Prevention and treatment of incontinence-associated dermatitis: literature review

Transcription

1 JAN JOURNAL OF ADVANCED NURSING REVIEW PAPER Prevention and treatment of incontinence-associated dermatitis: literature review Dimitri Beeckman, Lisette Schoonhoven, Sofie Verhaeghe, Alexander Heyneman & Tom Defloor Accepted for publication 28 January 2009 Correspondence to D. Beeckman: Dimitri Beeckman MA RN PhD Candidate Faculty of Medicine and Health Sciences, Ghent University, Belgium and Research Staff Department of Bachelor of Nursing, University College Arteveldehogeschool Ghent, Belgium Lisette Schoonhoven PhD RN Assistant Professor Nursing Science, IQ Healthcare, Radboud University Nijmegen Medical Centre, The Netherlands Sofie Verhaeghe PhD RN Assistant Professor Nursing Science, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Belgium Alexander Heyneman MA RN PhD candidate Nursing Science, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Belgium Tom Defloor PhD RN Professor Nursing Science, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Belgium BEECKMAN D., SCHOONHOVEN L., VERHAEGHE S., HEYNEMAN A. & DEFLOOR T. (2009) Prevention and treatment of incontinence-associated dermatitis: literature review. Journal of Advanced Nursing 65(6), doi: /j x Abstract Title. Prevention and treatment of incontinence-associated dermatitis: literature review. Aim. This paper is a report of a review conducted to describe the current evidence about the prevention and treatment of incontinence-associated dermatitis and to formulate recommendations for clinical practice and research. Background. Incontinence-associated dermatitis is a common problem in patients with incontinence. It is a daily challenge for healthcare professionals to maintain a healthy skin in patients with incontinence. Data sources. PubMed, Cochrane, Embase, the Cumulative Index to Nursing and Allied Health Literature, reference lists and conference proceedings were explored up to September Review methods. Publications were included if they reported research on the prevention and treatment of incontinence-associated dermatitis. As little consensus about terminology was found, a very sensitive filter was developed. Study design was not used as a selection criterion due to the explorative character of the review and the scarce literature. Results. Thirty-six publications, dealing with 25 different studies, were included. The implementation of a structured perineal skin care programme including skin cleansing and the use of a moisturizer is suggested. A skin protectant is recommended for patients considered at risk of incontinence-associated dermatitis development. Perineal skin cleansers are preferable to using water and soap. Skin care is suggested after each incontinence episode, particularly if faeces are present. The quality of methods in the included studies was low. Conclusions. Incontinence-associated dermatitis can be prevented and healed with timely and appropriate skin cleansing and skin protection. Prevention and treatment should also focus on a proper use of incontinence containment materials. Further research is required to evaluate the efficacy and effectiveness of various interventions. Keywords: dermatitis, incontinence, literature review, nursing, pressure ulcers, prevention, treatment Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd 1141

2 D. Beeckman et al. Introduction Incontinence-associated dermatitis (IAD), a clinical manifestation of moisture-associated skin damage, is a common problem in patients with faecal and/or urinary incontinence (Gray et al. 2007a). The lesions are characterized by erosion of the epidermis and a macerated appearance of the skin (Gray et al. 2007a). Incontinence and skin breakdown related to incontinence have a considerable effect on patients physical and psychological well-being (Sibbald et al. 2003, Newman et al. 2007). It is a daily challenge for healthcare professionals in hospitals, nursing homes and homecare to maintain a healthy skin in patients with incontinence. The most common organisms are Candida albicans, from the gastrointestinal tract, and Staphylococcus, from the perineal skin. The skin is not only exposed to chemical irritation, but also to physical irritation (friction). Friction is defined by the National Pressure Ulcer Advisory Panel (NPUAP) as the resistance to motion in a parallel direction relative to the common boundary between two surfaces (NPUAP 2007). Friction increases when perineal skin rubs over containment materials, clothing and bed or chair surfaces (Newman et al. 2007). The combination of chemical and physical irritation results in a weakened skin status. If these mechanisms affect the integrity of the skin recurrently, IAD and further skin breakdown will develop (Figure 1). Size of the problem Up to 50% of nursing home residents and 10 35% of community-dwelling adults are affected by urinary incontinence (Newman et al. 2007). Faecal incontinence has been reported in 23 66% of nursing home residents (Newman et al. 2007). Combined urinary and faecal incontinence, also defined as double incontinence, occurs in 50% of long-term care residents (Newman et al. 2007). The prevalence of IAD has varied in different studies from 5Æ6% to 50%, and the incidence rates were between 3Æ4% and 25%, depending on the type of setting and population studied. Usually incidence rates were measured in small sample, single-centre and longterm care settings over periods of 4 weeks (Gray et al. 2007a). Aetiology An important function of the skin is to protect the body against pathogens. The stratum corneum, which is the outermost layer of the epidermis, provides this critical barrier by prohibiting the invasion of micro-organisms. The stratum corneum consists of 70% protein, 15% lipids and 15% water. Lipids and water are important components in the skin s barrier function. In older patients, the volume of water decreases to <10% (Lekan-Rutledge 2006, Newman et al. 2007). The aetiology of IAD is complex and multifactorial (Jeter & Lutz 1996, Lekan-Rutledge 2006). When the skin is exposed to moisture (urine, faeces, double incontinence or frequent cleansing), its permeability increases and the barrier function reduces. Increased skin ph raises the risk of bacterial colonization. Colonization with microorganisms can lead to bacterial overgrowth, which may cause cutaneous infections. Terminology and definitions The terminology used to describe incontinence-associated skin problems is diverse, and more than 18 different terms occur. In the International Statistical Classification of Diseases and Related Health Problems (10th Revision Version for 2007) (ICD-10), the World Health Organization (WHO) classifies incontinence-related skin problems as Diseases of the skin and subcutaneous tissue (Chapter XII, L00-L99) in subcategory Dermatitis and eczema (L20-L30). Terminology used is: diaper/napkin dermatitis, diaper/napkin erythema or diaper/napkin rash. The term used to classify incontinence-related skin problems used in the Medical Subject Heading Terms database of the US National Library of Medicine (MeSH database) is diaper rash. Diaper rash is defined as a type of irritant dermatitis localized to the area in contact with a diaper and occurring most often as a reaction to prolonged contact with urine, faeces, or retained soap or detergent. In the North American Nursing Diagnosis Association (NANDA) no single terminology describing IAD was found (NANDA 2008). In international literature, no common terminology is used to indicate the presence of incontinence-associated skin problems. The terminology focuses on a description of the skin (e.g. skin maceration), the cause of the irritation (e.g. incontinence lesion and incontinence dermatitis), the location of the skin problem (e.g. perineal dermatitis) or the material causing the skin problem (e.g. diaper dermatitis). Gray et al. (2007a) define incontinence-associated skin problems as a reactive response of the skin to chronic exposure to urine and faecal material, which could be observed as an inflammation and erythema with or without 1142 Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd

3 JAN: REVIEW PAPER Incontinence-associated dermatitis: literature review MOISTURE Urine Faeces Double incontinence Frequent cleansing Urea-ammonia ph Microbes Faecal enzyme activity ph Microbes Urea-ammonia ph Faecal enzyme activity Chemical irritation + Physical irritation Microbes Permeability of the skin Barrier function Bacterial overgrowth Cutaneous infection WEAKENED SKIN INCONTINENCE ASSOCIATED DERMATITIS Friction: rubbing perineal skin over containment devices, clothing and bed or chair surfaces Figure 1 Aetiology of incontinence-associated dermatitis (based on Jeter & Lutz 1996 and Newman et al. 2007). erosion or denudation. This definition was used to conduct the review reported in this paper. Current practice Current prevention of IAD consists of cleansing, moisturization, and the application of skin protectants or moisture barriers. Treatment includes protecting the skin from further exposure to irritants, establishing a healing environment and eradicating skin infections (Gray et al. 2002). A wide range of skin care protocols, cleansers, moisturizers, moisture barriers, skin protectants and absorbents are available. Despite their widespread use in nursing practice, little is known about their efficacy and effectiveness (Gray et al. 2007a, Newman et al. 2007). A growing number of studies have been conducted to examine clinical and economic outcomes associated with prevention strategies, but little research exists on the efficacy of various treatments (Gray et al. 2007a). The review Aims The aims of this literature review were to assess the effectiveness of interventions for the prevention and treatment of IAD and to formulate recommendations for clinical practice and research. Design A literature search was performed using the databases PubMed, Embase, The Cochrane Library Central Register of Controlled Trials (CENTRAL) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Search methods The databases were searched for studies published in English, Dutch, French and German. There were no limitations Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd 1143

4 D. Beeckman et al. concerning the year of publication, authors or participating institutions. To increase the sensitivity of the filter, all entry terms of the MeSH terms were added to the filter as [Text Word]. Only studies with patients over the age of 18 years were included using the MeSH term adult in the search filter. Randomized controlled trials, meta-analyses, reviews, controlled clinical trials, clinical trials, comparative studies, evaluation studies and validation studies were included. The MeSH terms of these publication types were added to the search filter. Study design was not used as a selection criterion due to the explorative character of the literature review and the scarce literature on this issue. A similar search filter was used in all databases. The literature search was completed in September Conference proceedings of the European Pressure Ulcer Advisory Panel (EPUAP), the European Wound Management Association, the European Tissue Repair Society and the International Continence Society of the years were searched manually. The reference lists of all included publications were checked to identify additional studies not indexed in the databases or conference proceedings searched. Search outcome All studies describing interventions to prevent or heal IAD were included. The search strategy revealed 2379 publications. Based on the inclusion criteria and after eliminating any overlap and screening of title, abstract and keywords by two independent reviewers, 28 publications were found to be useful. After checking the reference lists of all included publications, eight additional publications were included. Thirty-six publications were included in this review (Figure 2). Two publications were indexed in the databases PubMed, Cochrane Library and CINAHL; four appeared in PubMed and CINAHL; two publications in PubMed and Cochrane Library; and 10 in PubMed. Subject areas of the publications in PubMed were: nursing (21), geriatrics (one) and dermatology (one). In 13 publications, the subject area was not stated, while in 30 the first author was a nurse. Quality appraisal The full text of potentially eligible studies was examined to determine whether the publications met the above-mentioned criteria. Titles and abstracts of publications obtained through the search strategy were initially screened independently on the inclusion criteria by two reviewers. In case of different opinions, the reviewers made a decision based on discussion of the full text papers. The Research Appraisal Checklist (RAC) (Duffy 1985), which contains 51 assessment criteria ordered in 10 categories, was used to assess the scientific quality of the included studies. Categories included title, abstract, problem, review of literature, methods (subjects, instruments, design), data analysis, discussion, and form and style. The RAC was tested for reliability and validity, and showed a total Cronbach s a of 0Æ91 and good construct validity. Assessments using RAC were conducted by two independent reviewers. They used the six-point rating scale to indicate the extent to which each criterion item was met in the report being reviewed (1 or 2 = not met; 3 or 4 = partially met; 5 or 6 = completely met). An N/A (not applicable) option was available if the criterion was not applicable. In accordance with Duffy (1985), summated scores were computed for each of the 10 categories, after which the category scores were added to produce a total score. Reports with a score between 0 and 102 are considered below average, between 103 and 204 are considered average, and scores between 205 and 306 are considered superior. PubMed (1079) Cochrane Library(890) Embase (371) CINAHL (39) PubMed(18) Cochrane Library(4) Embase (0) CINAHL (6) included 2351 excluded not meeting the inclusion criteria Handsearching journals Checking reference lists 36 Figure 2 Results of search strategy Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd

5 JAN: REVIEW PAPER Data abstraction and synthesis Details of relevant studies were extracted and summarized using a prespecified standardized table of evidence. Apart from authors and year of publication, data concerning publication type, design, setting and number of participants, in- and exclusion criteria, duration in days, intervention studied, study outcome, baseline characteristics of the patients and results were also included in the evidence table. The occurrence and incidence of IAD and the skin condition were identified as the main outcome measures to assess the effectiveness of IAD preventive interventions. Healing rate and skin condition were defined as outcome measures to assess the effectiveness of IAD treatment interventions. Effect sizes could not be reported as they were not described in the publications. Cost-effectiveness was evaluated by reviewing the direct costs (product cost and nursing time), total costs (sum of direct costs and costs of supporting treatment-related products) and indirect costs (related to quality of life, assistance in completing activities of daily living, days lost from work and litigation) (Phillips 2007). Results All included publications were published in English between 1983 and In the 36 included publications, 25 studies were reported. The median study period, reported in 21 studies, was 42Æ0 days (IQR = 14Æ0 90Æ0). The median number of patients included was 64 (IQR = 29Æ0 136Æ0). The patients were recruited from chronic care (14 studies) and acute care (six studies) settings. Two studies were conducted in both an acute and a chronic care setting (Leiby & Shanahan 1994, Dealey 1995). In three studies, the setting was not reported (Kennedy et al. 1996, Hampton 1998, Baatenburg de Jong & Admiraal 2004). Thirteen studies focused on treatment, eight focused on prevention and four on both treatment and prevention of IAD. An overview of the operational definitions of incontinence-related skin problems used in the studies is given in Tables 1 3. Economical evaluations were performed in 11 studies. An overview of these results is given in Table 4. Scientific quality of the studies The mean RAC score of the included studies was 208/306. Approximately one-fifth (20Æ2%) of the criteria of the RAC were not applicable. The criteria for abstract, problem and review of literature could not be assessed in 32Æ3% of cases. The mean RAC scores for methods and analysis were 37Æ2/90 and 16Æ7/24 respectively (Tables 1 3). RAC scores for the subjects, instruments and designs used in the studies were 15Æ4/36, 7Æ2/30 and 14Æ6/24 respectively. In nine studies, a randomized controlled trial was conducted. In 50% of the studies, a baseline comparison of patient characteristics was performed. In four studies, baseline evaluation was limited to a comparison of pressure ulcer risk assessment (Brown 1994a, Brown 1994b, Dealey 1995, Kennedy et al. 1996). In one study, the procedure for randomization was not described (Campbell et al. 2001). In five studies, no control group was used (Dealey 1995, Hampton 1998, Campbell et al. 2000, 2001, Warshaw et al. 2002). A prospective power analysis was conducted in three studies (Brown 1994a, Brown 1994b, Baatenburg de Jong & Admiraal 2004). Thirteen different observational instruments were used in 10 studies. One study used an observation scale that was tested for content validity and inter-observer reliability (Warshaw et al. 2002). In 15 studies, no observation scale was specified. Use of skin products Incontinence-associated dermatitis: literature review Skin protectants Zinc oxide-based products were evaluated in six studies. A topical zinc oxide preparation with antiseptic properties (Sudocrem Ò ) was found to be superior to traditional zinc cream for the treatment of IAD (Anthony et al. 1987). In eight studies, the use of a no-sting barrier film was evaluated. Campbell et al. (2000) and Hampton (1998) observed a reduction of erythema, skin maceration and skin stripping when comparing a no-sting barrier film and a petrolatumbased ointment in patients with IAD. Clever et al. (2002) observed a statistically significant reduction of pressure ulcer incidence in patients with incontinence when a skin protectant (active ingredient: dimethicone 3%) was used, incorporated into a thick disposable washcloth that cleansed and moisturized the skin (Table 1). Moisturizers Draelos (2000) observed reduced erythema, roughness and desquamation of the skin when a hydrogel/barrier repair cream was compared to a petrolatum-based moisturizing cream for the treatment of IAD (Table 1). Perineal skin cleansers Skin cleansers were found to be more effective than water and soap for the prevention of incontinence-related skin problems (Byers et al. 1995, Cooper & Gray 2001). Reduced skin erythema was observed in four studies comparing the effect of combining a perineal skin cleanser and a skin protectant (Whittingham & May 1998, Warshaw et al. 2002, Hunter Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd 1145

6 D. Beeckman et al. Table 1 Description of studies concerning the use of skin products Citation Study design Operational definition Study period (days) Patients included/ analysed RAC scores Methods Analysis Significant outcomes Skin protectants Zinc oxide vs. Antiseptic topical cream Anthony et al. (1987) RCT double-blinded Dermatitis due to the physical stress of incontinence 14 67/57 20/90 11/24 Reduced erythema and bacterial counts when using antiseptic topical cream vs. no-sting barrier film Campbell et al. (2001) Pre/post Incontinent dermatitis 10 16/14 21/90 5/24 Baatenburg de Jong and Admiraal (2004) RCT Skin damage resulting from 14 39/29 35/90 19/24 Reduced erythema and incontinence denudation when using barrier film vs. Petrolatum ointment vs. no sting barrier film Kennedy et al. (1996) RCT Perineal rash 12 40/ 30/90 20/24 vs. No-sting barrier film vs. ointment with 43% petrolatum vs. ointment with 98% petrolatum Bliss et al. (2007) Descriptive Incontinence dermatitis / 45/90 16/24 +Skin cleanser Dealey (1995) Pre/post Pressure ulcer / 36/90 10/24 No sting barrier film vs. Petrolatum-based ointment Zehrer et al. (2004a) Observational Comperative Incontinence dermatitis / 53/90 20/24 Frequency: 1 /day vs. frequency: 3 /week Zehrer et al. (2004a, 2004b) Observational comperative Incontinence dermatitis 42 78/ 53/90 20/24 vs. Campbell et al. (2000) Descriptive Incontinent dermatitis 33/ 21/90 14/24 Reduced erythema, maceration, skin stripping when using barrier film Hampton (1998) Observational comparative Nappy rash 62/53 32/90 13/24 Skin improvement Skin protectant in disposable wash cloth that cleanses and moisturizes the skin (active ingredient: dimethicone 3%) vs. Clever et al. (2002) Retrospective pre/post Pressure ulcer 90 64/ 33/90 17/24 Reduced skin lesions Moisturizers Hydrogel barrier/repair cream vs. Petrolatum-based moisturizing cream Draelos (2000) RCT Diaper dermatitis 28 80/73 33/90 13/24 Reduced erythema, roughness and desquamation when using hydrogel barrier/repair cream 1146 Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd

7 JAN: REVIEW PAPER Incontinence-associated dermatitis: literature review Table 1 (Continued) Citation Study design Operational definition Study period (days) Patients included/ analysed RAC scores Methods Analysis Significant outcomes Perineal skin cleansers Soap, water, moisture barrier vs. No-rinse cleanser with moisture barrier vs. no-rinse cleanser without moisture barrier Byers et al. (1995) Cross-over 21 12/10 36/90 19/24 Reduced erythema when using no-rinse cleanser with moisture barrier Lewis-Byers and Thayer (2002) Prospective descriptive Incontinence damaged skin 21 32/31 42/90 24/24 Foam cleanser vs. water, soap Cooper and Gray (2001) RCT Skin breakdown relating to incontinence 14 66/65 39/90 16/24 Reduced erythema when using foam cleanser Cleansing agent and barrier cream vs. aerosol mousse Whittingham and May (1998) Observational Comparative Excoriation due to incontinence 56 29/26 32/90 13/24 Cleanser protectant lotion vs. no-rinse cleanser spray + skin barrier paste or antifungal cream Warshaw et al. (2002) Post-test only Perineal skin breakdown 7 19/16 38/90 10/24 Reduced erythema and pain when using cleanser protectant lotion Barrier ointment (lanoline, beeswax, petrolatum) + body wash (petrolatum) vs. Hunter et al. (2003) Pre/post Perineal dermatitis / 42/90 15/24 Reduced perineal dermatitis Cleansing spray, washcloth, skin protectant vs. disposable washcloth with dimethicone vs. disposable washcloth without dimethicone Dieter et al. (2006) RCT Skin problems 94/ 28/90 9/24 More skin problems when using disposable washcloth without dimethicone RAC, Research Appraisal Checklist; pre/post, pre post-test design; RCT, randomized controlled trial; A, acute care; C, chronic care;, no result. Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd 1147

8 D. Beeckman et al. et al. 2003, Dieter et al. 2006). In these studies, different formulae were compared (Table 1). Use of a specific skin care and/or incontinence care regime The implementation of a structured skin care protocol combined with a pressure ulcer prevention protocol caused a statistically significantly lower IAD incidence (4Æ7% vs. 25Æ3%) and fewer grade 1 pressure ulcers (non-blanchable erythema of the intact skin). Use of the newly implemented skin care protocol resulted in a statistically significant reduction of total costs when product costs were calculated together with staff time (Bale et al. 2004). Bates-Jensen et al. (2003)conducted a randomized controlled trial to examine health outcomes of an exercise and incontinence intervention. Intervention patients were statistically significantly better in urinary and faecal incontinence and skin wetness outcome measures (limited to the back distal perineal area) than the control group (Table 2). Use of diapers and/or underpads Brown (1994a, 1994b) found no statistical differences in the incidence of skin alteration (colour, integrity or symptoms) between patients wearing diapers and those managed with underpads. More patients in a non-polymer diaper and underpads group experienced alterations (skin colour change, tingling, itching, burning, pain) than those in a polymer group. Therefore, polymer products, whether diaper or underpads, appeared to be more effective in preventing skin breakdown than non-polymer products. Leiby and Shanahan (1994) observed improved skin condition when underpads with a more absorbent capacity and higher ability to keep the skin dry was used (Table 3). Discussion In general, the quality of methods found in the included studies was rather poor, especially for participants and instruments. The absence of power calculations, correct randomization procedures, blinded assessments, standardized measuring methods and intention-to-treat analyses were the most common methodological flaws. Effect sizes were not reported. The number of patients included was small and the length of study periods was short. A wide range of different wound characteristics and observational instruments were used to classify and observe incontinenceassociated skin problems. These instruments were either not validated or validated only to a limited extent, which Table 2 Description of studies concerning the use of a specific skin care regime and/or incontinence care regime RAC scores Significant outcomes Methods Analysis Patients included/analysed Study period (days) Operational definition Citation Study design / 46/90 21/24 Reduced incidence of IAD Reduced severity of skin lesions Reduced grade 1 PU when using structured protocol Structured protocol vs. unstructured protocol Bale et al. (2004) Pre/post Incontinence dermatitis 56 15/ 64/90 24/24 Lyder et al. (1992) Pre/post Perineal dermatitis /144 63/90 24/24 Reduced skin wetness and erythema Perineal skin wetness Incontinence care vs. usual care Bates-Jensen et al. (2003) RCT doubleblinded RAC, Research Appraisal Checklist; pre/post, pre post-test design; RCT, randomized controlled trial; IAD, incontinence-associated dermatitis; PU, pressure ulcer;, no result Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd

9 JAN: REVIEW PAPER Incontinence-associated dermatitis: literature review Table 3 Description of studies concerning the use of diapers and/or underpads RAC scores Significant outcomes Methods Analysis Patients included/ analysed Study period (days) Operational definition Citation Study design Non-polymer diaper/underpads vs. polymer diaper/underpads vs. cloth underpads Brown (1994a, 1994b) RCT double-blinded Perineal dermatitis / 54/90 18/24 Reduced skin breakdown when using polymer diaper/underpads Underpads high absorbance vs. underpads low absorbance Leiby and Shanahan (1994) RCT Moisture-related /107 38/90 20/24 Improvement of skin skin problems integrity when using underpads high absorbance Copper acetate-containing diaper Häggbom et al. (1983) Observational 92/ 19/90 8/24 Reduced skin irritation and odour RAC, Research Appraisal Checklist; RCT, randomized controlled trial; A, acute care; C, chronic care;, no result. resulted in difficulties in comparing the outcomes of the studies. Due to the explorative character of the review, the scarce literature found and the aim to provide an overview of current (limited) evidence, the methodological quality of each study is reported in this review but was not used as an exclusion criterion. This allows identification of potential areas for additional and rigorously conducted research. Prevalence and incidence A wide variety in IAD prevalence and incidence was described in the literature. Only a few researchers reported prevalence or incidence data on IAD. Most studies were single-centred, conducted in chronic care settings and based on small samples. Prevalence proportions could not be compared, because no standardized method for determining prevalence was used. We suggest that the development of a uniform instrument and method to study IAD prevalence and management strategies across different patient groups are needed. Further research is also needed to obtain a clear picture of the prevalence and incidence in critical care units, in acute care and in community care settings. Pathophysiology Limited research was found focusing on the complex aetiology of IAD. Faecal incontinence and double urinary and faecal incontinence tend to appear more strongly associated with IAD than urinary incontinence alone (Jeter & Lutz 1996, Lekan-Rutledge 2006). Several components of faeces may contribute to this association, including faecal enzymes and bacteria, and excess moisture if the faeces are liquid (diarrhoea) (Jeter & Lutz 1996). The role of influencing factors, such as the perineal environment and the nature of incontinence (urinary, faecal or double urinary and faecal incontinence), the volume and frequency of incontinence, friction, irritating agents, and factors that compromise the skin s barrier function (hydration, ph, faecal enzymes, and fungal or bacterial pathogens) should be further investigated. Definition and observation A clear definition and a validated observation instrument for IAD are important in communication and the acquisition of knowledge. The ability to describe the nature of IAD would allow the development and implementation of rational clinical actions. Furthermore, a clear definition and observation instrument would enable a more Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd 1149

10 D. Beeckman et al. Table 4 Overview of cost-reducing interventions Cost-reducing intervention Direct costs Product cost Nursing time Total cost Indirect costs Zinc oxide vs. no-sting barrier film Campbell et al. (2001) No sting barrier film Reduced Reduced NE NE Baatenburg de Jong and No sting barrier film Reduced Reduced Reduced NE Admiraal (2004) Kennedy et al. (1996) No sting barrier film Reduced NE NE NE Bliss et al. (2007) No sting barrier film Higher Reduced Reduced NE Zinco oxide vs. petrolatum ointment Kennedy et al. (1996) Petrolatum ointment Reduced NE NE NE Petrolatum ointment vs. no-sting barrier film Zehrer et al. (2004a) No sting barrier film Reduced Reduced NE NE Cleansing agent and barrier cream vs. aerosol mouse Whittingham and May (1998) Aerosol mouse Reduced Reduced NE NE Cleanser protectant lotion vs. no-rinse cleanser spray + skin barrier paste or antifungal cream Warshaw et al. (2002) Cleanser protectant lotion Reduced Reduced NE NE Cleansing spray, washcloth, skin protectant vs. disposable washcloth with dimethicone vs. disposable washcloth without dimethicone Dieter et al. (2006) Disposable washcloth with dimethicone Reduced NE NE NE Structured protocol vs. unstructured protocol Bale et al. (2004) Structured protocol Higher Reduced NE NE Non-polymer diaper/underpads vs. polymer diaper/underpads vs. cloth underpads Brown (1994a, 1994b) Polymer diaper/underpads Higher Reduced NE NE, no result; NE, not evaluated. systematic observation of IAD and would probably improve research clarity and the applicability of results in practice. In the literature, a variety of terms was used to describe incontinence-associated skin problems. No predominant terminology was found. The use of the MeSH term diaper rash revealed 505 publications in PubMed, whereas the [Text Word] incontinence lesion revealed A variety of additional keywords was needed to increase the sensitivity of the search filter. In the ICD-10 (WHO 2008), different alternative terms (diaper/napkin dermatitis, diaper/ napkin erythema or diaper/napkin rash) were described. According to the NANDA (2008), incontinence-associated skin problems should be classified as (risk for) impaired skin integrity. Suggested assessment, therapeutic interventions and continuity of care were all focused on pressure ulcer prevention and treatment because the nursing diagnosis of impaired skin integrity focuses on pressure ulcers. Differentiation between IAD and pressure ulcers should be included in the widely used NANDA classification to create clear instructions for nurses caring for patients affected with IAD. Diagnosis In clinical and research settings, IAD is often combined with skin damage caused by pressure and shear or related factors, sometimes leading to confusion among clinicians about its aetiology and diagnosis. Also in pressure ulcer literature, incontinence is often referred to as a factor increasing the risk of pressure ulcer development (Jeter & Lutz 1996, Bates-Jensen 1997, Maklebust & Sieggreen 1150 Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd

11 JAN: REVIEW PAPER 2001, Houwing et al. 2007). Until recently, there was limited discussion about the differentiation between pressure ulcers and incontinence-related skin problems in the literature. Since 1999, a growing number of papers have been published on the issue (Defloor 1999, Defloor et al. 2005, Dealey & Lindholm 2006, Evans & Stephen-Haynes 2007, Gray et al. 2007b). A correct distinction between pressure ulcers and IAD is important in practice because the preventive measures to be taken are different. Based on this review, skin protection, hygiene and supporting interventions (incontinence training and use of containment materials) are suggested for IAD. Protection or repair of oxygen supply to the tissue is indicated for the prevention of pressure ulcers. Confusion between IAD and pressure ulcers will probably result in inadequate use of limited resources. Expensive and labour-intensive measures to prevent pressure ulcers will often be applied for patients affected with IAD. As a result, those needing pressure prevention will probably not receive optimal care because of limited resources. A clear consensus about the aetiology and the availability of unambiguous clinical descriptors of the distinction between IAD and pressure ulcers would probably avoid confusion and the inadequate application of preventive interventions. Efforts to clarify the difference between IAD and pressure ulcers are being made. In a recent position statement, EPUAP defined wound-related characteristics (causes, location, shape, depth, edges and colour) and patient-related characteristics to clarify the difference between a pressure ulcer and IAD (Defloor et al. 2005). These differential characteristics can help to distinguish both skin disorders. Healthcare professionals should be adequately educated about the principles behind the differentiation between IAD and pressure ulcers. Management Researchers tend to recommend a routine perineal skin-care programme that includes cleansing with a product with a ph as near as possible to that of normal skin. In a second step, a moisturizer, incorporated into a specially designed cleanser or cleansing system, can be applied. The use of a skin protectant is recommended for patients considered at risk of IAD, including those experiencing high volume or frequent incontinence or double urinary and faecal incontinence. The use of soap and water (applied with a washcloth) has traditionally been thought of as being the gold standard for skin hygiene and management. However, it has not been found to be the most appropriate for skin care of patients with incontinence. The use of perineal skin cleansers was found to be more effective for the prevention and treatment of IAD. Another option is the use of a no-rinse cleansing foam. Based on the results of this review, it appears that optimal skin care following each major incontinence episode, particularly if faeces are present, is important. Optimal skin care should be provided by the development of a structured skin care regime (containing a skin cleanser and a skin protectant). In addition, a skin protectant should be applied more frequently in patients with highvolume or frequent episodes of incontinence. Combined products can be used to optimize time efficiency and to encourage adherence to the skin care regime. Combined products include moisturizing cleansers, moisturizer skin protectant creams and disposable washcloths that incorporate cleansers, moisturizers and skin protectants into a single product. Cost-effectiveness In five studies, reduced cost was reported when a no-sting barrier film was used for the prevention and treatment of IAD. In a study by Zehrer et al. (2004a), a cost reduction was observed when a no-sting barrier film was applied three times a week instead of once daily. The validity and reliability of cost-effectiveness analyses should be interpreted carefully. A financial grant from the producer of the experimental intervention was mentioned in the studies. Another point of concern is that the cost-effectiveness analyses were limited to calculation of the direct costs [the product cost (cost per unit application rate) and nursing time (nursing time per application application rate)]. Total costs, defined as the sum of the product cost, nursing time and costs of treatment-related products (such as nonsterile gloves, spatulas, gauze, sweet oil, disposable material) was defined in only two studies (Baatenburg de Jong & Admiraal 2004, Bliss et al. 2007). Indirect costs were not taken into account. Caregivers and patients should be informed about direct costs as well as indirect costs so that they can choose the most cost-effective and appropriate intervention (Phillips 2007). Conclusion Incontinence-associated dermatitis: literature review Incontinence-associated dermatitis is an important problem in both chronic and acute care. This literature review reveals limited evidence concerning various preventive and treatment Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd 1151

12 D. Beeckman et al. What is already known about this topic Incontinence-associated dermatitis is a common problem in patients with incontinence. Faecal incontinence appears to be more strongly associated with incontinence-associated dermatitis development than urinary incontinence. A wide range of skin care products are available for prevention and treatment, but little is known about their efficacy and effectiveness. What this paper adds The use of soap and water is not the most appropriate method for skin care of patients with incontinence. Structured perineal skin care, including cleansing with a product of which the ph is near to that of normal skin, is suggested. A skin protectant is recommended for patients with incontinence who are at risk of developing incontinence-associated dermatitis. Implications for practice and/or policy Further research is needed to ascertain the safety and effectiveness of commonly used products and procedures. Caregivers and patients should be informed about direct and indirect costs so that they can choose the most appropriate intervention. Observation of incontinence-associated dermatitis should be more objective to improve the clarity of research results and applicability in practice. skin regimes. Additional research is needed to identify and evaluate the efficacy and effectiveness of various interventions for IAD, and larger sample studies are needed to ascertain the safety and effectiveness of commonly used products and procedures. This will require long-term data collection in multicentre studies. In view of the limited validation of observation instruments for IAD, additional research is recommended. Acknowledgements The authors would like to express their thanks to Ann Van Hecke MA RN and Lien Proost MA RN (Research Staff, Nursing Science, Ghent University), for their valuable support during this study. Conflict of interest No conflict of interest has been declared by the authors. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Author contributions LS and TD were responsible for the study conception and design. LS and TD performed the data collection. DB, LS and TD performed the data analysis. DB and TD were responsible for the drafting of the manuscript. DB, LS, SV, AH and TD made critical revisions to the paper for important intellectual content. TD supervised the study. References Anthony D., Barnes E., Malone-Lee J. & Pluck R. (1987) A clinical study of Sudocrem in the management of dermatitis due to the physical stress of incontinence in a geriatric population. Journal of Advanced Nursing 12, Baatenburg de Jong H. & Admiraal H. (2004) Comparing cost per use of 3M TM Cavilon TM No Sting Barrier Film with zinc oxide oil in incontinent patients. Journal of Wound Care 13, Bale S., Tebble N., Jones V. & Price P. (2004) The benefits of implementing a new skin care protocol in nursing homes. Journal of Tissue Viability 14, Bates-Jensen B. (1997) Incontinence management. In The Decubitus Ulcer in Clinical Practice (Parish L., Witowski J. & Crissy J., eds), Springer-Verlag, Berlin, pp Bates-Jensen B., Alessi C., Al Samarrai N. & Schnelle J. (2003) The effects of an exercise and incontinence intervention on skin health outcomes in nursing home residents. Journal of the American Geriatrics Society 51, Bliss D., Zehrer C., Savik K., Smith G. & Hedblom E. (2007) An economic evaluation of four skin damage prevention regimens in nursing home residents with incontinence: economics of skin damage prevention. Journal of Wound, Ostomy, and Continence Nursing 34, Brown D. (1994a) Diapers and underpads, Part 1: Skin integrity outcomes. Ostomy/Wound Management 40, Brown D. (1994b) Diapers and underpads, Part 2: Cost outcomes. Ostomy/Wound Management 40, 34 36, 38, 40. Byers P., Ryan P., Regan M., Shields A. & Carta S. (1995) Effects of incontinence care cleansing regimens on skin integrity. Journal of Wound, Ostomy, and Continence Nursing 22, Campbell K., Woodbury M., Whittle H., Labate T. & Hoskin A. (2000) A clinical evaluation of 3M no sting barrier film. Ostomy/ Wound Management 46, Campbell K., Keast D., Woodbury G., Houghton P. & Lemesurier A. (2001) The use of a liquid barrier film to treat severe incontinent 1152 Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd

13 JAN: REVIEW PAPER Incontinence-associated dermatitis: literature review dermatitis-case reports. Research Poster Presented at the 7th Annual Conference of the Canadian Association of Wound Care. London, ON, Canada, November. Clever K., Smith G., Bowser C. & Monroe K. (2002) Evaluating the efficacy of a uniquely delivered skin protectant and its effect on the formation of sacral/buttock pressure ulcers. Ostomy/Wound Management 48, Cooper P. & Gray D. (2001) Comparison of two skin care regimes for incontinence. British Journal of Nursing 10, S6, S8, S10. Dealey C. (1995) Pressure sores and incontinence: a study evaluating the use of topical agents in skin care. Journal of Wound Care 4, Dealey C. & Lindholm C. (2006) Pressure ulcer classification. In Science and Practice of Pressure Ulcer Management (Romanelli M., Clark M., Colin D. & Defloor T., eds), European Pressure Ulcer Advisory Panel & Springler-Verlag, London, pp Defloor T. (1999) Decubitus, de stand van zaken 1: urine veroorzaakt geen decubitus. Nursing 6, Defloor T., Schoonhoven L., Fletcher J., Furtado K., Heyman H., Lubbers M., Lyder C. & Witherow A. (2005) Statement of the European Pressure Ulcer Advisory Panel-Pressure Ulcer Classification: differentiation between pressure ulcers and moisture lesions. Journal of Wound, Ostomy, and Continence Nursing 32, Dieter L., Drolshagen C. & Blum K. (2006) The development of costeffective quality care for the patients with incontinence. Research Poster Presented at the 38th Annual Conference of the WOCN Society. Minneapolis, MN, USA, June. Draelos Z. (2000) Hydrogel barrier/repair creams and contact dermatitis. American Journal of Contact Dermatitis 11, Duffy M. (1985) A research appraisal checklist: appraising nursing research reports. pressure ulcer classification. In Measurement of Nursing Outcomes: Vol. 2. Measuring Performance: Practice, Education and Research (Strickland O. & Waltz C., eds), Springler Publishing Company, New York, pp Evans J. & Stephen-Haynes J. (2007) Identification of superficial pressure ulcers. Journal of Wound Care 16, Gray M., Ratliff C. & Donovan A. (2002) Perineal skin care for the incontinent patient. Advances in Skin & Wound Care 15, Gray M., Bliss D., Doughty D., Ermer-Seltun J., Kennedy-Evans K. & Palmer M. (2007a) Incontinence-associated dermatitis: a consensus. Journal of Wound, Ostomy, and Continence Nursing 34, Gray M., Bohacek L., Weir D. & Zdanuk J. (2007b) Moisture vs pressure: making sense out of perineal wounds. Journal of Wound, Ostomy, and Continence Nursing 34, Häggbom P., Norberg B. & Norberg A. (1983) The urine smell around patients with urinary incontinence: animal and human trials of skin tolerance towards diapers impregnated with copper acetate. Journal of Clinical & Experimental Gerontology 5, Hampton S. (1998) Film subjects win the day. Nursing Times 94, Houwing R., Arends J., Dijk M., Koopman E. & Haalboom J. (2007) Is the distinction between superficial pressure ulcers and moisture lesions justifiable? A clinical-pathologic study. Skinmed 6, Hunter S., Anderson J., Hanson D., Thompson P., Langemo D. & Klug M. (2003) Clinical trial of a prevention and treatment protocol for skin breakdown in two nursing homes. Journal of Wound, Ostomy, and Continence Nursing 30, Jeter K. & Lutz J. (1996) Skin care in the frail, elderly, dependent, incontinent patient. Advances in Wound Care 9, Kennedy K., Leighton B. & Lutz J. (1996) Cost Effectiveness Evaluation of a New Alcohol Free Film-Forming Incontinence Skin Protectant. White Paper 3M Healthcare, St Paul, MN. Leiby D. & Shanahan N. (1994) Clinical study: assessing the performance and skin environments of two reusable underpads. Ostomy/Wound Management 40, Lekan-Rutledge D. (2006) Management of urinary incontinence: skin care, containment devices, catheters, absorptive products. In / miscellaneoustext> Urinary & Faecal Incontinence: Current Management Concepts, 3rd edn (Doughty D., ed.), Mosby Elsevier, St Louis, pp Lewis-Byers K. & Thayer D. (2002) An evaluation of two incontinence skin care protocols in a long-term care setting. Ostomy/ Wound Management 48, Lyder C., Clemes-Lowrance C., Davis A., Sullivan L. & Zucker A. (1992) Structured skin care regimen to prevent perineal dermatitis in the elderly. Journal of ET Nursing 19, Maklebust J. & Sieggreen M. (2001) Assessment of pressure ulcers. In Pressure Ulcers: Guidelines for Prevention and Management (Maklebust J. & Sieggreen M., eds), Springhouse Corporation, Spring house, PA, pp National Pressure Ulcer Advisory Panel (2007) Terms and definitions related to support surfaces. Retrieved from NPUAP_S3I_TD.pdf on 12 June Newman D., Preston A. & Salazar S. (2007) Moisture control, urinary and faecal incontinence, and perineal skin management. In Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, 4th edn (Krasner D., Rodeheaver G. & Sibbald R., eds), HMP Communications, Malvern, pp North America Nursing Diagnosis Association (NANDA) (2008) Nursing Diagnoses: Definitions and Classification, North American Nursing Diagnosis Association, Philadelphia, PA. Retrieved from on 4 May 2008 Phillips T. (2007) Cost effectiveness in wound care. In Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, 4th edn (Krasner D., Rodeheaver G. & Sibbald R., eds), HMP Communications, Malvern, pp Sibbald R., Campbell K., Coutts P. & Queen D. (2003) Intact skin an integrity not to be lost. Ostomy/Wound Management 49, Warshaw E., Nix D., Kula J. & Markon C. (2002) Clinical and cost effectiveness of a cleanser protectant lotion for treatment of perineal skin breakdown in low-risk patients with incontinence. Ostomy/Wound Management 48, Whittingham K. & May S. (1998) Cleansing regimens for continence care. Professional Nurse 14, World Health Organization (WHO). (2008) International Statistical Classification of Diseases and Health Related Problems (The) ICD- 10, 2nd edn. World Health Organization, Geneva, Switzerland. Retrieved from on 9 July Zehrer C., Lutz J., Hedblom E. & Ding L.A. (2004a) Comparison of cost and efficacy of a non-alcohol barrier film applied once daily Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd 1153

14 D. Beeckman et al. and three times weekly in an incontinence dermatitis prevention protocol. Research Poster Presented at the 19th Annual Clinical Symposium on Advances in Skin & Wound Care. Phoenix, AZ, USA. Zehrer C., Lutz J., Hedblom E. & Ding L. (2004b) A comparison of cost and efficacy of three incontinence skin barrier products. Ostomy/Wound Management 50, The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original research reports and methodological and theoretical papers. For further information, please visit the journal web-site: Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd