And products containing lanolin have been associated with skin sensitivity, so they are generally avoided.

We find these products in several forms, including lotions, creams, gels, foams, ointments, and sprays. Some products contain a mixture of emollients and humectants. The choice of which products to use depends on the findings in the skin assessment. For instance, humectant functioning products should not be used on macerated skin.

An emollient skin care regimen will include emollient soap substitutes, as well as leave-on emollients and moisturizers (creams, lotions, ointments).

After cleansing, skin protectants can reduce exposure of affected skin to incontinence irritants and moisture. Liquid barrier films and moisture barrier creams or ointments may be used for repelling water for several days. Barrier films can be applied to damaged or intact skin and reduce maceration. In addition, they are alcohol-free and non-stinging. As with all products, topical barriers should be used according to instructions provided by the manufacturer to prevent misuse and complications.

It is worth mentioning here that when the skin’s barrier function is compromised, bacterial and fungal infections may take hold. While topical antibacterial products are helpful and important treatment and skin care options, topical antibacterial products should only be used when there are clinical signs of secondary infection, including more pain and discomfort with hot red skin. In addition, antifungal creams and powders should only be used if skin candidiasis has been diagnosed.

 

 

Skin loss restoration

Superficial skin loss may occur in severe cases of IAD, which can be very painful. In these cases, treatments may include semi-occlusive dressings that absorb wound fluid while promoting moist wound healing. Some of these are shaped to conform to specific areas to assure that the skin is not further damaged. Special products are used that reduce the risk for skin trauma, such as silicone dressings and others with advanced adhesives.

It gets tricky to apply dressings in the perineal area with skinfolds and creases, especially in cases where there is a continuous presence of moisture and incontinence. To get the best results, frequent assessment and changing of dressings that are soiled or saturated is necessary to reduce direct skin contact with moisture and contaminants.