Incontinence-associated dermatitisL22.-

Incontinence-associated dermatitis is an acute or chronic, irritant, toxic contact dermatitis, which mainly affects elderly and/or bedridden stool and/or urine incontinent people. Constant contact of the skin with stool and/or urine causes damage to the skin barrier and constant irritation of the skin.

The IAD is classified into "light", "moderate" and "heavy".

Incontinence-associated dermatitis is a frequently occurring problem in the health care system. The prevalence rate of IAD in the eligible populations is expected to be between 5.6 and 50%.

The main cause of incontinence-associated dermatitis is fecal incontinence (alone or in combination with urinary incontinence). The frequency of stool frequency, the composition of the stool, the consecutive constant moistening of the skin, ammonia, pH, stool enzymes as well as the age of the affected person and immobility play an important role. Furthermore, unsuitable skin cleansing products (alkalizing products), friction and shear forces within the epidermis (e.g. due to incorrect pressure on the skin of bedridden patients, improper drying of the skin), bacterial colonization or growth and occlusive incontinence products can have a significant influence on the IAD.

Intertriginous areas (groin region, perianal areas, vascular areas, less frequently lower abdomen and back)

In the initial stage, the intertriginous areas are reddish, possibly swollen and scaly, itchy or painful.

Later stages of incontinence-associated dermatitis are characterized by sharply or blurredly limited areal erosions, possibly by superimposed mycotic or bacterial infections (microbiological evidence). This can lead to a blurred, speckled edge of the contact lesion, which is sharply defined in itself.

It is important to differentiate between IAD and decubitus. The difficulty is that the appearance of the incipient to moderate IAD is similar to the first degree (classification according to NPUAP) of the decubitus. Furthermore, it is important to distinguish between these and genuine dermatological diseases such as mycotic (mostly yeast infections) and bacterial infections (Fölster-Holst R 2018), intertriginous psoriasis and, rarely, Darier' s disease or pemphigus diseases.

The tool consists first of all in the "classification in degrees of severity "of IAD. Therapeutically, 2 main interventions are crucial.

1. Management of incontinence
2. Implementation of a structured skin care program.

The management of incontinence aims to minimise or completely prevent skin contact with urine and/or faeces and thereby maintain the protective function. Reversible causes of incontinence must be identified and treated accordingly. (e.g. urinary tract infection, diuretics, constipation).

These causes are usually treated with non-invasive behavioural interventions such as optimising diet and hydration. Measures to promote continence, such as pelvic floor exercises or bladder or bowel training programmes, should be introduced in parallel. In men, a urinary condom can be used. In the case of very pronounced toxic dermatitis and urinary incontinence, a transurethral catheter should be placed temporarily to optimise treatment. Furthermore, other aids such as faecal collectors, anal tampons or stool drainage systems should be used if necessary.

Important: If absorbent products have to be used, open incontinence products close to the body (net pants with insert) are preferable to a closed system (briefs).

In parallel to these supportive measures, external therapeutics appropriate to the condition of the skin (initially mild glucocorticoid-containing, if necessary alternating with antimicrobial externals) should be used. Later, after healing of the acute dermatitis, prophylactic application of covering and skin-protecting ointments containing zinc. Cleansing of the areas with mild vegetable oils.

Incontinence-associated dermatitis has so far been known mainly in infants under the term "diaper dermatitis". In recent years, the term "Incontinence Associated Dermatitis (IAD)" has become increasingly accepted for this toxic-irritant dermatitis in adults with skin damage caused by incontinence.

1. Cecchi R et al (2017) Jacquet erosive diaper dermatitis with Stenotrophomonas maltophilia colonization. G Ital Dermatol Venereol 152:186-187.
2. Fölster-Holst R (2018) Differential diagnoses of diaper dermatitis. Pediatric Dermatol 35 Suppl 1:10-18.
3. Fujimura T et al (2016) The influence of incontinence on the characteristic properties of the skin in bedridden elderly subjects. Int J Dermatol 55: e234-240.
4. Holroyd S et al (2014) Prevention and management of incontinence-associated dermatitis using a barrier cream. Br J Community Nurs Suppl Wound Care: 32-38.
5. Takahashi H et al (2017) Preventive effects of topical washing with miconazole nitrate-containing soap to diaper candidiasis in hospitalized elderly patients: A prospective, double-blind, placebo-controlled study. J Dermatol 44:760-766.