What is incontinence associated dermatitis (IAD)?

Incontinence-associated dermatitis (IAD) is a global challenge! Historically this condition has received surprisingly little attention. This has changed in the last decade especially. There is now an increased focus on IAD, and there have been developed international guidelines for the prevention and treatment of this condition.

If you google "IAD Africa," you will get to the Institute for African Development at Cornell University, which is involved with important programs on the continent but will not help you get a better understanding of IAD in the world of wounds. Instead - google the term "incontinence associated dermatitis Africa," and you will get a few hits. You will realize that there is minimal information available about the prevalence of IAD on the African continent. From the little we know, it appears that the prevalence of IAD among institutionalized patients in Africa probably is alarmingly high. From a study published in 2016 by Fourie et al. (3M South Africa), the prevalence in two different hospitals in South Africa was 36% and 43%, respectively! There is a link to the article in pdf form further down this page. Remember that patients hospitalized in Africa are usually very sick, so it is difficult to compare such numbers to institutions in the western world. However, the prevalence of IAD in hospitals and nursing homes in western countries is also surprisingly high. A prevalence of 20-30% is not uncommon there, depending on the type of institution and the patient setting. 

IAD is a type of contact dermatitis caused by repeated or prolonged skin contact with feces and/or urine. These substances are aggressive on the skin and cause inflammation ( redness of the skin). This initial redness can turn into skin breakdown and ulcerations if no intervention is done. Per definition, the term IAD implies that the patient is incontinent. So- strictly speaking- if the patient isn't incontinent, it isn't IAD. A patient who is not incontinent can develop the same condition if exposed to feces/urine, but in that case, we should call this "moisture associated skin damage" (MASD) which is a more general term for this type of skin damage. IAD is a subgroup of  MASD. This may seem excessively particular, but if you want to look like an expert in the language of wound healing, then it is useful to differentiate these terms.   

What does IAD look like?

IAD is often localized around the perianal area and the scrotum or vagina. In cases with severe incontinence, it can affect large areas of skin like the entire buttocks and the groin areas.

In people with fair skin, it is usually straightforward to spot when the skin in the affected areas starts to get reddish. In the start, the skin will start to turn pinkish, and as the condition worsens, the skin can get very red indeed. In people with darker skin, the early stages of IAD especially can be harder to spot. Note that in dark-skinned people, the affected areas can be lighter OR darker in color, purplish, or even slightly yellowish.  

Figure 1  IAD has several stages of severity. On the left image, we see reddish skin, but it is mostly quite dry. In the middle image, we see a larger area affected, and if you look closely, you will notice moisture on the damaged skin. Once the skin is so irritated that it "sweats" a lot, it can break down very quickly if you don't react very fast. In the image on the right, the condition is severe, with bright red skin and skin breakdown in the perianal area. We lack good images of IAD in patients with darker skin- if you have some to share with us, please get in touch with us! ( remember to obtain informed consent from the patient)

IAD is an inflammation - therefore, the skin will feel warm to the touch. Often the skin and subcutaneous tissue become harder due to the inflammatory processes. Do not press or rub on the affected areas- this will only aggravate the condition.

Most patients with IAD experience pain - often a burning sensation over the affected areas. Note that the pain can be considerable even when the skin barrier is still intact. Some patients have itching as a primary symptom; others have itching and pain. 

When the skin damage is more serious, the skin's surface breaks down, and blisters of various sizes may develop. If no effective interventions are done, skin erosions will develop that resemble superficial ulcerations at first. Do not underestimate the severity of the condition - this can lead to severe ulcers that can get infected, increase the patient's suffering, and in the worst case, can lead to a patient's death.

Fungal infections, in particular, thrive in these areas of moist skin damage, and it is not rare to encounter candida albicans infections in these patients. It is not always easy to spot a fungal infection going on. Tell-tale signs of a fungal infection are increased redness and pain, increased secretion, and if the skin condition does not improve despite other adequate measures. Further down in this chapter, we present the GLOBIAD tool. This tool takes into consideration whether there is an infection present or not. The term " infection" refers to infections regardless of whether they are of fungal or bacterial origin. 

 

Remember- once the skin barrier has been broken, it is a short way from contamination with pathogenic bacteria from feces to a severe infection. If the patient is critically ill or has other causes for immunodeficiency, these bacterial ( and fungal) infections can lead to septicemia. 

In 2017 a new tool for IAD classification was presented - the GLOBIAD (Ghent Global IAD classification Tool). Since then, this tool has been adopted by many countries and is now in use globally, so the name is befitting. A task force has developed it at Ghent University in Belgia. It replaces the IADIT ( IAD assessment and intervention tool) and IADS ( incontinence associated and its severity tool). Are you by now confused by all these acronyms? GLOBIAD? IADIT? IADS? Luckily, from now on, you will only have to remember the first. 

The GLOBIAD classification tool is straightforward to use! You only need to address two questions: 1. Is the skin surface intact, or is the barrier broken? 2. Are there signs of infection ( either fungal, bacterial, or both)?

 

Once you have answered these two questions, you are ready to place the patient into one of the four categories:  1A  is IAD with an intact skin barrier and no infection. 1B is intact skin with signs of infection. Category 2A is a broken skin barrier without signs of infection, and 2B is a broken skin barrier with signs of infection.

 

WoundsAfrica likes the simplicity of the tool. It is practical, and it fulfills the need for a common language when we come to describe IAD in our patients. GLOBIAD has been translated to at least 15 languages ( click on the image below to get to a link to the source of the tool at skintghent.be) 

woundsafrica IAD globiad.JPG

Figure 2 Short version of the GLOBIAD tool. For the complete version in pdf, click on the image above. You will also find the complete list of languages available at the source site. To date (2021), it has not been translated into any African languages other than English. 

Which patients are most at risk for IAD?

  • Patients with either urine- or stool incontinence or double incontinence ( both urine- and stool incontinence) 

  • Delayed change of diapers or delayed cleansing of the skin

  • The use of soap and water can irritate the skin and dry it out, reducing the barrier effect

  • Patients with poor skin due to age or medications like steroids and chemotherapy. 

  • Patients with little mobility

  • Patients with impaired cognitive function

  • Poor nutrition

  • Critically sick patients

Why does prolonged exposure of the skin to urine/faeces cause damage? 

In an incontinent patient, the skin is repeatedly exposed to urine and/or faeces. Firstly- the moisture in these excretory substances causes moisture damage ( maceration) to the outer skin layers. Once the moisture has done its damage, the skin barrier is not optimal anymore, and chemicals in the urine/faeces can penetrate the skin, causing inflammation.  

 

Healthy skin has a slightly acidic pH between 4-6. This acidic pH is essential in maintaining the skin's barrier function and is also important for a healthy bacterial flora on the skin surface. When the skin comes into contact with urine/faeces, it becomes more basic. This is because bacteria on the skin's surface transform a chemical called urea from urine into ammonia. Many household cleaning detergents contain ammonia. This will make you appreciate that it is quite a strong chemical, and it is easy to understand that it can irritate the skin considerably. Furthermore- the basic pH due to the ammonia causes pathogenic bacteria and fungi to thrive better.  

Faeces contain several powerful enzymes that can damage the skin's outer layers. Thin, watery faeces causes more damage than drier faeces. Watery faces will obviously more easily cause moisture damage to the skin, but it also contains more of these aggressive enzymes.  

A combination of incontinence with both faeces and urine ( double incontinence)  is understandably the most threatening factor in developing IAD.

Are patients with IAD at increased risk of developing pressure ulcers? 

Of course! When the skin barrier has been broken due to moisture/ammonia/enzymes, the skin has less resistance to friction, shear and pressure!

The risk also runs the opposite way - that is - a patient with existing pressure ulcers may have moisture associated skin damage due to secretion from the pressure ulcer. This will make the skin more susceptible when coming into contact with urine/faeces.  

Sometimes it can be difficult to determine whether the skin damage we see is due to pressure or moisture. In reality, it does not matter so much if you mix up the two as long as you have understood that you will have to protect and treat the patient in very similar ways. Regardless of the cause of the skin irritation, we have to offload the affected areas and, at the same time, protect the affected skin from moisture/ contact with urine or faeces.   

Figure 3 IAD  and pressure damage are two entities that need to be addressed simultaneouslyy. It is easy to understand that moisture-damaged skin is more prone to further damage from shear, friction, or direct pressure. 

Figure 4 Many healthcare workers are confused when they see a situation like this. Is this IAD or a pressure ulcer? It would be helpful with a bit more clinical information about the patient to make a decision. However, note that the skin damage extends well into the perianal regions  - an area of the skin that is usually not affected by shear/friction or pressure. In this case, the initial skin damage was caused by an IAD - later on, in the course, the patient developed a pressure ulcer on the left buttock, which is an area typically in danger of pressure damage. Again, do not panic if you mix up pressure damage and IAD because, essentially, you will have to treat the patient in the same manner. This patient needs gentle cleansing of the affected area during incontinence episodes,  effective skin protection with barrier products, and a strict offloading regime!

How do you prevent and treat IAD?

All patients with urine and/ or fecal incontinence should have their skin inspected at least once daily to look for signs of IAD. In cases with more serious IAD, the skin should be inspected several times daily. Remember also to check areas with skin folds where moisture and stool rests can collect. 

To prevent and treat IAD, you will have to focus on these four key areas:

 

  • Gentle cleansing of the skin between incontinence episodes

  • Use of barrier products that reduce the contact between the irritating substances and the skin

  • Try to reduce the number of incontinence episodes

  • Offloading

We have written a separate chapter on the prevention and treatment of IAD - go back to the main page, and you will find the chapter there.

How is IAD coded in ICD-11?

Paradoxically there is currently no specific ICD-11 ( International Classification of Diseases Version 11) for IAD despite many global initiatives to address this skin condition. To date ( status 2021), we use the ICD-11 code L22, which refers to diaper-associated dermatitis ( nappy rash).   This is close but not entirely correct, as nappy rash is not the same as IAD in adults. We hope that future versions of the ICD-11 classification will address this. 

References:

Anika Fourie (3M Pty South Africa) 2016: The prevalence of incontinence-associated dermatitis in a South African sample: The impact of a preventative protocol. www.woundhealingsa.co.za

GLOBIAD  https://www.skintghent.be/en/onderzoek/Tools/2/incontinence-associated-dermatitis-iad

ICD-11: https://www.who.int/standards/classifications/classification-of-diseases