Fighting the Waves: Moisture Associated Skin Damage (MASD)

Transcription

1 Fighting the Waves: Moisture Associated Skin Damage (MASD) Laurie McNichol, MSN, RN, CNS, GNP, CWOCN, CWON-AP, FAAN Past President, Wound Ostomy and Continence Nurses Society (WOCN) Past President, National Pressure Ulcer Advisory Panel (NPUAP) 2017 Magnet Nurse of the Year New Knowledge, Innovation, and Improvement Clinical Nurse Specialist/WOC Nurse Cone Health Greensboro, North Carolina All content and images Copyrighted 1

2 Learner Outcome To improve the understanding and identification of MASD by clinicians and enhance patient outcomes All content and images Copyrighted 2

3 Disclosures Ms. McNichol is periodically consulted by Coloplast and 3M for the provision of education on this topic Neither Coloplast nor 3M has had any influence on the content of this presentation All content and images Copyrighted 3

4 Fighting the Waves All content and images Copyrighted 4

5 Fighting the (other) Waves All content and images Copyrighted 5

6 To Prevent Intertriginous Dermatitis (ITD) Peristomal MASD (PMASD) Periwound MASD (PwMASD) Incontinence Associated Dermatitis (IAD) All content and images Copyrighted 6

7 Recognized Etiologies of Chronic Wounds Pressure Injury (pressure and shear) Leg Ulcers (endothelial disease) -Venous -Arterial -Mixed Neuropathic -Diabetic Foot Ulcers All content and images Copyrighted 7

8 Moisture PLUS Increasingly Accepted as a 4 th Major Etiologic Factor for Skin Damage MASD: inflammation, erosion ± secondary infection associated with prolonged exposure to various sources of moisture including: Perspiration Urine Stool Mucus Saliva Wound exudate Effluent from an ostomy Effluent from a fistula Gray M et al. Journal of Wound, Ostomy & Continence Nursing 2011; 38(3): All content and images Copyrighted 8

9 MASD Pathophysiology Damage occurs from top down (the skin is exposed to an irritant resulting in inflammation) Requires that exposure is more than to moisture alone (i.e., moisture plus). The plus is typically microorganisms (bacteria, fungus), and/or mechanical forces (friction, pressure, shear) Occlusion exacerbates or accelerates process Other factors include: nutritional status, acuity of illness, immobility All content and images Copyrighted 9

10 3 Mechanisms of Moisture Associated Skin Damage All content and images Copyrighted 10

11 MASD Pathophysiology: Influence of ph Alkaline ph especially problematic; ph > 8.0 alone associated with inflammation of skin and activation of fecal enzymes, promotes colonization of coliform bacteria; common ph ranges include Healthy Skin Saliva Gastric Bile Pancreatic Intestinal/ stool Urine variable Colwell JC. et al. Journal of Wound, Ostomy and Continence Nursing 2011, 38(5): All content and images Copyrighted 11

12 MASD Pathophysiology: Microbiome & Bioburden Microbiome of skin more complex and more important to immune function of skin than previously suspected; infection is well accepted as impairing skin integrity and delaying healing Bioburden defined as nature and colony count of pathogens on human skin; different than classic infection Excessive bioburden linked to poor wound healing, and is associated with all forms of MASD 1. Chen YE, Tsao H. Journal of the American Academy of Dermatology 2013; 69(1): Gardner Se et al. Diabetes 2013; 62(3): Gray M et al. Journal of Wound, Ostomy & Continence Nursing 2011; 38(3): All content and images Copyrighted 12

13 MASD Pathophysiology: Microclimate Microcosm consisting of Temperature Humidity/Air movement at the interface of the patient s body and the support surface Emerging evidence links excessive moisture, and specific effluents (urine and stool) to an increased risk for pressure injury Absorbent Product ± Mattress/ Seating Cushion 1. Gefen A. Journal of Tissue Viability 2011; 20: Yusuf S et al. International Wound Journal 2015; 12(1): All content and images Copyrighted 13

14 Most Prevalent Forms of MASD in WOC Nursing Practice Periwound Moisture Associated Skin Damage (PwMASD) Peristomal Moisture Associated Skin Damage (PMASD) Intertriginous dermatitis (ITD) Incontinence Associated Dermatitis (IAD) All content and images Copyrighted 14

15 Periwound Moisture Associated Skin Damage (PwMASD) All content and images Copyrighted 15

16 PwMASD: Wound Exudate and MASD Periwound skin is not frequently exposed to friction, in contrast to intertriginous or incontinence associated dermatitis. However, epidermal stripping may occur when dressings are removed and this phenomenon has been associated with periwound maceration. Similar conditions exist for exudating wounds; this area is the least studied All content and images Copyrighted 16

17 PwMASD: Wound Exudate and MASD Consider Volume of exudate Bioburden Proteolytic enzymes (MMPs) adhere to the extracellular membrane Gray M, Weir D. Journal of Wound, Ostomy and Continence Nursing 2007; 34(2): 153. All content and images Copyrighted 17

18 Periwound Moisture Associated Skin Damage Principles of prevention and treatment Balancing act, avoid desiccation and excessive moisture in the wound and periwound skin Select topical dressings that protect the wound, absorbs excess exudate via vertical wicking, and preserve a moist wound base Consider frequency of dressing change (usually need to change frequency) Apply periwound skin protectant Consider a pouching system Colwell JC, Ratliff CR et al. Journal of Wound, Ostomy and Continence Nursing 2011; 38(5): All content and images Copyrighted 18

19 Peristomal Moisture Associated Skin Damage (PMASD) All content and images Copyrighted 19

20 Peristomal MASD Moisture Source: ostomy effluent Character and volume of effluent -Urine vs stool -Source of gastrointestinal effluent (large bowel, small bowel) -Consider additional sources of moisture (perspiration, participation in water sports, soaking in hot tub, swimming) Terms such as maceration, denudation and erosion now require inclusion under broader etiological category of MASD Photo courtesy of J. Hoeflok 1. Colwell JC. et al. Journal of Wound, Ostomy and Continence Nursing 2011, 38(5): Gray M et al. Journal of Wound, Ostomy and Continence Nursing 2013, 40(4): 40(4): All content and images Copyrighted 20

21 Peristomal MASD Prevention/Treatment Proper pouching principles: right fit, close to stomal/skin junction, right formulation and alteration of pouching system as indicated 1 WOC nurse education of patient, lay caregivers, first line nurses and other clinicians 1 Innovations in pouching system technologies 2,3 1. Gray M et al. Journal of Wound, Ostomy and Continence Nursing 2013, 40(4): 40(4): Colwell JC et al. Journal of Wound, Ostomy and Continence Nursing 2018; 45(1): Erwin-Toth P et al. Journal of Wound, Ostomy and Continence Nursing 2012; 39(4): All content and images Copyrighted 21

22 Peristomal MASD: Saliva/Mucus Few studies exist for this area of skin damage Substance must be contained while skin is protected PMASD can occur with prolonged contact, particularly with friction and/or bacteria or fungi Oral fistulas are often pouched, trachs with increased moisture require absorbent dressings over traditional gauze All content and images Copyrighted 22

23 Intertriginous Dermatitis (ITD) All content and images Copyrighted 23

24 Intertriginous Dermatitis (ITD) Often Misunderstood Misdiagnosed Mistreated Mistaken for Pressure Injuries Photo courtesy of S. Yates Black, J. Gray, M. et al. (2011) MASD Part 2: Incontinence-Associated Dermatitis and Intertriginous Dermatitis. Journal of Wound Ostomy and Continence Nursing, 38(4), All content and images Copyrighted 24

25 Intertriginous Dermatitis Intertriginous MASD occurs in the context of morbid obesity Prevalence growing in US and worldwide Research based evidence of morbid obesity on skin is sparse Evidence underpinning prevention and management of intertriginous dermatitis extremely sparse to absent What is known: BMI and skin folds impair body s ability to evaporate moisture (perspiration) from skin, maintain acid mantle and optimal microbiome 1 Loffler H, Aramaki JUN, Effendy I. Skin Research & Technology 2002; 8:19. All content and images Copyrighted 25

26 Intertriginous Dermatitis Moisture Source: Perspiration, multiple pluses here, least understood of the 4 Sweat contains primarily water, minute amounts of urea, glucose, sodium chloride and various salts Production in moderate climate: ml/day MASD occurs in context of moisture plus ; high volume perspiration in skin fold (i.e. occlusion and poor evaporation) Friction and secondary bacterial/ fungal bioburden almost certainly involved but precise role in pathophysiology of MASD not clear Gray M et al. Journal of Wound, Ostomy & Continence Nursing 2011; 38(3): 233. Black, J. et al. Journal of Wound ostomy and Continence Nursing 2011; 38(4): All content and images Copyrighted 26

27 Special Population Practice Considerations Persons of size Care must be taken to gently clean and dry between the skin folds in the bariatric population. A blow dryer on the cool setting is more comfortable and less traumatic than towel drying. Extra staff to help turn the patient and support skin folds is essential for thorough care. *Bryant & Nix, 2010; Gallagher, 2005 All content and images Copyrighted 27

28 Intertriginous Dermatitis (ITD) Definition: An inflammatory dermatosis of opposing skin surfaces caused by moisture Commonly found in inframammary, axillary, subpannicular and inguinal skin folds Do not overlook posterior thigh, neck, back and knee skin folds Risk Factors: Any patient with a skin fold Hyperhydrosis Diabetes Steroid use Broad spectrum antibiotic use Urinary and fecal incontinence All content and images Copyrighted 28

29 Abdominal Folds (Sub-pannicular) Photo courtesy of S. Yates All content and images Copyrighted 29

30 Groin/Inguinal Photo courtesy of S. Yates All content and images Copyrighted 30

31 Groin/Inguinal All content and images Copyrighted 31

32 Inframammary All content and images Copyrighted 32

33 Prevention of ITD Cleanse with ph balanced product (5.5) Gentle cleansing, no scrubbing Soft cloth, not a washcloth Pat dry or blow dry Prevent skin-on-skin friction Reduce heat and moisture in the folds All content and images Copyrighted 33

34 Ineffective or Unproven Treatments Use of talc or cornstarch Use of antiperspirants Use of gauze (or coffee filters!) in the fold Use of bed or bath linen Wet tea bags, Domeboro s soaks, Burrow s solution, dilute vinegar solution, hydrocolloid dressings May promote fungal overgrowth Untested in large folds Does not relocate moisture Absorbs moisture but does not allow evaporation No clinical research to supporting use All content and images Copyrighted 34

35 Skin Fold Management An antimicrobial textile product is available for skin fold management The system was specially designed to manage moisture, odor and inflammation in skin folds and other skin-toskin contact areas. The textile significantly improves the symptoms associated with intertrigo such as: Maceration Denudement Inflammation Itching Erythema Satellite Lesions All content and images Copyrighted 35

36 Incontinence Associated Dermatitis (IAD) All content and images Copyrighted 36

37 Incontinence Associated Dermatitis (IAD) All content and images Copyrighted 37

38 A Rose By Any Other Name? Over the years we have called this condition a variety of other names: Diaper rash Moisture maceration injury Moisture associated dermatitis Perineal dermatitis Irritant dermatitis Contact dermatitis Excoriation (incorrect term) Denudation (denuded skin) Heat rash *Fiers & Thayer, 2000; Gray et al., 2007; Gray, 2007 All content and images Copyrighted 38

39 Confused with Pressure Injuries Depending on whether or not the patient developed this condition during their admission, a facility could be held accountable for a hospital or facility acquired pressure injury (HAPI or FAPI) Patients families might think their loved one has a pressure injury when they don t Distinguishing factor: IAD is typically not full thickness All content and images Copyrighted 39

40 Incontinence Associated Dermatitis (IAD) Moisture Source: Urine & Stool Urine: water, ammonia, bacterial and/or fungal bioburden skin hardness, rendering it more susceptible to friction and erosion 1,2 Alkaline urine particularly harmful; permeability to pathogenic species and activates fecal enzymes in stool 3 Stool: Protease & lipase potentially break down both principal elements of moisture barrier 4 Stool consistency, liquid stool richer in enzymes, damages more rapidly than formed or semi-formed stool 5 1. Berg W et al. Pediatric Dermatology 1986; 3: Leyden JJ et al. Archives of Dermatology 1977; 113: Zimmerer RE et al. Pediatric Dermatology 1986; 3: Atherton DJ Eur Academy Dermatology Venereology 2001; 15 (Supp1): Beeckman D et al. Incontinence-associated dermatitis: moving forward. Wounds International 2015; All content and images Copyrighted 40

41 Incontinence Associated Dermatitis (IAD) The relationship between moisture/incontinence and pressure injury has been long suspected All PI risk instruments include some sort of moisture or incontinence assessment Most clinical guidelines for PI prevention recommend moisture management (broad term designed to include management of UI/FI) 3 recent studies provide strong evidence establishing incontinence and IAD as independent risk factors for PI, including full-thickness ulcers (Stage 3 and 4) Beeckman D et al. Research in Nursing and Health. 2014;37(3): Lachenbruch C et al. Journal of Wound Ostomy and Continence Nursing; 2016;43(3): Gray M, Giuliano KK. Journal of Wound Ostomy and Continence Nursing 2018; 45(1): All content and images Copyrighted 41

42 Definition: IAD An inflammation of the skin as a result of chronic or repeated exposure to urine or fecal matter It manifests as redness with or without blistering and skin erosion (Junkin & Selekof, 2008) It is a frequent complication of urinary and fecal incontinence and predisposes the person to other problems such as infections, pressure injuries and pain. All content and images Copyrighted 42

43 WHO s ICD-10 The current version of the World Health Organization s International Classification of Diseases (ICD-10, in use since 1994) contains coding for diaper dermatitis but does not contain separate coding for IAD An expert consensus panel recommended that IAD be defined and included in the ICD and that it should be differentiated from diaper dermatitis, age being an important distinction. Activity on adding IAD to ICD-10 is underway so that it will be uploaded/included into future iterations of ICD codes *World Health Organization. International Classification of Diseases Available at All content and images Copyrighted 43

44 Location, Location, Location IAD may involve the perianal area, buttocks, (inner and lower) thighs, lower abdomen, scrotum, labial folds, adjacent skin folds and the perineum (the area between the vulva and the anus in women and the scrotum and anus in men) *Borchert, Bliss, Savik & Radosevich, 2010 Image : Royal College of Surgeons Edinburgh All content and images Copyrighted 44

45 Clinical Manifestations Erythema Edema Maceration Denudation Papular/vesicular formations Erosion of the epidermis and/or dermis Poorly demarcated borders Flaking Crusting Weeping All content and images Copyrighted 45

46 Clinical Manifestation (cont.) Usually diffuse, found in skin folds and often falls within the confinement area of a body worn absorbent product (e.g., a diaper), if worn May have areas of consolidated or patchy inflammation Skin loss may appear as a shallow ulcer leading to a misdiagnosis of a Stage 2 pressure injury All content and images Copyrighted 46

47 Differential Diagnosis IAD Bright red in people with light skin tones, subtle red in darker skin tones Perineal or peri-genital skin, especially near anus, skin folds or beneath containment garments One or more islands of erosion to extensive loss of epidermis and dermis Borders are diffuse No necrotic tissue Exudate: None or scant serous Symptoms: itching or burning Pressure Injury Deep red, maroon to bluish/purple in DTPI Typically over a bony prominence or beneath a medical device Varies from partial to full thickness Well demarcated borders Black eschar or slough can be present Exudate: volume and characteristic depends on wound Stage Symptoms: pain, itching exacerbated by dressing change All content and images Copyrighted 47

48 NPUAP Definition: Stage 2 Pressure Injury Stage 2 Pressure Injury: Partial thickness skin loss with exposed dermis Partial thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD), including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). All content and images Copyrighted 48

49 NPUAP Definition: Stage 2 Pressure Injury Heals by re epithelialization, not granulation Clinician must define MASD, MARSI, IAD, ITD All content and images Copyrighted 49

50 IAD Complications Most concerning: Bacterial or fungal infections, pressure injuries and severe pain Odds of developing pressure injuries are greater for hospitalized adults with fecal incontinence (Beitz, 2006; Gray, 2007; Bliss et al., 2009) Secondary fungal infections are frequently present with IAD and are characterized by bright to dull red maculopapular rash with discreet satellite lesions at the border or a dark red scaling rash. Bacterial infections also cause red scaling areas All content and images Copyrighted 50

51 Fungal Infection All content and images Copyrighted 51

52 Urine The ph of urine influences the likelihood of developing MASD/IAD (normal urine ph is ) Dilute urine has a more neutral ph and is less irritating to the skin The more dilute the urine, the longer skin can tolerate being in contact with it What are the implications for practice? All content and images Copyrighted 52

53 Stool Stool contains both proteolytic and lipolytic enzymes that have the potential to destroy the protective features of the top layer of skin, the stratum corneum. Liquid stool is associated with an increased risk for IAD-particularly when the period of contact is prolonged (ph >7.6) Solid stool has a more neutral ph and fewer active enzymes than liquid stool. Normal ph is Stool is rich with coliform bacteria (including fungi) and this commonly complicates incontinence-associated dermatitis All content and images Copyrighted 53

54 Goal Prevent IAD, manage urinary and fecal incontinence, maintain skin s integrity and protective capacity, minimize contact with irritants, reduce pain, and treat secondary cutaneous infections All content and images Copyrighted 54

55 Prevention Studies suggest that early assessment for risk and intervention with a structured perineal skin care regimen (usually consisting of a combination of a cleanser, moisturizer and a skin protectant) are associated with lower incidence of IAD in high risk populations including the infant, and fragile elderly patient. Fewer ingredients in products translates into decreased opportunities for sensitivity Products must be easily accessible All content and images Copyrighted 55

56 Management Routinely assess patient s risk for IAD Provide toilet substitutes such as bedside commodes and urinals; minimize incontinence with scheduled toileting programs Consider drug therapy to control noninfectious diarrhea Use skin care products that cleanse, protect and when appropriate, restore (moisturize) Consider external collection devices before internal management devices All content and images Copyrighted 56

57 External Methods of Managing Urinary Incontinence External urinary catheters for males (also called condom catheters) External female urinary collection devices (powered) Ostomy pouching systems used as external collection devices Intermittent catheterization All content and images Copyrighted 57

58 Indwelling Urinary Catheters They are indicated for the management of urinary incontinence when Behavioral methods have failed or are not possible Containment garments and skin protection are ineffective Intermittent catheterization is not feasible The patient has Stage 3 or 4 pressure injuries All content and images Copyrighted 58

59 Fecal Containment Devices Advantages They: contain liquid stool and odor minimize the spread of infectious organisms reduce skin breakdown track and quantify output decrease nursing time increase patient comfort All content and images Copyrighted 59

60 Fecal Containment Devices External (pouches) Non-invasive Adhere directly to skin around anus Adherence may be up to 2 days Can hold up to several hundred milliliters of fluid Are odor proof May contain valves to control flatulence All content and images Copyrighted 60

61 Fecal Containment Devices Internal (indwelling bowel management systems) Soft, latex free tube Held within the rectum with a low pressure balloon filled with saline or water Collection bag can be removed and replaced with a new bag All content and images Copyrighted 61

62 Treatment Continue structured skin care program; change skin protectant if no improvement Consider absorptive containment briefs or use underpads to minimize moisture and heat trapping Ensure adequate nutrition, hydration and reduce pressure on skin to support perfusion Consider support surface with feature to change microclimate Treat fungal infections with antifungal powders, creams or ointments, bacterial infections with organism-specific antibiotic and allergic dermatitis with topical cortisone and oral antihistamines All content and images Copyrighted 62

63 Summary Moisture-associated skin damage is defined as inflammation and erosion associated with prolonged exposure to stool, urine, mucus and/or saliva, ostomy effluent, fistula effluent, perspiration, or wound exudate Moisture plus is becoming increasingly accepted as a fourth major etiologic factor for skin damage To prevent MASD, clinicians should be vigilant in both maintaining optimal skin conditions and in diagnosing and treating minor cases of MASD before progression and further damage occurs All content and images Copyrighted 63

64 Thank you for your attention. All content and images Copyrighted 64