The definition of incontinence is acknowledged as any involuntary loss of urine or the inability to control the bowels (International Continence Society [ICS], 2013). It is not a life-threatening condition but has a significant and distressing effect on the physical, psychological and social quality of life of those affected (Lukacz et al, 2011). Isolation, anxiety, depression and embarrassment are commonly reported by people who have a bladder or bowel issue (Wan and Wang, 2014). Urinary incontinence is more common than breast cancer, heart disease or diabetes among older women (Sexton et al, 2011; Tannenbaum et al, 2013). Incontinence is not gender or age specific, it can affect people of all cultures at any point from childhood to old age and can have devastating implications for the individual and their family. Many people may fail to seek help with incontinence for years due to embarrassment and stigma. 
Prevalence of bladder and bowel incontinence is increasing worldwide, in part due to an ageing population. Current estimates of the number of individuals in the UK who suffer from urinary incontinence are approximately 14 million, with a further six million estimated sufferers of faecal incontinence (Bladder and Bowel Foundation, 2015a; 2015b; Royal College of Nursing [RCN], 2019). 

The issue of incontinence is recognised to increase with age (DuBeau et al, 2009; Thirugnanasothy, 2010; Day et al, 2014), although it is not an inevitability of getting older (McGrother and Donaldson, 2005; Dongjuan and Kane, 2013; Goodman et al, 2013; Day et al, 2014).

There is still a very real social stigma surrounding continence. It remains a topic that is taboo, rarely discussed openly in public. Children are taught to manage their continence from a young age, instilling the social niceties and an emphasis on privacy — toileting is managed behind closed, locked doors. In adult life, this can affect behaviours and willingness to adapt to other environments, such as using a bedpan or commode (Booth, 2013; Bickerman, 2014; Holroyd, 2015). 
Many adults will not easily use a public toilet due to embarrassment, fearing unpleasant odour or noise. Booth (2013) quite rightly challenges this behaviour as unnatural — toileting is not a unique function afforded to only a few, we all have a need to micturate and defecate several times in a 24-hour period. 

An increasing number of people require assisted living, care or admission to residential and nursing homes. As said, older adults who find themselves in need of assistance with personal care, may find their dignity challenged due to the social conditioning instilled as a child, leading to a feeling of vulnerability or loss of control. Open toilet doors, assistance from a healthcare professional to access a toilet, or even a simple medical examination, can affect a person’s dignity, which in turn leads to increased feelings of vulnerability, dependence on others, and a lack of control over the environment or events (Booth, 2013). Indeed, the fear of dependency on others for the most intimate of bodily functions may make many individuals reluctant to report incontinence symptoms (Bedoya-Ronga and Currie, 2014). 
MOISTURE-ASSOCIATED SKIN DAMAGE 
The skin is the largest organ in the body, providing a natural barrier to excessive moisture, external harmful substances and environmental irritants. The structure of skin consists of the epidermal and dermal layers, which prevent harmful fluid gain or loss (Voegeli, 2012). The epidermis is the body’s main and outermost barrier to harm. It is constructed of five different layers: stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, stratum basale (Figure 1). 
The uppermost layer is the stratum corneum, a barrier constructed with protein-rich corneocytes (disc-shaped horny cells primarily made up of keratin) (Casey, 2002). These are bound together with a lipid-rich substance creating a ‘bricks and mortar’ style defensive structure (Cork, 1997; Voegeli, 2012). The epidermis also contains enzymes that work with the phospholipids to produce ceramides, a mixture of cholesterol and fatty acids. These bind the corneocytes together to form a rigid protein mass capable of attracting and retaining water within the stratum corneum (Harding, 2004). This is known as natural moisturising factor (NMF) — its purpose being to increase intracellular water content, enabling the corneocytes to retain their shape and turgidity. This process creates and maintains an effective and well-hydrated skin barrier that is flexible (Harding, 2004). The NMF is created from a breakdown of protein filaggrin, creating a mix of salts, amino acids and their derivatives. The NMF is capable of absorbing atmospheric water, enabling effective hydration of the outer skin layers in spite of environmental factors. Normal skin pH is 4.5–6.2, creating an acid mantle that is an effective neutralising barrier to viruses, bacteria and other contaminants or irritants that are alkaline in nature (Bardsley, 2013). 
Moisture-associated skin damage (MASD) is defined as the damage occurring in response to prolonged skin exposure to moisture (Gray et al, 2007). Once the skin is saturated it becomes more susceptible to friction and shearing force damage, which in turn allows the normally harmless skin flora to penetrate the barrier, resulting in secondary infection (Newman et al, 2007). The irritation and damage is a result of the disruption of intracellular lipid mortar within the stratum corneum and the corneocytes, resulting in a dissolving effect on the physical barrier of the skin (Warner et al, 2003). 
PRACTICE POINT 
Older people are at a higher risk of moisture-related skin damage due to a thinning of the overall epidermis that occurs with age. The intersection between the dermis and epidermis flattens with age. Elasticity is reduced, collagen synthesis decreases, and loss of connective tissue leads to a generalised atrophy of the skin and enzyme balance is easily disrupted, reducing the resistant capability and increasing the risk of damage from friction (Gray et al 2007; Voegeli, 2012).
Disruption to the skin’s protective mechanisms often leads to an excess in skin moisture or dryness, which may result in the breakdown of the skin surface. This can be demonstrated in the extremities of hands and feet after a prolonged soak in the bath, where excess moisture results in the wrinkling of the fingers/toes, or with repeated handwashing episodes leading to dry skin. Excessive moisture also increases the risk of friction damage due to skin maceration (Mayrovitz and Sims, 2001). 
 
Prolonged exposure of the skin to any moisture results in damage (Gray et al, 2007; Newman et al, 2007). Excess moisture has multiple causative factors, including: 
  • Continuous contact with faeces/urine 
  • Heavily exudating wounds 
  • Wetness around peristomal skin or excessive perspiration, particularly in the folds of skin (Gray et al, 2007). 
While incontinence-associated dermatitis (IAD) is the most recognised form of MASD (and which this paper focuses on), other elements included under the term are: 
  • Intertrigo 
  • Peri-wound maceration 
  • Peristomal skin. 
Intertrigo 
This is a relatively common inflammation between the skin folds in relation to friction, perspiration and bacterial or fungal elements. Despite a lack of specific coding for this condition within the international classification of diseases (ICD-10) (World Health Organization [WHO], 2010), it is suggested that intertrigo incidence rates in adults are 6% in hospitals, 17% in nursing home residents and 20% in people receiving care in their own home (Mistiaen and van Halm-Waters, 2010). The trapped moisture causes the skin to stick together, increasing friction. This can occur in any part of the body where two skin surfaces are close together. It is more common where natural large skin folds occur, such as under breasts, groins and axilla. Obesity and age also play a significant role in increasing the risk of intertrigo (Voegeli, 2012). 
Peri-wound maceration 
This breakdown of the skin is caused by excess wound exudate. Production of wound exudate is a normal response to inflammation within the wound healing phase. However, a high or increased volume of exudate will affect the healing phase, since over-hydration results in maceration of the skin (Cutting, 1999).

Peristomal skin 
Peristomal skin has a higher chance of developing problems due to the risk of a poorly fitting appliance leading to leakage of urine or faecal effluent, leakage from a percutaneous gastrostomy tube, and skin excoriation from repeated removal of adhesive bags or dressings. The epidermis becomes overhydrated, increasing skin pH to alkaline. This activates the digestive enzymes and bacteria present in faeces leading to epidermal damage (Black et al, 2011; Voegeli, 2012). 
INCONTINENCE-ASSOCIATED DERMATITIS (IAD) 
Incontinence-associated dermatitis (IAD) occurs as a result of prolonged exposure of the skin to faeces or urine, either from incontinence or an inability to cleanse and dry the skin adequately after toileting. It is prevalent in nursing home environments and people receiving long-term care or assistance at home, with rates varying from 5.6% to 50% — the highest incidence rate being in people with faecal incontinence or receiving long-term care (Gray et al, 2007). In the author’s clinical opinion, it is a worrying thought that many people with IAD may be unknown, as they try to self-manage or have no access to support and care. 

Typical presentation of IAD is inflammation of the skin’s surface, redness, swelling, and possible blister formation. Urinary incontinence dermatitis typically affects the female labial area and male scrotal areas, with thighs and buttock damage in both sexes. The combination of faecal and urinary incontinence leads to a significantly increased risk of IAD. The over-hydration of the epidermis and an increase in skin pH to a more alkaline level activates the richer digestive enzymes and bacteria contained in liquid faeces, leading to damage of the epidermis (Black et al, 2011; Voegeli, 2012). In people who have restricted movement or mobility, the combined effects of chemical irritants and physical elements of care may cause friction or shearing and result in a weakened skin structure and breakdown (Beeckman et al, 2009). 
Diagnosis 
IAD is often difficult to identify, with many cases misdiagnosed as pressure-related damage (Beeckman et al, 2010; Borchert et al, 2010). It is estimated that 50% of people with urinary or faecal incontinence are affected by IAD (Gray et al, 2007), but these figures are likely to be underestimated due to a lack of validated assessment and recording tools (Borchert et al, 2010) and confusion with pressure ulcers. Incorrect diagnosis may lead to inappropriate treatment, thus prolonging the damage and delaying the healing process (Beeckman et al, 2010). 
The European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Ulcer Advisory Panel (NPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA) (2019) have produced guidelines to assist in making the differentiation between IAD and pressure ulcers and providing advice regarding appropriate care and treatment. 

It is generally accepted that pressure ulcers occur over hard bony or cartilaginous prominences, including the ears, coccyx, heels and elbows. They are a result of ischaemic skin damage resulting from restricted blood flow, caused by prolonged pressure. The presentation generally demonstrates full or partial tissue damage with well-defined margins (EPUAP/NPAUP/PPPIA, 2019). 

IAD can occur over any part of the perineal area. It is moisture related, as the name suggests, and tissue damage is generally superficial, affecting the upper dermal and epidermis area. IAD does not usually confine itself to one small area, the skin damage occurs wherever there is contact with urine or faeces. 
The edges of the lesion are irregular in shape and the surrounding areas are almost always reddened due to irritants in urine and faeces (Beeckman et al, 2009). For example, a patient who is lying in a wet bed may experience skin damage as high as their shoulder blades if there is sufficient exposure to urine. 

IAD is a common skin disorder affecting a wide group of people and presents a significant challenge in maintaining skin integrity. It crosses all ages, gender and culture, but is particularly prevalent in the older person or those with surgical and/or medical comorbidities (Holroyd and Graham, 2014). With an increasing global population and individuals living longer, it is expected that there will be a continuing increase in the number of people presenting with IAD (Beldon, 2012; Kottner et al, 2013). Thus, healthcare professionals should maintain their knowledge and understanding of both conditions to ensure safe and effective practice.
Assessment tools 
There are several visual assessment tools to use in practice. Healthcare professionals should review the latest evidence available for guidance. 
The Skin Excoriation Tool for Incontinent Patients was developed by the National Association for Tissue Viability Nurses in Scotland in 2009 (Holroyd and Graham, 2014). In the author’s clinical experience, it has been beneficial in assessing skin and suggesting appropriate treatment options, as it offers a clear guide to clinicians in a way similar to the Waterlow score when it was first introduced. The tool provides a visual and textual reference to assist in identifying and grading tissue damage. It does not replace clinical judgement and should only be used as an additional tool to clinician experience and judgement. 
The Perineal Assessment Tool (Nix and Haugen, 2010) is another example of assessing risk of skin breakdown as a result of limited continence and may be of use in clinical practice. This assessment tool is based on four factors that have been identified as determinants in causing perineal skin breakdown: duration of irritant contact with skin, intensity/type of irritant, perineal skin condition, and any contributing factors that may cause diarrhoea. The tool presents a final risk score determined from the four factors in a similar way to the previously mentioned Waterlow Scoring system, which has been in use for pressure damage assessment for several decades. 
Prevention and treatment 
Preventing prolonged exposure to moisture will clearly reduce the risk of IAD. Individual and comprehensive assessment, including a regular top-to-tail inspection of the skin is essential in managing patients with continence issues (Bardsley, 2013; Payne, 2015). Regularity of a full skin inspection will vary depending on multiple factors, including frequency of incontinence, volume of exudate and the level of care support available. 
Barrier and skin care products 
A structured skin care routine, using appropriate products which are designed to keep moisture away from the skin, in combination with prompt treatment of any secondary infections, should be an essential component of treatment (Bardsley, 2012; Beldon, 2012; Voegeli, 2013). 

A careful, considered approach includes ensuring optimal skin cleansing, drying and moisturising after every single episode of involuntary loss of body effluent (Beeckman et al, 2009).
Furthermore, adopting a structured approach to skin care with the appropriate use of protocols and guidelines can reduce the incidence of IAD from 25% to less than 5% in many environments (Beeckman et al, 2009). This should include effective cleansing, moisturising and appropriate use of barrier products. It should be noted that not every episode of reduced continence requires a barrier cream or spray (Beeckman et al, 2009). 

Many modern soaps are alkaline and therefore may alter the natural protective acid mantle of the skin structure, increasing the risk of damage to skin integrity. It was suggested many years ago that reducing use of such soaps or avoiding them altogether should be a consideration in the successful avoidance of IAD in relevant patient groups (Kirsner and Froelich, 1998).
Later studies have demonstrated that the use of cleansers with pH values similar to that of skin, combined with a moisturising component, emollient or humectant, will help to maintain and protect skin integrity, and lower the risk of damage (Beeckman et al, 2010; Voegeli, 2008; 2012). 

Barrier products play an important role in effective and protective skin care routines (Nix, 2006). However, there are many available and so it is a healthcare professional’s responsibility to understand the difference between products and ensure appropriate use to promote optimal skin integrity. 
OTHER CONCERNS 
Many people who suffer incontinence issues manage their symptoms with the use of containment pads. These are widely available to purchase privately without any assessment or input from a healthcare professional. In recent years, there has been an increase in advertising for incontinence aids, enabling people to take control of their conditions without the need to speak to anyone about their symptoms. While helpful to many, this approach may increase the taboo surrounding incontinence with some medical conditions going undetected. It is the author’s experience that many of the commercial products do not include advice to the consumer to seek professional help. Sadly, many people are unaware that there is professional help available and that many incontinence issues may be treatable and reversible. 

Containment pads have different absorbency levels dependent on the volume of urine. Inappropriate use of too high or too low an absorbency can contribute to an increased risk of skin damage. Too low an absorption will lead to increased volume of effluent on the skin, over hydration of the epidermis and skin breakdown (as previously described), as well as leakage thereby increasing the surface area of skin affected by contact with the effluent. Use of too high absorption product/pad may cause natural moisture to be drawn from the skin, leading to under hydration and skin breakdown in extreme cases. Too high absorption products may also reduce the clinical contact with a patient, reducing the amount of times the patient’s position is changed/ relieved, again resulting in skin damage (Hillery, 2019). Incorrectly fitted products, which may result in leakage issues or infrequent changes, will also have an impact on skin integrity (Payne, 2015). 

Pads are effective if used appropriately, although there are restrictions on choices available via NHS services and a wide variability of practice, depending on the area. In the author’s clinical opinion, the publication of national guidelines on pad provision (Association for Continence Advice [ACA], 2017) should help to address the postcode lottery of pad provision if commissioners in each area embed it within local policy surrounding continence services. 

Some barrier products will affect the efficacy of continence pads, causing a waterproof barrier which alters the absorbency capacity of the pad (Dougherty and Lister, 2011; Corcoran and Woodward, 2013). This can lead to skin damage from urine or faeces, rather than offer the protection it is designed for. It is therefore essential that those involved in the care of individuals who are at risk of IAD are competent to carry out a robust and individual assessment to ensure that an appropriate management plan is in place. This assessment should identify those at a higher risk of developing IAD, who should have barrier products included within their normal skin-care routine. All products should be single-patient use to prevent any issues with cross-infection. 

Carer education is also a key component of successful management of IAD. As previously identified, those at the highest risk of IAD are in long-term, looked-after care. It is therefore essential that those providing care understand the importance of a structured skin care routine and are capable of carrying this out effectively. Choosing the product to contain continence and appropriate barrier creams or products to protect and moisturise the skin is key to successfully treating individuals (Beeckman et al, 2010; Bardsley, 2012).
CONCLUSION 
IAD is a common occurrence that affects many individuals in all areas of health and social care. It impacts physical, psychological and social health and is challenging for healthcare professionals to accurately identify and effectively treat. Early identification, appropriate and effective treatment, and risk assessment to prevent future occurrence will not only improve patient quality of life, but also reduce the cost of treatment to health and social care organisations. A structured skin care regimen that focuses on effective cleansing, protection and reduction in excess moisture should be routine in all patients who are at high risk of IAD. Education for staff and the use of appropriate risk assessment tools will improve identification of this condition and ensure appropriate, effective and timely management plans are adopted, thereby improving clinical outcomes and patient quality of life and experience.
This piece was first published in the Journal of Community Nursing. To cite this article use: Holroyd S (2021) Moisture-associated skin damage caused by incontinence. J Community Nurs 35(4): 58-64

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