Incontinence associated dermatitis: protection and repair of the skin

If we have a patient that already has IAD related skin damage, we have to address the following questions: 

 

1. How do we clean the skin from urine/faeces residues?

2. What type of barrier products can we use to protect the skin from new contact with urine/faeces?

3. Are there products that can accelerate the repair processes? vi påføre huden noe for å fremskynde reparasjonsprosessen? 

How do we clean the skin from urine/faeces residues?

 

The skin should be thoroughly cleaned after every incontinence episode involving soiling with faeces, but you do not need to wash the skin after every urinary incontinence episode. 

 

Traditionally soap, water and a washcloth are used for cleaning the skin after incontinence episodes. Do not use regular soap as this usually has a too high pH value. However, also, soaps with lower pH may cause harm if used repeatedly on these skin areas that are already irritated. If you have to use the washcloth method, try to obtain a pH-neutral soap. Be very gentle with the washcloth. Never rub the skin hard, as repeated friction from the cloth can considerably aggravate skin irritation.

If you have the resources to use single-use wipes, this is probably the most gentle method for cleaning the skin. There is a wide choice of single-use wipes available. Some wipes are dry, and you have to apply a washing cream before use, pre-moistened wipes without barrier function and pre-moistened wipes that contain both cleansing and barrier agents.

 

An advantage of these wipes is that they all are soft and cause minimal friction. Studies show that the threshold for washing the patients regularly is lower when caregivers can use wipes instead of the traditional washcloth method. Furthermore, wipes are probably cheaper in the long run because they are time saving and because a washing cloth/ washbasin will have to be washed at high temperatures afterwards. Some studies show a reduction of catheter-related infections when using wipes.

 

Use wipes without barrier agents/ cleansing agents to remove most of the soiling, and after this, wipe with barrier agents/cleansing agents. When using wipes, the skin usually dries sufficiently, thus avoiding the friction caused by a drying towel. Note that a package of wipes should follow one patient - i.e. not be shared with other patients for hygienic reasons.  

We do not really see a reason for using dry wipes with washing creams. It makes more sense to simply use pre-moistened ready-to-use wipes. 

Figure 1  Single-use wipes impregnated with gentle cleansing products are recommended today for cleaning the skin during incontinency episodes.  Some wipes only contain cleansing agents, while others contain additives that provide a barrier function to protect the skin from moisture and feces.

Barrier products in fluid/spray form

After the skin has been cleaned, a barrier product should be applied to protect it from IAD. If the patient already has developed an IAD, the barrier product will facilitate quicker healing. If a wipe with barrier agents has been used, this can be sufficient to protect the skin in patients who have a low to moderate risk for IAD. Suppose you suspect that the patient has a high risk of developing IAD or already has an IAD. In that case, you should supplement with an additional barrier product because the barrier effect from wipes is weaker.

 

Often we use a barrier product in fluid form or as a spray for this. Most of the barrier products are dimethicone or acrylate derivatives. They are easy to apply and do not need to be removed. Most of these products are transparent and allow for a continuous evaluation of the skin status. 

The main disadvantage of regular barrier products is that they do not adhere well to moist surfaces and may have to be applied often. Cavilon Advanced is a unique product that differs from all other barrier products. It adheres well onto moist surfaces and is therefore very useful for IAD with broken, moist skin. The product is almost like a very thin skin glue and adheres so well that it only needs to be applied about twice weekly. Note that you should not use wipes with barrier function when using Cavilon Advanced as this can result in a rather sticky surface. You should not cover Cavilon Advanced with other products like creams, lotions, or pastes. Cavilon Advanced appears to be a unique product that solves many of the challenges with the prevention and treatment of IAD.

Figure 2 Barrier products as sprays. The same products are also available as brushes/lollipops or wipes. 

Figure 3 Cavilon Advanced is different from other barrier products in that it adheres surprisingly well to moist, broken skin. It also has a unique application mechanism. Under optimal conditions, it can last up to 7 days, but the twice-weekly application is recommended. 

Video 1 Link to a  video by 3M for using Cavilon Advanced

Barrier products in cream-, lotion- or paste form 

Traditionally, zinc paste has been used as a barrier product for many years. If applied quite thickly, it can provide adequate protection against IAD. Zinc also has anti-inflammatory properties. One of the disadvantages is that the diapers or sheets may absorb the zinc. Also, removing zinc paste residues may cause friction on the skin.   

More modern barrier creams/ lotions are easier to apply, often have better barrier qualities, and are easier to remove. In addition, they often contain additives that help to repair skin damage. While most liquid/spray barrier products are quite similar (except for Cavilon Advanced), barrier products such as creams/lotions are very different in their mode of function. From our own experiences, we see considerable differences in how well they perform. Some perform very well, while others only provide a slight barrier effect. 

When should you use a barrier cream/lotion? If you have applied a fluid/spray barrier product, you usually do not need a barrier cream/lotion on top of this. However, these products are useful if you only have the washcloth/washbasin method available and do not have fluid/spray products available. With the exception of the Medihoney barrier product, it is our opinion that most of the cream/lotion products are not ideal for treating  IAD skin with open wounds. In these cases, Cavilon Advanced is the ideal product if available. 

Figure 4 Barrier products in cream/lotion or paste form. There is a confusing choice of products available, and these are quite different in what they contain and how effective they are. In general, these products help prevent IAD in patients with low- moderate risk for developing IAD. Many of these products are not a good choice for treating IAD with open wounds. In our experience, the Medihoney barrier product sets itself apart from some of the other products here in that it works well in open wounds as well. 

Products for treating fungal infections 

It is common for fungal infections to thrive in areas with IAD. The high moisture levels and the broken skin barrier make it easy for fungus to establish itself here, especially in skin folds, the groin- and perineal areas. Sometimes it will be easy to determine whether there is fungus present - a whitish layer and a particular smell may be tell-tale signs of fungus. It may be more challenging to determine whether a fungal infection is present at other times. Have a high level of suspicion if the skin seems very irritated or if there is more exudate coming from the areas with broken skin than you would expect. Also -patients with fungal infections in areas with IAD usually have more pain.  

Fungus thrives in warm, moist environments. Changing a diaper often can, in some cases, be sufficient to make the fungal infection disappear. If the patient does not have very frequent incontinence episodes, it may be worthwhile to try a period without diapers if that is a practical option.  

Traditionally anti-fungal creams have been used to treat fungal infections in patients with IAD. Clotrimazole ( for example, Canesten) is probably the anti-fungal cream that has been most widely used. One of the main disadvantages of such a product is that they do not contain any barrier function, and it is not possible to apply a barrier product over this as it will not adhere to and protect the skin. In our experience, anti-fungal creams work very slowly in these cases and often take at least 7-10 days before the fungal infection has cleared. Remember also that Clotrimazole does not work against all strains of fungi. 

Some caregivers use Sorbact dressings for treating fungal infections in IAD.  Sorbact can be used as a contact layer and it can be placed directly on the skin after a barrier product has been applied.  Sorbact works by trapping bacteria and fungi withing the structure of the dressing.  It may be somewhat challenging to  steder brukes Sorbact produkter til behandling av sopp ved IAD.  Sorbact er et produkt som trekker sårvæske og mikrober til seg og låser de inn i bandasjen. I lyskefolder kan man for eksempel legge en sorbact netting men på enkelte områder kan det være praktisk vanskelig å feste en slik bandasje.

Figure 5  Clotrimazole cream ( for example, Canesten) is often used in cases with IAD  with fungal infections.  It is relatively cheap, but it has the disadvantage that it does not provide a barrier effect. If you use a barrier product first, the antifungal cream will not be very effective; We, therefore, recommend using a dressing with antifungal properties like Sorbact or gentian violet 1% solution. 

wounds iad sorbact 3.png

Figure 6  An example where Sorbact dressing is applied to an area with IAD in the perianal area/gluteal folds. Note the strips of tape holding the dressing in place. A thin barrier product should be applied to the skin first. When treating fungal infections, the Sorbact dressing should be changed daily and at every incontinence interval  Image by courtesy of Abigo, Sweden.

wounds iad sorbact 2.JPG

Figure 7 An example where Sorbact dressing is applied to an area with fungal infection in a breast fold. Obviously, this is not caused by incontinence, but the principle is the same. This is also a moisture-associated skin rash, and the principles of treating this are very similar to treating IAD. Again, strips of skin-friendly tape are used to keep the dressing in place. You can see how the dressing keeps nicely in place on the image to the right when the patient is prone. Images by courtesy of Abigo, Sweden.

An excellent product for treating fungal infections in IAD is a 1% gentian violet solution. It is cheap and highly effective against most strains of fungi and bacteria. It has astringent properties, which usually rapidly dries out the areas with IAD. In most cases, you will see an improvement already within 2-3 days.    Gentian violet is generally readily available in most parts of Africa. In our opinion, it is the most effective agent against fungal infections in IAD-damaged skin. Its only disadvantage is that it will permanently stain clothes, bed linen, etc. 

When using gentian violet, this should be applied directly to the area with IAD after it has been cleaned. Note- if you have used a barrier product beforehand, the gentian violet may not be able to penetrate down to the skin. Therefore, it is essential to apply the Gentiana violet before you use a barrier product. In our experience, gentian violet works well with most types of barrier products- also Cavilon Advanced. App y  gentian violet liberally to all areas with IAD skin changes - also where there are open wounds. Contrary to belief, the gentian violet will not cause permanent discoloring of the skin even when applied to open wounds. 

 

Use gloves when applying the product to avoid staining your fingers. After applying the gentian violet, let it air dry for about 2-3 minutes before applying the barrier product. If you do not have a barrier product available, applying gentian violet once daily for about 7-10 days is advisable. If you have a barrier product available, this will determine the frequency of applying gentian violet. Suppose you are using Cavilon Advanced, for example. In that case, it will not be very useful to apply the gentian violet more than every third day as it will not be able to penetrate the barrier layer. If you are using other acrylate-type barrier products or creams, you can apply gentian violet daily as long as you do it before applying the barrier product. 

Dressings and IAD

It can be difficult and impractical to use dressings in many cases with IAD. Placing a dressing in the perianal area, for example, and keeping it there may be challenging. If there are frequent incontinence episodes, it may also become costly if we change an absorbent dressing every few hours.

 

In many cases, it is sufficient to apply a good barrier product to the areas affected by IAD without using any other dressings. This applies especially if the patient is using diapers. However,  whether to use or not use absorbent dressings depends on several factors ranging from patient preference to economic aspects. For example, if there is much exudate, it may be wise to use an absorbable pad until the wound areas have become drier. The moisture from the wound exudate can worsen the IAD, and as long as the dressing is changed regularly, it may prevent deterioration of the wound areas. Be aware that a saturated and wet dressing with exudate will make things worse - so if you decide to use a dressing, make sure you change it regularly.

What kind of dressings can be used here? This depends primarily on the amount of exudate you expect. If there is much exudate, you should consider using hyper-absorptive pads/foams - preferably with a silicone inner layer to protect the damaged skin from further irritation. Many types of polyurethane foam dressings have these qualities. The dressing should be soft as it often has to be placed in skin folds where a stiff dressing can cause friction. 

Reimbursement for patients with IAD

In many European countries, patients with IAD can be reimbursed for expenditures for barrier products, skin creams, gloves, diapers, and absorbable pads. Obviously, this is not the case in African countries unless the patient has private insurance.