Educational Webinar: Incontinence-Associated Dermatitis Prevention and Care

Transcript:

Conference Title: Essity: Incontinence-Associated Dermatitis Prevention and Care 

Date: Wednesday, 9th April 2025 

Brandon Martin:  Hello, and thank you for joining us today. My name is Brandon Martin here at McKesson Medical Surgical, and I’m so excited to welcome you to today’s presentation, Incontinence-Associated Dermatitis Prevention and Care, brought to you by Essity.  

Before we get started, I’d like to direct your attention to our disclaimer. While you are reviewing that information, I will remind you that this presentation is being recorded. And within a day or two, you can expect to receive a link to rewatch the presentation. If you have a question, feel free to enter it into the Q&A panel right in that mid-left side of your webinar window at any time, and we will do our best to answer at the end of the presentation.  

Our speaker today is Britney Ann Butt, Wound Management Program Coordinator with Keck Medical Center at the University of Southern California. Ms. Butt honed her skills as a clinical nurse specialist at North York General Hospital in Toronto from 2015 to 2024 before taking her current position as wound coordinator at the Keck Medical Center.  

She earned her Bachelor of Science and Nursing degree in 2012 from the University of Ottawa and her Master of Clinical Science Degree in Wound Healing in 2017 from the University of Western Ontario. She also earned her enterostomal therapy  nursing certificate in 2014 from the Canadian Association of Enterostomal Therapy, now referred to as the Wound, Ostomy and Continence Institute.  

As the Program Development Lead at the Wound, Ostomy and Continence Institute, Britney developed educational programs, including the Wound Debridement Program, Wound Care Practice Enrichment Series for Paramedics and the Skin Wellness Associated Program. She became WOCC-certified from the Canadian Nurse Association in 2018 and CWOCN certified from the Wound, Ostomy and Continence Nurse Certification Board in 2024.  

Britney, thank you so much for joining us today.  

Britney Ann Butt: Thank you so much for that introduction, and I’m really excited to talk to you about incontinence dermatitis today. How we – why it happens and how we can prevent it, and then if it does happen, how we can treat that.  

So let’s jump into it. Some of our lecture objectives, you know, understanding that terminology when we’re talking about, you know, type one – type A incontinent dermatitis. What does that mean? What is – what does a corneum stratum mean? What does moisture-associated dermatitis? What is some of the data behind why we do what we do? What is the role of moisture in the skin barrier function, differentiating IED from other skin conditions? So is it a pressure injury? Is it incontinence  dermatitis? Is it a skincare? What are some effective skincare routines? What are some evidence-based treatments, dietary modifications, and how can we collaborate with each other? And different healthcare providers collaborate for the prevention of incontinence dermatitis and looking at the Ghent tool.  

So today, let’s talk about moisture-associated skin damage, or MASD. This condition refers to skin injuries caused by prolonged exposure to moisture. When the skin remains wet for too long, its natural barrier becomes compromised, making it more vulnerable to irritation, inflammation, and even skin breakdown. MASD can develop in a variety of situations. It is especially common among patients dealing with incontinence, excessive sweating, or those who have medical devices that trap moisture against the skin for extended periods. Understanding these risk factors is essential for the prevention and effective management.  

Okay. First, we have intertriginous dermatitis, which is the inflammation that occurs in the skin folds, where the two skin services are rubbing up against each other, creating friction and trapping moisture.  

Next, there’s peristomal dermatitis. This refers to redness and irritation around the stoma, such as the colostomy or ileostomy site, typically caused by exposure to stool.  

The third type is periwound moisture-associated skin damage. This occurs when the skin around the wound becomes damaged due to prolonged moisture from wound exudate. Think of like your venous leg ulcerations, tons and tons of edema, lots of moisture. You can get a lot of periwound skin damage.  

Then there’s immersion foot. It’s also known as trench foot. Yeah, a lot of this happened in World War II, which results from extended exposure to wet conditions usually affecting the feet.  

And finally, really what this topic is going to be about is that fifth one, which is incontinence-associated dermatitis, or IED. This condition is caused by prolonged exposure to urine or stool, most commonly affecting the skin in the perineal area.  

Recognizing these subtypes is crucial for tailoring appropriate treatment and prevention strategies based on the source of the moisture and the areas involved. While we have our creams and our ointments, a lot of the time it’s identifying, well, why is the moisture there in the first place? So how can we reduce it?  

So let’s take a closer look at the prevalence and impact of incontinence among older adults, specifically those age 65 and older. Research shows the prevalence of all types of incontinence in this age group ranges from about 28% to 46%. In one particular study, more than 25% of these cases were already present on admission into a healthcare facility. However, a staggering 73% developed incontinence during hospitalization. So they didn’t have it prior to coming in. They got it when they came into our care setting, highlighting the importance of prevention and early identification in clinical settings.  

Patients with incontinence, especially those with dual incontinence, meaning both urinary and fecal incontinence, are at even higher risk for complications. In fact, these individuals are 1.6 times more likely to develop a facility-acquired pressure injury compared to those without incontinence. And that’s one of the things to keep in mind.  

Well, when we talk about incontinence dermatitis, especially with administrators, people can kind of go, “Well, it’s just rash”. When we start talking about it in the context of pressure injuries because that’s the thing everyone cares about, it starts perking those ears up and going, “Huh, maybe we should take a little bit a look at this because we really want to impact our pressure injury numbers”. So that’s kind of your way to take incontinence dermatitis and kind of push it forward is usually through pressure injury prevention.  

When looking at incontinence dermatitis specifically, the same study revealed that the severity of cases among affected patients, 52% were mild, 27% were moderate, but 9% were severe. Additionally, 14% actually had a fungal infection as well, adding another complexity to their care. These statistics underscore the need for proactive management, strategies to minimize complications and improve patient outcomes.  

So what are some of the IAD risk factors? Several factors contribute to the development of this condition, and understanding them is key to prevention and management. Individuals, obviously with urinary fecal incontinence are particularly high risk because their skin is constantly exposed to moisture from bodily fluids. Over time, this weakens the natural skin barrier and making it more prone to damage.  

Older adults are typically more at risk because they have thinner, more fragile skin. It’s the very advanced stage population and the very, very young that have the most fragile skin. So it’s going to be your neonates and it’s going to be your frail elderly always, on that spectrum.  

Diseases such as diabetes or peripheral vascular disease can impair skin integrity – to skin integrity and slow down healing. And that’s kind of with all wounds, right? Certain medications, like corticosteroids can thin the skin or disrupt the skin’s moisture balance, increasing their susceptibility to IAD. One of the things that I see is someone who’s been on hydrocortisone cream for a year in their perineal area, and that over time actually does damage. But when someone is taking something systemically, that can do even greater damage as well.  

When areas are prone to moisture, aren’t clean regularly, so poor hygiene practices, irritants and bacteria can accumulate, raising the risk of skin breakdown. Without proper moisturizing or the use of protective barriers, the skin becomes more vulnerable to damage from constant moisture exposure. And limited mobility can make it difficult for individuals to maintain personal hygiene, meaning to prolong moisture exposure and increasing the risk of IAD.  

A lot of incontinence is not that true incontinence, where the patient cannot hold their urine or their stool. A lot of incontinence is they know they have to go, they can hold it, they just can’t get to that bathroom fast enough or get to it at all, or relying on caregivers to bring them. So there’s a lot of functional incontinence that is happening where they can’t get to the toilet, not that they’re having that true incontinence where they can’t hold that urine.  

A poor nutritional status weakens the skin’s ability to heal and maintain skin integrity. And when the body lacks sufficient hydration, the skin can become dry and crack, making it more susceptible to damage when exposed to moisture.  

So let’s talk about the development of how incontinence dermatitis from that pathophysiology, like what is happening at the cellular level to cause incontinent dermatitis? Because I think it’s really important when you understand the why, it’s really easy to understand, well, this is why we’re treating it, right?  

So IAD is primarily linked to the skin’s barrier function and how moisture affects the skin’s overall integrity. To understand this barrier, let’s briefly look at the structure of the skin. The outermost layer of the skin, known as the epidermis, is made out of several layers. The most important for maintaining hydration is the stratum corneum. This layer consists of dead keratinocytes, filled with keratin and surrounded by a lipid matrix. So kind of like those fatty oils.  

Together, this structure serves as two crucial functions. It prevents excessive water loss from the body and it protects the skin from external elements like bacteria and irritants. So it’s not letting the water out and it’s not letting the bacteria irritants in. However, when the skin is exposed to moisture, especially from stool or urine, this protective barrier can be compromised very quickly. In fact, the damage can begin to occur within 10 to 15 minutes of contact. This rapid breakdown highlights the importance of timely care and prevention strategies to maintain skin integrity and reduce the risk of IAD.  

So skin damage can begin within both 10 to 15 minutes of contact with moisture from stool or urine. So there’s two different pathways. We have urinary incontinence and we also have your fecal incontinence. So your urinary continence episodes happen and urine is deposited onto the skin and the urea transforms into ammonia, which elevates the skin’s pH. Your skin is actually more acidic. It likes to live in an acidic environment, whereas your urine is actually more basic. So you think about that chemistry class you were forced to take. This is the reason acids and basics and how that actually transforms.  

So as your urine starts to deposit more and more urea onto your skin, your acidic mantle, which is actually there to help protect the skin and keep it slightly acidic, starts to break down. And so the acidic mantle becomes more compromised and reduces that skin’s chemical barrier effect. So that’s what’s happening with your urine.  

Then on your stool side, fecal incontinence episodes, while all of those enzymes over there to break down your food are actually starting to kind of break down your skin as well. So you end up getting corrosive damage to the epidermis. So between this almost chemical burn that you’re having and this enzymatic issue, you – some people can actually get very, very bad incontinence dermatitis because you actually have the combination effect going on. And so this is sort of that way that incontinence dermatitis from that kind of cellular level starts to break down.  

So let’s show the IAD pathophysiology. I like photographs. That’s how I learn the best. You know, anything that I can’t figure out, I draw a picture. So that’s why I’m showing you kind of in picture format. So prolonged exposure to moisture can lead to maceration, a condition where the epidermis, the skin’s most outer layer becomes overly hydrated and soft. And this weakens the skin’s ability to act as a protective barrier.  

So when moisture disrupts the lipid matrix of the stratum corneum, the skin not only loses its ability to retain internal moisture, but also becomes more vulnerable to irritants and pathogens. Over time, your keratinocytes, the cell’s main skin layer, it can swell and lose cohesion, increasing the skin’s permeability and reducing its barrier function.  

The skin’s natural pH is slightly acidic. Typically ranges from 4.5 to 5.5. This acidity supports the skin’s barrier. However, when the skin becomes in contact with urine, which contains urea and ammonia and electrolytes, its pH can shift. When we talked about that pH ranging with urine, it – unfortunately it changes the skin’s pH about 5.5 to seven, and unfortunately it actually decreases the skin’s defense mechanism from those irritants and bacteria.  

A more alkaline pH just have the lipid structure. So those little dots that you see in there, that’s actually your lipid barrier and that’s what’s keeping all of your skin’s cells together. So your skin is strong because it has that lipid barrier that’s keeping everything together. However, when that lipid is removed, your skin cells have little spaces in between them so that urine and those irritants can actually start to deposit.  

And more finally, with the weakened barrier, your transepidermal water loss can happen. So TEWL, transepidermal water loss. What ends up happening is the water in your skin actually starts to evaporate. So even though your skin is more hydrated from urine and ammonia, your skin is actually dehydrated when it comes to water.  

So when you look at incontinence dermatitis, it’s actually dehydrated skin, even though I know it’s a weird thing to think about. So when we talk about moisturization of the skin, sometimes it’s a hard concept to kind of overcome because you’re thinking, well, if I’m adding a moisturizer to the skin, I’m going to over hydrate it. But really what you’re doing is replacing that lipid barrier so that you stop having transepidermal water loss. When you stop having transepidermal water loss, your skin can actually heal. And then you can – again, you’re having a better lipid barrier. You’re not having irritants come in, your pH normalizes. So by hydrating the skin with the right thing, we can actually improve those outcomes.  

So let’s talk about IAD differentiation. So let’s take a look a little step and go, well, what isn’t incontinence dermatitis? So let’s look at all these three conjunction. Because pressure injuries and skin tears and incontinence dermatitis, that is the triangle of people not understanding what things are. So we’ll get skin tears on people’s bumps. People will say there’s incontinent dermatitis on the [inaudible]. So what does each one look like?  

So first we have skin tears. These wounds result because of sheer and friction and a blunt force. But when you think of a skin tear, think of well what force or what impact happened or how were we ripping of the skin? They lead from the separation of the skin layers and are most commonly found on the arms and the legs, and particularly in patients with fragile skin who are elderly. So think of skin tears as more of like a rip.  

Next is incontinence-associated dermatitis. This condition is caused by prolonged exposure to urine or stool as we just talked about. And this will usually happen in the buttocks or the groin or perineal area.  

And then we have stage two pressure injuries. So a stage two pressure injury is a partial thickness skin loss and it – of exposed dermis. And it’s over a bony prominence or underneath a medical device. There has to be an area of pressure. So if you’re taking a look at the picture of incontinence dermatitis, sometimes that will get labeled as stage two pressure injury. But that’s not how a stage two pressure injury occurs. You can see there’s a scattered pattern. So stage two pressure injury isn’t all over the patient’s butt or all over their groin. You have to think about, well, what caused it? You’ll notice incontinence dermatitis because those are the ones you can’t measure. Those are ones that it’s all over the place. You don’t know where it starts, you don’t know where it ends. It’s just all over. And that’s incontinence dermatitis.  

Pressure injuries are more defined, more distinct. It is over the bony prominence. It is under the medical device. There is a border with it. If you don’t feel like there’s a border, like in our incontinence dermatitis photo, it’s probably a pressure injury. Now you can have both. Two things can be true. You can have a patient with incontinence dermatitis who then develops a pressure injury in the center. So you can have both etiologies co-mingling with each other.  

So this is a stage two pressure injury. With a stage two pressure injury, you’re having that force being applied and then that actually causes that damage, but it’s more impactful right at that center. And then we have skin tears, and it’s due to skin adhesives ripping off the skin, right? So you’ve put down a adherent tape, rip it off. Well there comes that epidermal layer.  

So let’s talk about categorization of incontinence dermatitis, and let’s look at the Ghent tool. So there was an update a little while ago to how we differentiate incontinence dermatitis. And this is through the Ghent tool. Typically, prior was type zero. Then we had one and two, but we’ve expanded it to include fungal. So when we have category 1A, this is persistent redness without any clinical signs of infection. So your ones are closed skin, your twos are open skin, your A’s are no infection, and your B’S are infection.  

Okay, so you’re taking a look at our little picture here. We have persistent redness, but there’s no signs of infection and no open tissue. Hopefully, this is where you catch your IAD, right?  

Next, we have type 1B, so closed skin, but you can have a fungal infection. And you’ll notice an fungal infection because you’ll have like little dots that will start to kind of creepy crawl outside of that area, where that urine or stool is. Also sometimes can be a little bit more painful and a lot more itchy. It’ll sometimes look scaly as well. There’s a misconception that there will be a large odor that comes with it, not necessarily, but it will look a lot more scaly. And these are the patients that will need an antifungal agent.  

Then we have type 2A. This is where it’s open moist tissue when you’re like putting cream, but it’s kind of smearing all over the place because it’s just open and weeping. These very painful for that patient, but there’s no signs of infection. So that’s 2A. And then we have your 2B. So this is kind of your worst case scenario. Your patients got open, weeping skin, and then you got an infection. In this particular case, you could have a superseding fungal infection, but you could also have a bacterial infection as well, especially since the patient has been sitting in stool. These particular patients they may need an antifungal agent, they may need an antibacterial agent as well. And definitely getting your specialists involved in these particular cases.  

So let’s talk about treating and preventing incontinence. So I’m a WOCN. You know, there’s always the treatment, but we always want to talk about the prevention side. How do we prevent incontinence in the first place? If they just don’t have incontinence, we don’t have incontinence dermatitis. So let’s talk about it a little bit here.  

So an interdisciplinary approach is essential for effective managing of incontinence-associated dermatitis. So the first thing you want to do is collaboration. So we’re closely with your team of healthcare professionals, including nurses, physicians, dieticians, that’s a really big one, and your wound care specialists. Working with your physiotherapy team as well and your occupational therapy team is really essential when it comes to mobility. Can that patient hold their urine or stool? Great, but can they get there? Do they need a mobility aid for that as well?  

Staff training. So it’s crucial to educate your healthcare staff about prevention and management. This includes emphasizing the importance of regular skin assessments. So even just the fact of looking at that skin and assessing that skin daily. And proper skincare techniques and making sure everyone is on the same page and everyone’s consistently doing it. Sometimes it’s less about the product and about the consistent use of the said product. That is – makes a really big change.  

And using early intervention and prevention strategies. So catching it early and putting everything in place when something is happening early, not waiting till it gets super bad and then going, okay, we should do something about it. Right?  

And then patient and caregiver education. So providing education to both patients and their caregivers are vital. Especially when you’re in a hospital setting, if patient is eventually going to go home or go to a different care setting. So it’s sharing that information as they go is important.  

Let’s talk a little bit about diet. So this is really where you want to get your dieticians involved, but let’s talk a little bit about some of the irritants that can increase irritation in the bowel and the bladder that would affect incontinence.  

So common bladder irritants can trigger overactive bladder or diarrhea. And their effects can vary from person to person. While some individuals may be highly sensitive to certain foods or beverages, others might not experience any issues at all. So just remember this is just a guideline. This isn’t a rule. Everyone is a little bit different. All your patients are individual, but just as a general guideline of what would cause some irritants. So bowel irritants.  

Dairy foods. So if your patient is having a lot of diarrhea, okay, are they having dairy foods. Vegetables that are – so like your onions and your peppers and things like that. Beans, legumes, and processed foods. So they’re having very heavily processed foods. So think about are those things in their diet? Maybe we can reduce some of those things to help prevent diarrhea. Obviously pulling out any infectious or systematic issues causing that.  

Then we have bladder irritants. So like alcohol, carbonated beverages. Those will irritate the bladder as well. And then we have things that are actually combination that will irritate the bladder and the bowels. So caffeine, that is probably my number one thing is someone’s having incontinence, how much coffee are you’re drinking? Or how much diet coke are you having? Because you’re not having regular coke because they don’t want the sugar but they’re having the diet coke. So that actually has a lot of caffeine in it.  

Chocolate – artificial sweeteners. That’s another thing that could irritate the bladder because people are trying to look at their sugars and making sure they’re not intaking sugar, but they’ll have artificial sweeteners but that can irritate things as well. Spicy foods, acidic foods, citrus fruits, tomato products and vinegar and pickled fruits. I know I like pickles. So those are all things when you’re looking at the patient’s diet and considering what things can maybe we taper back on because having less irritants means less incontinence.  

So elimination support. This one is very, very big. So elimination support plays a vital role in managing functional incontinence, a condition where individuals are unable to reach the bathroom in time due to physical or cognitive limitations. So first thing you want to think about is toilet accessibility. Making the bathroom easily accessible, not having a bunch of stuff in the way so the patient can get there.  

Bedside commodes. So if the patient isn’t able to get to the bathroom effectively or the bathroom is too small to have those mobility aids. Lighting is a big one. Assistive devices. So walkers or canes, wheelchairs. Do we have the appropriate devices to get the patient to the toilet?  

Regular time void. So establishing a bathroom schedule, like every two hours, checking in with that patient, do you need to go to the bathroom? Are you feeling that urge? And then taking them to the bathroom. And using verbal or visual reminders to encourage regular visits and reduce the likelihood of accidents. And easy to remove clothing. The worst is when need to go to the bathroom, you need to go right now, but you can’t get the clothing off. So there is modifiable clothing, but using things like elastic waistbands that are easy to get off and got on to, to promote the patient’s own continence.  

So now let’s talk about topical management. So now we have incontinence dermatitis or we’re trying to prevent incontinence dermatitis because the patient has many episodes of incontinence. So what can we do and what are the things that we want to think about?  

So incontinence product selection and monitoring are essential components to effective incontinence management. So when it comes to product selection, what are the things you want to think about? So first thing is your absorbent products. So choose high quality absorbent products designed to whip moisture away from the skin while providing a comfortable fit. And it’s important to change these products regularly to prevent prolonged moisture exposure and reduce the risk of skin damage.  

There is some products on the market that can keep longer. So you really want to look at the product you’re using it, is it moisture wicking? The other thing you want to think about is making sure people aren’t brief stuffing. So the worst thing I see is you open up a brief and there are layers and layers of things in their brief. The thing is, it’s not actually doing what you think it’s doing. It’s just absorbing the liquid. It is not wicking away from the skin. So having the patient’s skin in contact with the brief specifically or with the underpad that actually wicks the moisture away is way better than stuffing things inside of the brief. Because unfortunately you see that practice and it’s not doing what you think it’s doing. Also putting double briefs, things like that. That – those aren’t – not allowing the skin to breathe. Using skin friendly materials, offer breathable materials and minimize skin irritation.  

The next thing is monitoring. Regular monitoring. Regular assess the patient’s skin, document any changes, irritation or breakdown, and use the standardized skin assessment tool. So within your facility, making sure everyone’s doing the same assessment is always way beneficial than Brenda doing something from Jane. So making sure everyone’s doing the same thing.  

And respond to interventions. So keep detailed records of how individuals respond to a specific intervention. So it’s one thing to give a treatment, but it’s another thing to say if you did that treatment work, did it work? Great. How do they respond? Did they not work? How do we go beyond and choose a different treatment?  

By combining proper selection and monitoring, we can protect the skin integrity and minimize complications and improve the overall wellbeing of our individuals incontinence.  

So let’s talk about the actual products themselves and let’s talk about the ingredients. So this is not brand specific. This is just what are some of the ingredients and how do they affect the skin? So an effective skincare routine, essential for maintaining skin integrity, especially for individuals at risk of moisture-associated skin damage.  

A proper regimen should include cleansing, drying, and moisturizing the skin daily. There are two types of moisturizing agents to incorporate. So there’s humectants. These ingredients draw moisture into the stratum corneum by attracting water from the air or deeper layers helping maintain hydration.  

Then there’s emollients. These are comprised of lipids and fatty acids that soften the skin by creating a protective barrier. Emollients fill the gaps in between the skin cells, preventing water loss and improving skin texture. So when we talked about those lipids when it came to incontinence dermatitis, this is helping replenish those lipids to keep that skin strong because we have those bond.  

By combining humectants and emollients into a regular skincare routine, we can effectively hydrate and protect and maintain the skin’s natural barrier. So while I talk about incontinence dermatitis, I also like to talk about skin health in general and kind of combine those things.  

Then we have skin cleansing and barrier products. So using a gentle pH balance cleanser is important. So everybody talked about how the skin likes to be more acidic, but your urine is more basic. That’s why you want a pH neutralizing cleanser that is going to push the skin more on the acidic side. That’s why just using water is not effective in incontinence dermatitis prevention or management because it’s not on – water isn’t slightly acidic. Pushing that back to that nice aesthetic mantle and neutralizing that basic urine pH.  

So surfactants play a key role in cleansers by reducing the surface tension and helping to remove the dirt and the oil without stripping the skin. The biggest thing is you want to cleanse the skin. You don’t want to remove all the oil. So all of kind of the older type of soaps and dyes, we don’t use that anymore. We want to use something gentle, pH neutralizing, something that’s going to be good for that sensitive skin. I always look towards what’s good on NICU skin, what’s good on the babies. If it’s good in that, sometimes it would be good on my older adults because they both have really fragile skin. But making sure that whatever agent you are using is skin friendly. It’s pH neutralizing. And it’s something that is free of irritants and dyes and fragrances.  

Okay. Next thing is applying a barrier product. So apply barrier creams or ointments to help protect the skin from moisture, urine and feces. Always apply these products to clean dry skin. So you really want to make sure your skin is clean before you’re putting your occlusive agents, but we also want to make sure the skin is dry. Occlusives are – create a protective physical layer on the skin, helping to lock in the moisture and prevent transepidermal water loss. So keeping that barrier, keeping that water where it needs to be, which is in the skin. And it reinforces the skin’s natural skin barrier. So you think of your – the things that you’re most commonly when you look in the back of any of your barrier projects, what is it probably going to say? It’s probably going to maybe have a dimethicone in there, maybe it’s going to have a petroleum, maybe it’s going to have a zinc. Probably one of the three, maybe all of them. So those are always those pre – those occlusives over top of the skin.  

And then we’ll talk about the management of damaged skin. So that was kind of that prevention. But what are some of the treatments we can use when the skin is actually damaged? One of the first ones is cyanoacrylates. So it’s a synthetic adhesive, often to referred as a liquid bandage and there’s several many – but it forms a waterproof barrier within seconds of contact with moisture, shielding the skin from irritants and contaminants. Once it’s cured, it maintains flexibility and allows the normal movement of the skin without breaking the bond, making ideal for sensitive areas.  

Another one and very common, you’ve probably used this many times is zinc oxide. So zinc oxide creates a protective barrier that prevents skin irritation caused by moisture, urine, and feces. It also helps soothe irritated skin and reduces inflammation. And that’s really why I like to use zinc sometimes is because it really is soothing. And it really cuts down on that irritation on that skin. And it creates a nice barrier keeping the skin dry and shielded from irritants.  

And lastly is we have our antifungal agents. So fungal infections on the perineal area are common due to constant moisture exposure. Antifungal powders, creams or ointments help reduce moisture and inhibit fungal growth.  

Kind of a word on antifungals. When you put an antifungal agent on, make sure to put that antifungal agent on first. Okay? Don’t clean the skin, put on kind of your zinc and then slap on an antifungal agent. That has to go on first. Do it nice and thin. And then anything else you can put over top. If you have a combo cream, that’s even better. But if you’re putting on antifungal, you always need to do that first before you put any of your other agents.  

So what are the some of the things that we don’t want? So when you’re looking at a manufacturer and there are so many manufacturers out there, it’s what you don’t want. So look on the back of the bottle, is there fragrances or perfume that’s very sensitizing to the patient’s skin. There’s many patients that are allergic. We don’t want any alcohol in there. There’s also a list of ingredients that are considered a little bit more harsh on the skin. So your sodium lauryl sulfate, that’s a little bit more harsh on the skin. We don’t want formaldehyde, lanolin, parabens and those microbeads. Again, all – they’re very abrasive to the skin and can hurt the environment.  

So when choosing a product line, you just want to make sure that it’s good for your patient and just really good for their skin. Healthy. The less inconvenience, the better often.  

Now let’s look at the Ghent tool again. So when you’re looking at that Ghent tool, you’re thinking, okay, now I know what it is, but how am I going to put that together with the actual products? And so I’m going to be brand neutral and talk about what are some things you want to think about with treatment of each type.  

So we have category 1A, so that is that persistent redness without clinical signs of infection. And then we have that 1B, persistent redness but with infection. 2A, we have skin loss, no infection. 2B, we have skin loss with signs of infection.  

And we’ll put it all together here. So with 1A, you always want to clean with a gentle surfactant. We want to always make sure we’re moisturizing the patient’s skin head to toe. So using that emollient or humectant. We can kind of skip that antifungal because we don’t have a fungal infection. And then we want to go to an inclusive barrier. Or this would be a good time to use a cyanoacrylate because the patient doesn’t have a fungal infection. I try not to use cyanoacrylates in the presence of a fungal infection because it does seal it. So you want to treat your fungal infection before you would use a cyanoacrylate.  

And when you’re looking at this topical management kind of algorithm, your patient can move throughout it. So if your patient was originally a 2A, but a couple days later they’re actually a 1A, then you can switch up your treatment. So making sure that your treatment is relevant for the patient at that time and not using a treatment or, say, you know, four weeks, and you know, what your patient’s condition has changed. So constantly updating the treatment based on what you’re seeing.  

1B, again, cleansing, gentle surfactant cleansing, moisturizing your patient’s skin, using your antifungal agent first and then use an occlusive barrier. For 2A, same thing, gentle cleanser, moisturizer, skipping that antifungal, but then we’re using an occlusive barrier. This is the one I’m adding maybe a zinc in there, maybe just from an anti-inflammatory perspective. And then you can also use a cyanoacrylate instead of the cream.  

And then 2B, that we’re using a gentle surfactant. We’re using it – we’re moisturizing patient’s skin, using the antifungal first and then using an occlusive barrier. Again, dimethicone and maybe a zinc combination would be good. And again, they can move throughout this – throughout their journey. Just remember, again, there’s tons of brands out there. Just look at the back and take a look at what are their ingredients. It will help kind of frame how you would use that brand within this algorithm. Because this is non-brand specific.  

And let’s just do a little summary here, just to kind of capture what we’ve talked about today.  

So moisture-associated skin damage is caused by prolonged exposure to moisture and leads to inflammation, irritation and tissue breakdown. Prolonged moisture weakens the skin’s barrier and causes maceration, inflammation and pH imbalance, increasing transepidermal water loss and allowing entry of irritants and pathogens.  

It’s common in healthcare settings among patients who are incontinent and especially in your frail, elderly. And dual incontinence raises the risk of pressure injuries. And that’s one thing, again, to keep in mind is that by having incontinence, it does increase your risk of having pressure injuries. So when you’re look – working in a facility and you’re trying to get people to pay attention to incontinence dermatitis, I do like to frame it in that manner. I find that usually you get more resources or if you can combine it with your pressure injury prevention protocol, because if you look at your Braden Scale, moisture’s right in there. So by targeting incontinence dermatitis within your pressure injury prevention protocol and not as its own protocol, I find it a lot more helpful and more meaningful.  

We talked about clinical manifestations. You know, it appears red. There’s maceration, there’s skin breakdown, often flows with the path of the irritants. So you know, if you’re having irritation under the breast, it’s probably not incontinence dermatitis. You’re probably looking at intertrigo. If it’s in between the toes, you probably got immersion foot. But if it’s in the groin and it’s following a pattern of incontinence dermatitis, that’s what it probably is.  

We categorize based on that Ghent tool, 1A, two – 1A, 1B, 2A, 2B. And looking at prevention and treatment. So regular assessing the skin, using pH neutralizing cleansers, applying moisture barrier products using appropriate incontinence products and using treatments as cyanoacrylates, zinc oxide. And looking at interdisciplinary approach, working with your physiotherapist or your occupational therapist from a mobility standpoint, getting that patient to the bathroom is always more beneficial than the patient having an incontinence episode. Again, further there are some patients that are not able to mobilize and then that’s okay, but for the patients that can, we really want to get them up involving your dietician when it comes to sensitizing agents and making sure what they’re eating is appropriate.  

And then working with your physicians as well and other nursing staff and really providing education to everyone so everyone’s on the same page, including the patient and including the family members. And then focusing on our underlying causes and promoting skin friendly practices.  

And so thank you so much for listening to my talk today. And if you have any questions, I’m here to answer them. Thank you.  

Brandon Martin:  Excellent. Thank you so much, Britney. I really appreciate your time today. While we are allowing for some time for questions. Excellent. Thank you so much, Britney. I really appreciate you today. I just want to let everyone know that you will receive in the coming days a copy of this presentation and also some information on how to reach out for your Continuing Education credits. So we’ll just give a minute or two in case anybody has any questions.  

Okay. Excellent. Well, if you do have any questions, do please feel free to enter them into the chat there below or, you know, feel free to reach out to us. And like I said, in the next day or so, you can expect to receive an information email with copies of the slides as well as some information on obtaining your Continuing Education credit.  

Britney, I want to thank you again so much for joining us today. I certainly learned a lot and I really appreciate your time and expertise.  

Britney Ann Butt: Thank you so much. It was lovely presenting and please reach out if you have any questions. And I’m happy to engage. Thank you so much.  

Brandon Martin:  Excellent. So thank you. Thank you. For a full list of our upcoming events, definitely encourage you all to visit us at mms.mckesson.com/learning-webinars. And there you can register for a future webinar, share events with your colleagues, or sign up to receive regular updates on our webinar schedule.  

Thank you again to our audience for taking the time to join us today. Again, if you do have any questions or concerns, please feel free to reach out to us. And I hope everyone has a great day.