Incontinence Associated Dermatitis (IAD): A quick guide for low resource clinics

If you have the time, we advise you to look at the other chapters on IAD to get a complete oversight of what IAD is and what the standard of care is internationally.

For many clinics in Africa, fancy barrier products like Cavilon Advanced and single-use barrier wipes, which we present in the other chapters, are an unrealistic option.

So how can you manage patients with IAD when none of the modern alternatives are available? We provide you here with some simple alternatives:

Alternatives to cleansing products:

Ensure that you have established a plan for the caregivers to often check for incontinence episodes and clean the patient as soon as possible when an incontinence episode has occurred. Lack of financial resources is not an excuse for not providing basic hygienic principles to the incontinent patient.

The washcloth/washbasin method is usually the only option in areas with few resources. The caregivers must be aware that they should not use soap to clean away incontinence residues as these often have a high pH, which can damage the skin and worsen or lead to IAD. Body temperated water alone is usually enough. A tip is to apply body lotion to the washcloth once the main soiling has been removed—this aids with removing fecal residues gently and provides moisture to the skin.   Make sure the washcloth is of soft quality, and it is essential that rubbing of the skin is avoided. Never rub the skin dry - pat it dry gently. 

Clean the washbasin with boiling water between use- do not share washbasins between patients unless you can guarantee that they have been appropriately decontaminated. The same applies to washcloths. 

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Figure 1 For most patients in Africa, the washbasin/washcloth method is the only realistic option for cleaning away incontinence episodes. This is by no means an inferior method as long as it is carried out correctly. Do not use soap, and do not rub the skin! Remove most of the incontinence residues with a moist washcloth. After that, apply some skin lotion on a new washcloth and remove the last residues with this. 

Alternatives to diapers:

Single-use diapers are expensive, and understandably many people cannot afford these, especially when the incontinence lasts over a more extended period of time. Diaper alternatives from folded sheets of soft cotton are a good option here. The caregivers, at all times, must have a sufficient stock of cloth available to allow for frequent changes of these improvised diapers. Contrary to modern diapers, cloth diapers do not channel fluids away from the skin - once they are wet, they are wet and need to be changed as soon as possible. 

There are many ways to fold a sheet of cloth into a diaper - if you google " folding a cloth into a diaper," you will be amazed at how many methods exist. Popular techniques are the airplane-, kite-  or angel technique. 

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Figure 2 Single-use diapers are prohibitively expensive in Africa and not a realistic option for many patients. Reusable improvised diapers can be made from absorbable cotton sheets. There are many techniques for folding a sheet into a diaper shape. In the diagram above, the so-called "airplane" method is shown. 

Alternatives to barrier products and antifungal products

Commonly dimethicone-based barrier products are used to prevent and treat IAD today. These are not readily available in many African settings. However, petroleum jelly ( vaseline or white petrolatum) can be purchased at every corner store in Africa. This is a fairly good barrier product that protects and gives some slight hydration to the skin. It will need to be applied often as it will be absorbed into the (cloth) diaper or bed linen, but this should not be a problem since it is so cheap. It should be applied three times daily and at every incontinence interval. Zinc oxide ointment is another alternative. It too provides a good barrier, and zinc also has anti-inflammatory properties. Zinc oxide ointment is somewhat more expensive than white petrolatum. Depending on the consistency, it can also be a bit difficult to remove - do not be tempted to rub it off the skin as this can aggravate the problem. Some people have mixed white petrolatum with zinc oxide as a 50:50 mixture - this is an off-label mixture. The two ingredients do not mix that well, and it will require some stirring, but the end product may combine the advantages of each product. We have to date, not tried this ourselves. 

Another tip from some caregivers is to mix white petrolatum with honey in a 70:30 ratio. The theory is that the honey content has calming properties on the skin and may speed up the healing process. It may also protect the damaged skin from secondary infections. Again, this is something we have not tried ourselves, but a well-known barrier product- Medihoney barrier cream- also contains 30% honey.  

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Figure 4  White petrolatum ( vaseline, petroleum jelly) works quite well as a barrier product as long as it is applied regularly. The same applies to zinc oxide. If you suspect there to be a fungal infection, 1% gentian violet solution is an excellent product for clearing up the infection and, at the same time, drying out the wet IAD areas. Since it has very good adstringent ( drying-out) properties, we also like to use it in IAD cases with no fungal infection. In these cases, the gentian violet solution has to be applied once daily for about a week. You will need to apply the barrier product after each application with gentian violet as the latter has no barrier properties.

Gentian violet is an excellent agent to dry out and calm inflamed wet skin. We usually use a 1% solution for this, and it can generally be obtained relatively cheaply at most pharmacies in Africa. If applied daily, it is often possible to turn around a hopeless situation into something more manageable within a few days. The gentian violet solution must be applied before the barrier products are put on the skin. It is usually enough to apply the gentian violet once daily for about 5-7 days. It is also one of the best antifungal agents and usually rapidly resolves a fungal infection in IAD cases within a few days. Note: do not use gentian violet that contains alcohol! This will cause a strong burning pain and irritate the skin even more!

Use gloves when applying the gentian violet as it will stain your fingers for many days! Another downside is that the gentian violet will permanently stain the bedsheets and the patient's clothes if it comes into contact with these. 

Alternatives to dressings:

Many cases of IAD can be managed without dressings. In fact, since IAD often is situated in anatomically challenging areas of the body, it may be impractical to keep a dressing in place there. Applying barrier products and regularly checking for incontinence episodes is sufficient in most cases. If there is deeper ulceration, a polyurethane dressing may be indicated. If all you have available are cotton gauze dressings, you will have to use these. To avoid these adhering to the wound bed, you can cover the part of the gauze touching the skin/ulcer with a layer of white petrolatum ( first choice) or zinc oxide (second choice) to minimize adherence to the wound bed. Cotton gauze has the downside that it becomes wet once saturated- it is, therefore, important to change the gauze often ( maybe even many times daily) to avoid maceration and moisture damage from the dressing itself!

Alternatives to absorbent pads:

With absorbent pads, we mean large pads which can be placed underneath the patient to prevent contamination of the bedsheet/mattress. These are often expensive and not an option for many patients in Africa. When nothing else is available, a thick cotton blanket can be cut into appropriate sizes and used as an improvised absorbable pad. This will not stop leakage down to the mattress, and you will have to use some form of plastic sheet underneath the bedsheet to prevent contamination of the mattress.