Overview

Moisture-associated skin damage (MASD) is a common problem for wound clinicians. It connotes a spectrum of skin damage caused by inflammation and erosion (or denudation) of the epidermis resulting from prolonged exposure to various sources of moisture and potential irritants.

These can include urine, stool, perspiration, wound exudates, or ostomy effluent. MASD includes several different categories: incontinence-associated dermatitis (AID), intertriginous dermatitis, periwound skin damage, and peristomal MASD. Of these categories, IAD is one of the more challenging issues for clinicians to recognize and treat. It is not uncommon for IAD to be inaccurately assessed as a stage 2 pressure injury. For the purposes of this blog, the focus is on differentiating between IAD and pressure injuries. Treatment strategies are also addressed.

The ammonia in urine and/or stool creates an alkaline environment that potentiates the proteolytic activity of fecal enzymes (protease and lipase) on skin, thus leading to IAD. These enzymes disrupt the skin acid mantle and make it easy for irritants to penetrate the skin and trigger an inflammatory response.

IAD is found in the perineal and perianal areas and typically manifests as diffuse erythema, but it may also be characterized by erosion, edema, scaling, papules, or bullae containing serous exudate with accompanying pruritus, burning, or pain. The damage is usually partial-thickness in depth, and the margins of denuded surfaces are often very irregular. Secondary Candida infections may be present as well. IAD, as mentioned, can be confused with stage 2 pressure injuries. A stage 2 pressure injury, according to the National Pressure Injury Advisory Panel, is defined as “partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, red, moist and may also present as an intact or ruptured serum filled blister. Adipose is not visible and deeper tissues are not visible.“ These injuries are often the result of an adverse microclimate and shear forces, especially in the pelvic or heel areas. “Stage 2 pressure injury” should not be used to describe MASD.

Management of MASD or IAD

Correct or Contain Incontinence

In some cases, the use of a Foley catheter may be necessary to mitigate skin damage caused by moisture. Foley catheters should be used judiciously and for as short a time as possible if they are used specifically for MASD or IAD. In cases of severe fecal incontinence with diarrhea resulting from an infectious agent or malabsorption, the cause can be managed with a fecal management system. This involves the insertion of a soft silicone device with an inflatable bulb into the rectum.

Most fecal management systems can be used for up to 30 days. Of course, addressing the etiology of the loose stools is also important and may require antibiotics or other pharmacological agents to control stool frequency and consistency.

Use Clinical Barriers

Patients with IAD should receive routine continence care and application of a barrier on a regular basis, every one to two hours as indicated. Petrolatum is a product found in barrier products that forms a seal over the skin to reduce transepidermal water loss and provides a mechanical barrier between urine or stool and the skin. Zinc oxide, another common ingredient in barrier products, works in a manner similar to petrolatum but may have a modest anti-inflammatory and soothing component.

Dimethicone products are also very useful and because they allow for some water vapor transfer and may reduce the risk of any miliaria (heat rash). They are also fairly easy to apply. Petrolatum, zinc, and dimethicone products need to be applied several times a day and as needed after continence care. Polymer barriers consist of a product in a water or organic solvent that provides a thin film over the area and that can also afford some protection. The ingredients in some of these products can cause stinging and irritation when applied.

These products are ideally beneficial for prevention or for very early or mild cases of MASD or IAD. They should be applied daily and as needed. Cyanoacrylate formulations comprise another option for management of MASD or IAD and create an adherent bond to the skin. These products can also be applied over wet or denuded areas and offer significant protection. They are designed to stay on for several days at time and are more resistant to removal.

Conclusion

Clinically, it may be difficult sometimes to distinguish between MASD or IAD and pressure-related skin damage. Keep in mind that any patient with MASD or IAD is also likely at risk for pressure injury development and should be on a preventive program to mitigate skin damage from pressure as well. Patients with MASD resulting from IAD need to have continence addressed and require routine care. If there is a secondary yeast infection, then topical application of an antifungal agent may be necessary. Some barrier products do contain 2% miconazole, which may be very beneficial in these cases.

Resources

1. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen, M. Revised National Pressure Ulcer Advisory Panel pressure injury staging system: revised pressure injury staging system. J Wound Ostomy Continence Nurs. 2016;43(6):585-597. doi:10.1097/won.0000000000000281
2. McNichol LL, Ayello EA, Phearman LA, Pezzella PA, Culver EA. Incontinence-associated dermatitis: state of the science and knowledge translation. Adv Skin Wound Care. 2018;31(11):502-513. doi: 10.1097/01.ASW.0000546234.12260.61
3. Woo KY, Beeckman D, Chakravarthy D. Management of moisture-associated skin damage: a scoping review. Adv Skin Wound Care. 2017;30(11):494-501. doi: 10.1097/01.ASW.0000525627.54569.da

About The Author

Dr. Dianne Rudolph is a nurse practitioner board-certified in Gerontological advanced practice nursing and as a wound, ostomy and continence nurse. She has been a nurse for more than 30 years with experience in trauma care, acute care, home care, hospice, long term care, rehab and wound care. She is very passionate about caring for adults and older adults with complex medical and wound needs. She has been a faculty member for several schools of nursing and is currently adjunct faculty at the University of Texas Health Science Center in Houston. She has presented multiple lectures and has published articles and book chapters on a variety of topics. She is currently working for South Texas Wound Associates, a practice which provides complex wound care for patients in the clinic, acute care and long term care settings.