Strategies for gaining control of incontinence-associated dermatitis (IAD)

An elderly woman’s back shows healthy ageing skin.

By actively promoting good skin health, carers can reduce the risk of IAD among nursing home residents, significantly improving quality of life and lightening their own workload.

People living with incontinence are at a higher risk of incontinence-associated dermatitis – a type of skin inflammation caused by prolonged exposure to urine or faeces. Prevention of IAD is crucial, as it causes considerable discomfort, and is a major risk factor for pressure ulcers, which are expensive and time-consuming to treat, and can become life-threatening if infection takes hold.¹ In this article we explore some of the factors that contribute to IAD, and how to address them.

_{1 Nix D, Haugen V. Prevention and management of incontinence-associated dermatitis. Drugs Aging. 2010;27(6):491-496}

Risk factors for IAD, and how to address them

Double padding
Obesity
Poor continence care
Faecal incontinence

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Double padding (using multiple products)

TENA incontinence products are designed to be used one at a time. They come in different types and sizes, with different absorption levels. To properly meet the needs of the resident, it’s important to choose the right incontinence product.

Double padding – the practice of inserting a “booster” pad inside an individual’s absorbent product – may seem like a good way to provide extra protection, but in fact it reduces functionality, and comes with several risks:

Wetness against the skin: When a resident voids more than the capacity of the booster pad, the urine may not pass through the backing of this pad into the outermost absorbent product. Instead, the overfilled booster pad will cause wetness against the skin, resulting in overhydrated skin, which can lead to skin breakdown.

Leakages on clothes: Urine that the booster pad can’t absorb will leak out on the sides. And since the outermost product is not snugly fitted to the groin, it may not be able to properly absorb the leaked fluids.

Skin irritation and pressure ulcers: In addition to its effect on the resident’s personal dignity, the extra bulk between the legs may cause rubbing against the skin. The poor fitting of the outer product may contribute to this, and there’s also a risk of friction when the booster pad is removed.

A nurse helps an elderly resident take a picture of a rose on her phone.

Obesity – risks and prevention

Obese residents are more likely to:

Experience leakages on clothes and linens due to poorly fitted incontinence products
Have difficulties performing personal hygiene due to inability to reach all areas of the body
Endure skin breakdown resulting from impaired mobility and excess body weight
Perspire heavily, leading to friction and chafing as skin rubs together within folds
Experience malnutrition and diabetes that further increase the risk of skin damage

Include a daily examination of the condition of your residents’ skin in their care plans. Check skin folds in particular. Keep them dry and clean to prevent friction. Barrier creams or zinc creams can also help reduce skin-to-skin friction. Make sure to use products that specifically meet the unique needs of clinically obese users.

An elderly resident and her carer walk and talk outside a care home.

An elderly resident speaks with his carer in her office.

Poor continence care and risks for skin damage

Good continence care is essential for good skin health. Prolonged exposure to urine and/or faeces leaves residents’ skin at greater risk of irritation and maceration. Wearing an incontinence product that is the wrong size or has the wrong level of absorbency can result in chafing of the skin. Using non-breathable bed protection may also increase the risk of skin damage, as does leaving a resident in a wet or soiled product for longer periods.

Preventive perineal skincare is important too. Washing with ordinary soap and water in the sensitive genital area can cause skin irritation. It’s important to use skincare products that gently cleanse, moisturise, and preserve the skin’s natural barrier and keep it healthy, resilient, and protected.

With the right products, right toileting and changing routines, and good skin care, it’s possible to maintain good skin health in the genital area.

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A nurse helps an elderly resident put on her stockings.

Faecal incontinence – reduce the risk of IAD with proper bowel management

A proper bowel management programme will help prevent unplanned bowel movements and avoid complications like constipation. Residents’ skin should not be exposed to faeces or urine more than necessary. Prolonged contact with faeces is a key risk factor for IAD as they contain harsh enzymes and corrosive compounds that can quickly degrade the skin. Make sure to remove any faeces promptly by wiping from front to back to avoid faecal bacteria entering the urethra.

Take advantage of the gastrocolic reflex, which is responsible for the urge to defecate after a meal, by helping your residents with regular mealtimes, ensuring the best eating conditions, and encouraging them to use the toilet after meals – especially after breakfast when the reflex is strongest. Ensure a correct toilet position that facilitates bowel movement.

Faecal incontinence can be a devastating condition, but effective treatment and management can improve quality of life. Learn more about how to maintain a healthy bowel here.

The bare arms of two elderly residents sitting in sun chairs.

The difference between IAD and pressure injuries

IAD presentations are often mislabelled as pressure injuries, but there are important differences. Whereas IAD forms on the surface of the skin and is related to the skin’s prolonged exposure to urine or stool, pressure injuries start deeper in the skin layers, appearing from the inside out. A pressure injury is a localized injury, usually over a bony prominence, and is a result of pressure, or pressure combined with shear. Pressure injuries can appear anywhere on the body.

Research shows a clear link between IAD and an increased risk of pressure injuries in the buttock regions. Both IAD and pressure injuries cause considerable discomfort and can be difficult to treat – another reason why preventive perineal skincare and good continence management is so important.

A nurse helps an elderly resident out of the bathroom.

Promoting good skin health: hands-on tips for nurses and caregivers

There are many factors that can interfere with the skin’s balance. In this article we examine some of the important factors to have in mind when it comes to incontinence care and personal hygiene.

Read the article

Audited by Josefine Grandin, District nurse, urotherapist, 2022-04-25

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