Incontinence-associated dermatitis: consensus statements, evidence-based guidelines for prevention and treatment, and current challenges

Exploration of current practice and context for the prevention and treatment of incontinence associated dermatitis for adults living in care homes and community settings: a qualitative study

AIMS

This study aimed to explore current practice and context for the prevention and treatment of incontinence associated dermatitis (IAD), identify challenges and solutions, current prevention and treatment strategies, and products used.

MATERIALS AND METHODS

Using a qualitative cross-sectional approach online focus groups were conducted with stakeholders including experts by experience of IAD (n = 5) and health/care professionals (n = 16). Verbatim transcripts were coded independently by two researchers and analysed using framework analysis.

RESULTS

Four themes and two sub-themes were identified: (1) Impact of IAD: "significant" damage could occur in a short space of time; (2) Uncertainty, is it IAD? Correct diagnosis of IAD was challenging, especially in people with black skin. Uncertainty was underpinned by a lack of education and clear guidance on skin inspection. (3) Lack of resources (sub-themes human resources and product resources): Lack of human resources related to the number of staff available, deficiency of knowledgeable and skilled staff, and limited leadership. Lack of availability of pads was a challenge and carers reduced the number of pad changes to "conserve pads"; (4) Variation in practice, both for cleansing skin and applying a leave-on 'barrier' product.

CONCLUSION

Care for adults with incontinence to prevent and/or treat IAD is challenging in the social care sector. Wide variation in practice exists and there is a need for educational interventions in the sector, targeting an international and transient workforce.

Risk Factors for Incontinence-Associated Dermatitis in Adults: A Systematic Review and Meta-Analysis

PURPOSE

A meta-analysis was conducted to comprehensively identify risk factors of incontinence-associated dermatitis (IAD) in adults and provide evidence-based support for healthcare professionals to formulate IAD preventive interventions and bundled interventions.

METHODS

Systematic review and meta-analysis of pooled findings.

SEARCH STRATEGY

Two researchers independently searched databases PubMed, EBSCO, Cochrane Library, Embase, Medline, Web of Science and Scopus and 4 Chinese databases (CNKI, Wanfang Data, VIP and CBM) for relevant studies published from their inception to March 15, 2023. Two researchers independently extracted relevant data and literature characteristics and evaluated the quality of the included studies.

FINDINGS

Twenty-seven studies that collectively enrolled 4046 participants were included in our systematic review. Five were written in English, 1 was written in Spanish, and the other 21 were written in Chinese. The odds ratios (ORs) and 95% confidence intervals (CIs) of the risk factors for IAD were determined. Fecal incontinence, an etiologic factor (OR = 5.79; 95% CI = [1.88-17.87]), stool characteristics (OR = 5.28; 95% CI = [2.51-11.07]), and daily frequency of bowel movements (OR = 5.76; 95% CI = [4.48-7.42]) were associated with an increased likelihood of IAD. The following risk factors: fever (OR = 4.23; 95% CI = [1.89-9.46]), age (OR = 1.04; 95% CI = [1.01-1.09]), hypoproteinemia (OR = 3.30; 95% CI = [1.90-5.72]), impaired consciousness (OR = 2.43; 95% CI = [1.66-3.54]), days of antibiotic use (OR = 4.13; 95% CI = [3.11-5.49]), diabetes mellitus (OR = 2.90; 95% CI = [1.73-4.86]), and a higher overall Perineal Assessment Tool (PAT) score (OR = 2.56; 95% CI = [1.23-5.30]) emerged as independent risk factors for IAD in adult patients. In contrast, a higher serum albumin level (OR = 0.88; 95% CI = [0.84-0.93]), a higher Braden Scale for Predicting Pressure Score Risk (Braden Scale) score (OR = 0.66; 95% CI = [0.56-0.77]), and a higher Braden Scale mobility subscale score (OR = 0.86; 95% CI = [0.74-1.00]) were protective factors that reduced the likelihood of IAD.

IMPLICATIONS

Identification of risk factors for IAD may be used to identify patients at risk and in need of preventive interventions. Identification of modifiable risk factors may be used to design novel preventive interventions.

[Development of items for the assessment of paediatric incontinence-associated dermatitis in German: Delphi study]

Development of items for the assessment of paediatric incontinence-associated dermatitis in German: Delphi study Abstract: Background: Paediatric incontinence-associated dermatitis (PIAD) is a common problem in premature infants, neonates, infants and young children. Standardized instruments for the assessment of PIAD can support clinical decision-making, but no standardized instrument is yet available for German-speaking countries. Aim: Selection, development and agreement of appropriate items for the assessment of PIAD in newborns, infants and young children in German (aIADchild Delphi). Method: Using a Delphi technique, international items were formulated in German by a steering committee, the items were assessed by panellists using an online survey, and a consensus (I-CVI > = 75%, comments) was formed by the steering committee and panellists. Results: 54 experts from four German-speaking countries were recruited. 44 (1st round) and 33 (2nd round) completed the questionnaire in full. Twelve items for the assessment of PIAD were rated as relevant, comprehensive and comprehensibility: erythema, skin change without and with damage to the skin surface, exudation, bleeding, oedema, overheating, signs of mycotic/bacterial superinfection, pain, itching, localization/extension and duration. Conclusion: The items aIADchild Delphi for the assessment of PIAD in German should be tested for their measurement properties prior to clinical use and the construction of an instrument.

Irritant Contact Dermatitis Due to Fecal, Urinary, or Dual Incontinence: It Is Time to Focus on Darkly Pigmented Skin

GENERAL PURPOSE

To review best practices related to the assessment of irritant contact dermatitis due to fecal, urinary, or dual incontinence (ICD-FIUIDI) among patients with darkly pigmented skin.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and registered nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Identify risk factors for the development of ICD-FIUIDI.2. Describe clinical features and manifestations of ICD-FIUIDI.3. Propose recommendations to improve care related to ICD-FIUIDI.

Effects of Nursing Program in Preventing Incontinence-Associated Dermatitis by Applying Zinc Oxide and Petroleum Jelly Skin Protection Products Among Older Patients in Semi-Intensive Medical Care Units: A Pilot Study

Aim

Incontinence-associated dermatitis is a common health problem among older clinical patients, causing related severe skin damage such as pressure ulcers, secondary infection, and long length of hospital stay. This pilot study aimed to develop and examine the effects of nursing programs in preventing incontinence-associated dermatitis (IAD) among older patients. Ten older patients at high risk of incontinence-associated dermatitis were included in this study: five patients received a nursing program combined with mixed products, and another five received a nursing program combined with separate use of products. The program was evaluated using a perianal assessment tool (PAT-T) for risk assessment, the incontinence-associated dermatitis invention tool (IADIT-T) for severity assessment, the skin surface pH, and skin surface moisture. The results revealed that the nursing program and skin products are usable and acceptable, provide step-by-step details, and are simple and easy to follow. The nursing program combined with using zinc oxide products followed by petroleum jelly can prevent and decrease the severity of incontinence-associated dermatitis in older patients. Moreover, it can also improve the skin surface pH to a mild acidity appropriate for the skin condition and increase the skin's moisture better the nursing program with mixed skin products. This pilot study confirmed that the developed program can be applied in practice. Moreover, the program could be used to decrease the incidence of IAD and skin surface pH but increase skin moisture. However, future study with a larger sample size and applying a more substantial research design for more accuracy and generalization is needed.

Clinical Trial Registration Number

OSF https://osf.io/8gj3d.

Eficacia y seguridad del ácido hipocloroso pH 5,5 en el manejo de heridas complejas en usuarios pediátricos

SINOPSIS

Serie de casos que sugieren los beneficios de la implementación de una solución limpiadora no citotóxica de pH ácido en el tratamiento de heridas complejas en usuarios pediátricos en dos centros de salud de Santiago, Chile. Se propone como tratamiento adicional al manejo etiológico el uso de una solución limpiadora compuesta de ácido hipocloroso (HOCl) en una concentración de 330 ppm y pH 5,5 (Vashe® Wound Solution, Urgo Medical, Texas, Estados Unidos) la cual ha demostrado ser segura y efectiva en el manejo de heridas en usuarios pediátricos. Se evidencian beneficios significativos en términos de cicatrización acelerada y reducción del dolor en los casos tratados. Aunque existen limitaciones en la evidencia actual, los resultados preliminares sugieren que el HOCl pH 5,5 puede ser una opción terapéutica efectiva en el manejo de heridas y alteraciones cutáneas en el usuario pediátrico.

Effectiveness of an External Urinary Device for Female Anatomy and Trends in Catheter-Associated Urinary Tract Infections

PURPOSE

The purpose of this study was to examine the effectiveness of an external female urinary management system (external urinary device for female anatomy [EUDFA]) in critically ill women unable to self-toilet and to identify rates of indwelling catheter use, catheter-associated urinary tract infections (CAUTIs), urinary incontinence (UI), and incontinence-associated dermatitis (IAD) before and after the introduction of the EUDFA.

DESIGN

Prospective, observational, and quasi-experimental design.

SUBJECTS AND SETTING

The sample comprised 50 adult female patients in 4 critical/progressive care units using an EUDFA at a large academic hospital in the Midwestern United States. All adult patients in these units were included in the aggregate data.

METHODS

Prospective data collected from the adult female patients over 7 days included urine diverted from the device to a canister and total leakage. Aggregate unit rates of indwelling catheter use, CAUTIs, UI, and IAD were retrospectively examined during 2016, 2018, and 2019. Means and percentages were compared using t tests or chi-square tests.

RESULTS

The EUDFA successfully diverted 85.5% of patients' urine. Indwelling urinary catheter use was significantly lower in 2018 (40.6%) and 2019 (36.6%) compared with 2016 (43.9%) (P < .01). The rate of CAUTIs was lower in 2019 than in 2016, but not significantly (1.34 per 1000 catheter-days vs 0.50, P = .08). The percentage of incontinent patients with IAD was 69.2% in 2016 and 39.5% in 2018-2019 (P = .06).

CONCLUSIONS

The EUDFA was effective in diverting urine from critically ill female incontinent patients and indwelling catheter utilization.

The effectiveness of a hydrocolloid crusting method versus standard care in the treatment of incontinence-associated dermatitis among adult patients in an acute care setting: A randomised controlled trial

INTRODUCTION

Incontinence-associated dermatitis (IAD) is a type of irritant contact dermatitis due to prolonged exposure of the skin to moisture induced by urine or/and faeces. The main principles when treating IAD involves protecting the skin from further exposure to irritants, establishing a healing environment, and eradicating skin infections. This study aimed to evaluate the effectiveness of the hydrocolloid crusting method (HCM) versus the standard care method (SCM) in treating IAD.

METHOD

A randomised controlled trial was conducted in an acute tertiary hospital in Singapore between August 2019 to September 2021. Using computer-generated numbers, patients were randomised into either HCM or SCM treatment groups. HCM treatment involved cleansing the affected area with a pH-neutral non-rinse moisturising cleanser, and the application of alternate layers of hydrocolloid powder, and non-sting film barrier spray (repeated three times during each use). Patients in the SCM treatment group received the same cleanser followed by a 30% zinc oxide barrier cream. IAD was assessed daily for up to seven days by the wound care nurses using the IAD severity tool. The primary outcome of the study was the mean difference in IAD score per day between both methods.

RESULTS

Forty-four patients were eligible and recruited (22 in HCM; 22 in SCM). Patients in both groups were comparable in age and gender. IAD Category 2 was more predominant in both methods. The most common location of IAD was at the perianal skin and diarrhea related to gastroenteritis was the most prevalent cause of IAD. More patients in the SCM group (n = 12; 54.5%) had their IAD healed within seven days compared to HCM, (n = 7; 31.8%) group. However, the average decrease in IAD scores per day for both methods were found to be similar.

CONCLUSION

HCM can be considered as a treatment of IAD along with the use of SCM. A skin care regimen should include effective cleansing, skin protection, and moisturization in IAD management.

[Justification of nurses' interventions for skin cleansing and skincare: Qualitative results of the SKINCARE-Pilot study]

Justification of nurses' interventions for skin cleansing and skincare: Qualitative results of the SKINCARE-Pilot study Abstract. Background: Skin care interventions are core tasks of nursing. Various factors influence the implementation of evidence-based care. Aims: To explore the perspectives of nursing staff on the relevance of skin care interventions in long-term care settings and the justification of clinical decisions about the application of such interventions. Methods: Qualitative part of a mixed methods study in three long-term-care facilities, consisting of short interviews with nursing staff members directly after nursing assistance with personal hygiene, focus group discussions with nursing staff members, and semi-structured interviews with nursing managers. The data were analyzed by means of content analysis. Results: The sample (N = 30) comprises 10 short interviews, 3 focus groups (n = 17), and 3 individual interviews. Nurses predominantly assigned a high relevance to nursing support in personal hygiene. As a basis for their decision-making, residents' needs and preferences, nurses' personal knowledge as well as own experiences and preferences were reported. Evidence-based sources of knowledge were hardly mentioned. The availability of skin cleansing and skin care products, staff and time resources, and nurse-physician cooperation were identified as influencing factors. Conclusions: Decisions about nursing support in personal hygiene seem poorly informed by evidence-based sources for clinical decision-making. Evidence-based decision support could facilitate the use of appropriate nursing interventions.

Quality and clinical applicability of recommendations for incontinence-associated dermatitis: A systematic review of guidelines and consensus statements

AIMS AND OBJECTIVES

The aim of this study was to assess methodological quality of all currently available guidelines and consensus statements for IAD using the Appraisal of Guidelines, Research and Evaluation (AGREE) II and the AGREE Recommendation Excellence (AGREE-REX) instruments.

BACKGROUND

Globally, incontinence-associated dermatitis (IAD) is a significant health challenge. IAD is a complex healthcare problem that reduces quality of life of patients, increases healthcare costs and prolongs hospital stays. Several guidelines and consensus statements are available for IAD. However, the quality of these guidelines and consensus statements remains unclear.

DESIGN

A systematic review of guidelines and consensus statements.

METHODS

Our study was undertaken using PRISMA guidelines. We searched seven electronic databases. Guidelines and consensus statements had to be published in English, Chinese or German languages. Five independent reviewers assessed the methodological quality of guidelines and consensus statements using the AGREE II and AGREE-REX instruments. Mean with standard deviation (SD) and median with interquartile range (IQR) were calculated for descriptive analyses. We generated bubble plots to describe the assessment results of each domain of each guideline and consensus statement.

RESULTS

We included ten guidelines and consensus statements. The NICE guidelines, obtained the highest scores, fulfilled 86.11%-98.61% of criteria in AGREE II and 76.67%-91.11% for AGREE-REX. In the domains 'Stakeholder Involvement' (4.39 ± 1.64), 'Rigor of Development' (3.38 ± 1.86), 'Applicability' (3.62 ± 1.64), 'Editorial Independence' (3.91 ± 2.56) and 'Values and Preferences' (2.98 ± 1.41), the remaining guidelines and consensus statements showed deficiencies.

CONCLUSIONS

Altogether, this study demonstrated that the currently available guidelines and consensus statements for IAD have room for methodological improvement. NICE guidelines on faecal incontinence and urinary incontinence have better quality. Remaining guidelines and consensus statements showed substantial methodological weaknesses, especially the domains of 'Stakeholder Involvement', 'Rigor of Development', 'Applicability', 'Editorial independence' and 'Values and Preferences'. This study was registered on INPLASY. (Registration number: INPLASY202190078).

RELEVANCE TO CLINICAL PRACTICE

The currently available guidelines and consensus statements on IAD have room for methodological improvement.

Moisture-Associated Skin Damage: Expanding and Updating Practice Based on the Newest ICD-10-CM Codes

Moisture-associated skin damage (MASD) occurs when skin is repeatedly exposed to various sources of bodily secretions or effluents, often leading to irritant contact dermatitis with inflammation, with or without denudation of affected skin. In 2020, the Wound, Ostomy and Continence Nurses Society took an initiative that led to the addition of multiple International Classification for Diseases codes for irritant contract dermatitis caused by various forms of MASD for use in the United States (ICD-10-CM). In the last issue of the Journal of Wound, Ostomy and Continence Nursing, a clinical practice alert identifying the various new codes was published that summarized each of the new codes and provided highlights of the descriptions of each of the these codes. This is the first in a series of 2 articles providing a more detailed description of the newest irritant contact dermatitis codes linked to MASD. Specifically, this article reviews the clinical manifestations and assessment, pathophysiology, epidemiology, prevention, and management of irritant contact dermatitis due to saliva, respiratory secretions, and fecal or urinary incontinence.

Development and Psychometric Testing of a Knowledge Instrument on Incontinence-Associated Dermatitis for Clinicians: The Know-IAD

PURPOSE

The purpose of this study was to describe the development and evaluation of the psychometric properties of an instrument used to assess clinician knowledge of Incontinence-associated dermatitis (IAD).

DESIGN

The instrument was developed in three phases: Phase 1 involved item development; Phase 2 evaluated content validity of the instrument by surveying clinicians and stakeholders within a single state of Australia and, Phase 3 used a pilot multisite cross-sectional survey design to determine composite reliability and evaluate scores of the knowledge tool.

SUBJECTS AND SETTINGS

In Phase 1, the instrument was developed by five persons with clinical and research subject expertise in the area of IAD. In Phase 2, content validity was evaluated by a group of 13 clinicians (nurses, physicians, occupational therapists, dietitians, and physiotherapists) working in acute care across one Australian state, New South Wales, along with two consumer representatives. In Phase 3, clinicians, working across six hospitals in New South Wales and on wards with patients diagnosed with incontinence-associated dermatitis, participated in pilot-testing the instrument.

METHODS

During Phase 1, a group of local and international experts developed items for a draft tool based on an international consensus document, our prior research evaluating incontinence-associated dermatitis knowledge, and agreement among an expert panel of clinicians and researchers. Phase 2 used a survey design to determine content validity of the knowledge tool. Specifically, we calculated item- and scale-level content validity ratios and content validity indices for all questions within the draft instrument. Phase 3 comprised pilot-testing of the knowledge tool using a cross-sectional survey. Analysis involved confirmatory factor analysis to confirm the hypothesized model structure of the knowledge tool, as measured by model goodness-of-fit. Composite reliability testing was undertaken to determine the extent of internal consistency between constituent items of each construct.

RESULTS

During Phase 1, a draft version of the Barakat-Johnson Incontinence-Associated Dermatitis Knowledge tool (Know-IAD), comprising 19 items and divided into three domains of IAD-related knowledge: 1) Etiology and Risk, 2) Classification and Diagnosis, and 3) Prevention and Management was developed. In Phase 2, 18 of the 19 items demonstrated high scale content validity ratios scores on relevance (0.75) and clarity (0.82); and high scale-content validity indices scores on relevance (0.87) and clarity (0.91). In Phase 3, the final 18-item Know-IAD tool demonstrated construct validity by a model goodness-of-fit. Construct validity was excellent for the Etiology and Risk domain (root mean squared error=0.02) and Prevention and Management domain (root mean squared error=0.02); it was good for the Classification and Diagnosis domain (root mean squared error=0.04). Composite reliability (CR) was good in the Etiology and Risk domain (CR=0.76), Prevention and Management domains (CR=0.75), and adequate in the Classification and Diagnosis domain (CR=0.64). Respondents had good understanding of etiology and risk (72.6% correct responses); fairly good understanding of prevention and management of IAD (64.0% correct responses) and moderate understanding of classification and diagnosis (40.2% correct responses).

CONCLUSIONS

The Know-IAD demonstrated good psychometric properties and provides preliminary evidence that it can be applied to evaluate clinician knowledge on IAD.

A Qualitative Study on the Experience and Training Needs of ICU Nurses for Incontinence-Associated Dermatitis

OBJECTIVE

To explore the experience of incontinence-associated dermatitis (IAD) as perceived by nurses, obstacles in the nursing process, and need for IAD training and management.

METHODS

This single-setting descriptive qualitative study was conducted from June 5, 2018, to June 22, 2018. Ten nurses working in the respiratory ICU of a local hospital participated in semistructured interviews. The content analysis method was used to analyze, summarize, and refine the interview data.

RESULTS

The experience of ICU nurses with IAD can be divided into four types: nursing based on experiential knowledge, seeking self-improvement, disunity of cleaning methods and wiping skills, and postponement of nursing care because of priority allocation. Obstacles in the nursing process include a lack of relevant nursing knowledge and awareness, as well as the medical supplies needed. The goals of training and management include establishing IAD preventive nursing procedures, providing IAD care products, enhancing the practicality of training content and diversifying training methods, and establishing an information system to assist nurses caring for patients with IAD.

CONCLUSIONS

The knowledge and behavior of ICU nurses regarding IAD need to be improved. Training and management are imperative. Facilities and nurse managers should actively seek solutions to stated obstacles, formulate training methods suitable for clinical needs, and promote the standardization of nursing for IAD.

Comparison of terminology mapping methods for nursing wound care knowledge representation

BACKGROUND

Standardized clinical terminologies are increasingly used to design and support advanced information systems. In order to examine the representativeness of these terminologies for different professional groups or clinical areas, researchers may perform different methods of terminology mapping.

OBJECTIVE

The purpose of this study was to evaluate the ability of four mapping methods to identify concepts related to wound care in SNOMED CT.

METHODS

A class diagram of 107 concepts was developed to represent the nursing context of wound assessment, wound diagnosis, and goal of care for wound management. All concepts were mapped to SNOMED CT and identified as a direct match, a one-to-many match, or no match using four mapping methods (manual, automated, comparison, and concordance). The manual, automated and comparison methods produced candidate lists of SNOMED CT concepts, which were then used by two nursing wound care experts. The experts completed concordance mapping, which produced the final list. The SNOMED CT concepts from the manual, automated and comparison mappings were compared to the concordance mapping to generate a proportion of representation by each mapping method.

RESULTS

The manual, automated and comparison mappings produced partial lists of unique candidate concept matches not found in the other mapping methods. The concordance mapping produced a final list which included: 43 terms (40%) that had direct matches, 2 terms (2%) that had one-to-many matches, and 62 terms (58%) that had no matches to SNOMED CT. All mapping methods were necessary to achieve the representativeness captured in the final list.

CONCLUSION

To increase the representativeness of candidate mapping lists, multiple mapping methods and considerations may be necessary.

Conceptual Framework for Incontinence-Associated Dermatitis Based on Scoping Review and Expert Consensus Process

Incontinence-associated dermatitis (IAD) has been studied over the last decades, but gaps in the knowledge related to its identification, etiological agents, and risk factors remain. We carried out a scoping review about IAD that included systematic reviews, experimental, and observational studies about IAD and its potential risk factors. We retrieved 24 articles that described 100 potential risk factors and which were synthesized by the authors and proposed to a panel of experts. Panelists used a structured process of consensus development to create a conceptual framework of factors associated with IAD. This framework proposes that liquid fecal material, when combined with exposure to urine and stool, and bacterial contaminated urine are etiological factors for development of IAD. The framework also proposes 2 pathophysiological mechanisms and 8 main risk factors for IAD development. The proposed model could improve the quality of care for patients with or at risk of IAD, assisting healthcare professionals to identify at-risk patients, diagnose the type of lesion, and establish adequate and effective prevention and treatment measures.

Implementing best available evidence into practice for incontinence-associated dermatitis in Australia: A multisite multimethod study protocol

AIMS

Incontinence-associated dermatitis (IAD) is an insidious and under-reported hospital-acquired complication which substantially impacts on patients' quality of life. A published international guideline and the Ghent Global IAD Categorisation Tool (GLOBIAD) outline the best available evidence for the optimal management of IAD. This study aims to implement theguideline and the GLOBIAD tool and evaluate the effect on IAD occurrences and sacral pressure injuries as well as patient, clinician and cost-effectiveness outcomes.

MATERIALS AND METHODS

The study will employ a multi-method design across six hospitals in five health districts in Australia, and will be conducted in three phases (pre-implementation, implementation and post-implementation) over 19 months. Data collection will involve IAD and pressure injury prevalence audits for patient hospital admissions, focus groups with, and surveys of, clinicians, patient interviews, and collection of the cost of IAD hospital care and patient-related outcomes including quality of life. Eligible participants will be hospitalised adults over 18 years of age experiencing incontinence, and clinicians working in the study wards will be invited to participate in focus groups and surveys.

CONCLUSION

The implementation of health district-wide evidence-based practices for IAD using a translational research approach that engages key stakeholders will allow the standardisation of IAD care that can potentially be applicable to a range of settings. Knowledge gained will inform future practice change in patient care and health service delivery and improve the quality of care for patients with IAD. Support at the hospital, state and national levels, coupled with a refined stakeholder-inclusive strategy, will enhance this project's success, sustainability and scalability beyond this existing project.

Which Characteristics of Fecal Incontinence Predispose Incontinence-Associated Dermatitis? A Classification and Regression Tree Analysis

OBJECTIVE

To investigate which characteristics of fecal incontinence (FI) are predictors for incontinence-associated dermatitis (IAD) using the Classification and Regression Tree method.

DESIGN AND SETTING

Data collected from 2014 to 2016 during the Austrian Nursing Quality Measurement 2.0, an annually conducted, cross-sectional, multicenter prevalence study, were merged and analyzed.

MAIN OUTCOME MEASURE

The duration, frequency, and amount of FI were used as predictors for IAD. Nurses were asked if the participants suffered from IAD based on their clinical judgment (yes/no).

MAIN RESULTS

In total, 1,513 participants with FI were included in this analysis. More than 75% of the participants with FI were to a great extent or completely care dependent. Of all FI participants, nearly 6% suffered from IAD, and more than 70% received special skin care for IAD prevention. Participants with FI had the highest risk of developing IAD if they experienced FI every day, had FI for less than 3 months, and had developed the FI in their current institution.

CONCLUSIONS

Nurses face many challenges while helping patients with FI maintain healthy skin. Knowledge of the results of this study and accumulated knowledge about the specific characteristics of FI that are associated with the development of IAD can help healthcare personnel prevent IAD. Based on these results, improving patient education for persons with newly diagnosed FI to prevent IAD is recommended. Research studies should use the definition of FI established by the International Continence Society.

Development and validation of the incontinence associated dermatitis knowledge, attitude and practice questionnaire

AIM

This study aimed to develop and test the validity and reliability of the Knowledge, Attitudes and Practices of Incontinence-associated Dermatitis Questionnaire (KAP-IAD-Q) for Nurses.

METHODS

A psychometric validation design was employed. Phase I of the study entailed the development of items through an extensive literature review and a double Delphi procedure with 11 experts specialised in wound, ostomy and continence to examine content validity of the KAP-IAD-Q. Phase II involved administering the KAP-IAD-Q to a convenience sample of 263 Registered Nurses from a public hospital in Singapore to evaluate its construct validity, internal consistency and test-retest reliability.

RESULTS

The instrument showed acceptable content validity (S-CVI = 0.85). Exploratory factor analysis showed all 22 items demonstrated strong factor loadings >0.4 and the four factors KAP-IAD-Q explained 58.1% of total variance. The four factors were☹1) knowledge om IAD aetiology and identification, (2) knowledge on IAD risk factors; (3) attitudes, and (4) practices. The overall internal consistency was excellent (Cronbach's α = 0.913). The KAP-IAD-Q showed good overall test-retest reliability as well (ICC = 0.89 (95% CI 0.69-0.96, p < 0.001).

CONCLUSION

The KAP-IAD-Q demonstrated good psychometric properties and is effective in measuring levels of IAD-related KAP among nurses. Further confirmation of the proposed factor structure is recommended. Future research should explore determinants of nurses' KAP and associations between IAD knowledge, attitudes and practices.

Management of incontinence-associated dermatitis patients using a skin protectant in acute care: a case series

Objective:

Incontinence-associated dermatitis (IAD) is a common type of irritant contact dermatitis. It is categorised by persistent erythema and can be associated with denudation and/or colonisation and infection. IAD is challenging to treat and affects 3.4–50% of patients. This case series evaluates a novel, elastomeric, advanced skin protectant (3M Cavilon Advanced Skin Protectant) in a UK acute health-care setting, for the management of IAD in patients suffering from moisture-associated skin damage (MASD) in the sacral/genital area.

Method:

The patient's skin was assessed by clinicians using the GLOBIAD classification tool at the point of recruitment and to monitor progress throughout the study period. The product was applied as a single layer in accordance with the instructions for use. Patients, when able, were asked to assess their own pain level using the Wong-Baker FACES pain scale. Photographs were taken as part of the ongoing assessment.

Results:

The skin protectant was used on average every 2.28 days. Of the 18 IAD patients recruited, 79% (n=11) were classified as IAD-free, based on the GLOBIAD categorisation tool, by the end of the evaluation period. Skin deterioration during the evaluation period was seen in one patient (6%), and of the patients able to complete pain assessments, 55% (n=6) reported a reduction in pain.

Conclusion:

These results suggest that the elastomeric skin protectant, applied every three days, plays a role in the improvement of IAD. The skin protectant adheres to wet and weeping partial-thickness wounds and may aid IAD management. Reducing application to every third day supports a change in practice which may offer benefits to patients and caregivers.

ELECtric Tibial nerve stimulation to Reduce Incontinence in Care homes: protocol for the ELECTRIC randomised trial

BACKGROUND

Urinary incontinence (UI) is highly prevalent in nursing and residential care homes (CHs) and profoundly impacts on residents' dignity and quality of life. CHs predominantly use absorbent pads to contain UI rather than actively treat the condition. Transcutaneous posterior tibial nerve stimulation (TPTNS) is a non-invasive, safe and low-cost intervention with demonstrated effectiveness for reducing UI in adults. However, the effectiveness of TPTNS to treat UI in older adults living in CHs is not known. The ELECTRIC trial aims to establish if a programme of TPTNS is a clinically effective treatment for UI in CH residents and investigate the associated costs and consequences.

METHODS

This is a pragmatic, multicentre, placebo-controlled, randomised parallel-group trial comparing the effectiveness of TPTNS (target n = 250) with sham stimulation (target n = 250) in reducing volume of UI in CH residents. CH residents (men and women) with self- or staff-reported UI of more than once per week are eligible to take part, including those with cognitive impairment. Outcomes will be measured at 6, 12 and 18 weeks post randomisation using the following measures: 24-h Pad Weight Tests, post void residual urine (bladder scans), Patient Perception of Bladder Condition, Minnesota Toileting Skills Questionnaire and Dementia Quality of Life. Economic evaluation based on a bespoke Resource Use Questionnaire will assess the costs of providing a programme of TPTNS. A concurrent process evaluation will investigate fidelity to the intervention and influencing factors, and qualitative interviews will explore the experiences of TPTNS from the perspective of CH residents, family members, CH staff and managers.

DISCUSSION

TPTNS is a non-invasive intervention that has demonstrated effectiveness in reducing UI in adults. The ELECTRIC trial will involve CH staff delivering TPTNS to residents and establish whether TPTNS is more effective than sham stimulation for reducing the volume of UI in CH residents. Should TPTNS be shown to be an effective and acceptable treatment for UI in older adults in CHs, it will provide a safe, low-cost and dignified alternative to the current standard approach of containment and medication.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03248362. Registered on 14 August 2017. ISRCTN, ISRCTN98415244. Registered on 25 April 2018. https://www.isrctn.com/.

Skin injury prevalence and incidence in China: a multicentre investigation

OBJECTIVE:

To quantify the prevalence and incidence of different skin injuries, pressure ulcers (PU), skin tears (ST) and incontinence-associated dermatitis (IAD) in China, and to identify their causes to aid prevention and control.

METHOD:

A cross-sectional observational study was conducted across nine tertiary hospitals. Registered nurses were trained on a standard approach to injury assessment and examination. The study was carried out at the same time on the same day across the participating centres. Participating patients were examined for PU, ST or IAD.

RESULTS:

A total of 13,176 inpatients were assessed and 233 PU were identified, of which 126 occurred in hospitals, 99 cases at home and eight cases within community hospitals. In addition, there were 141 skin tears and 97 IADs.

CONCLUSION:

This study involved the largest number of hospitals, to date (in China). Therefore, the prevalence and rate of incidence of skin injury obtained in this study may represent a regional baseline in China.

Differentiating Deep Tissue Pressure Injury (DTPI) From Other Causes of Purpura in the Sacrococcygeal Area: A Multiple Case Series

BACKGROUND

Recent revisions to the pressure injury staging system include guidance on differential diagnoses for deep tissue pressure injury (DTPI). Accurately identifying DTPI is critical; however, purpura in the setting of vascular disorders and systemic infectious processes can share similar features confounding diagnosis.

CASES

In this three-case series, we describe suspected DTPI with an uncharacteristic shape or occurring in the presence of additional lesions distributed outside of typical pressure areas prompted further evaluation.

CONCLUSIONS

The interdisciplinary approach we adapted was useful in determining the cause of purpura when the DTPI was ruled out by the certified wound care nurse.

Prevention and Management of Incontinence-Associated Dermatitis in the Pediatric Population: An Integrative Review

An integrative review was conducted to synthesize evidence on prevention and management of incontinence-associated dermatitis (IAD) in the pediatric population. A 5-step integrative process was used to guide the review. Articles published from January 2000 to April 6, 2017, were identified and retrieved from CINAHL, PubMed, ProQuest (MEDLINE), and Scopus; key terms were associated with IAD, pediatric, prevention, and management. Supplemental and manual searches were carried out to identify other relevant studies. The studies' findings were extracted and summarized in a table of evidence, with their quality evaluated using the Joanna Briggs Institute's Critical Appraisal Checklist. Sixteen articles were included in the review. Articles explored prevention and management strategies including skin cleansing technique, diaper selection, and the application of topical skin care products. Inconsistent and limited evidence was found regarding the benefits of using disposable wipes in preference to water-moistened washcloths in the cleansing process and on the use of superabsorbent polymer diapers with breathable outer lining in IAD prevention. Findings were inconclusive with regard to the best topical skin care product for IAD care. However, the application of skin protectants was encouraged by the authors, as well as promoted in various clinical guidelines. The development of a structured skin care regimen supplemented by a comprehensive patient education program was advised to enhance the prevention and management of IAD.

Independent risk factors for pressure ulcer development in a high-risk nursing home population receiving evidence-based pressure ulcer prevention: Results from a study in 26 nursing homes in Belgium

The aim of this study was to identify independent risk factors for pressure ulcer (PU) development in a high-risk nursing home population receiving evidence-based PU prevention. This study was part of a randomised controlled trial examining the (cost-)effectiveness of static air support surfaces compared with alternating pressure air mattresses. The sample consisted of 308 residents at a high risk of PU development (presence of non-blanchable erythema, Braden score ≤ 12 or Braden subscale "mobility" ≤ 2). PU incidence was monitored for 14 days. Demographic variables; functional, physical, and psychological characteristics; and data on skin assessment were collected. Independent risk factors were identified using multiple logistic regression analysis. The overall PU incidence (category II-IV) was 8.4% (n = 26), and 1.9% (n = 6) of the residents developed a deep PU (category III-IV). PUs (category II-IV) were significantly associated with non-blanchable erythema, a lower Braden score, and pressure area-related pain in high-risk residents even if preventive care was provided. These results highlight the need of a systematic risk assessment, including pain assessment and skin observations, in order to determine and tailor preventive care to the needs of high-risk individuals.

[Absorbent products for urinary incontinence management]

INTRODUCTION

Despite therapeutic strategies of female and male urinary incontinence (UI) are currently well defined, there is no precise indication of the real place or strategy use of absorbent products regardless of the etiology of the incontinence or the clinical context.

METHODS

We performed a research from the PubMed database using the following keywords: (urinary incontinence [MESH Terms]) AND absorbent pad [MeSH Terms]; allowing us to isolate 362 articles.

RESULTS

Many protections designs are available over-the-counter without prescription and without reimbursement in France. For "light UI", disposable insert pads are the design that seems to be the most suitable for women, compared to disposable menstrual pads, OR=0.27 [0.14, 0.52], washable pants with integral pad OR=0.12 [0.06, 0.26] or washable insert pads OR=0.05 [0.02, 0.26]. For moderate to severe UI, there is no "best universal product". There are differences between the gender and the use of a panel of protections seems the most appropriate. Both women and men prefer pull-ups to disposable insert pads, OR=0.41 [0.20, 0.87] and OR=0.39 [0.22, 0.68] respectively. In men, a preference in 70 % of subjects for urisheats is observed compared to the protections they usually use (P=0.02). The use of protections improves independence in daily OR activities=0.102 [0.046, 0.158] and quality of life related to UI OR=4.40 [1.74, 7.07] compared to patients not using protections. Despite this, their use must remain cautious because of the potential infectious urinary complications, more frequent in particular in institutional people, with 41 % of users developing at least one urinary infection over an evaluation period of 12 months vs. 11 % of non-users (P=0.001), or immuno-allergic with the "dermatitis associated incontinence" whose prevalence can reach a rate of 50 %.

CONCLUSION

Comparative analyzes of risk-benefit, economic costs, patient satisfaction, protections vs. other measures are lacking. It is necessary to continue the development of these products and to compare more precisely their intrinsic characteristics, to best support patients choices.

User perspectives, preferences and priorities relating to products for managing bladder and bowel dysfunctions

A great many people of all ages around the world cannot fully control their bladder or bowel, or both. Either in the short or long term, they rely upon products and devices to manage the emptying of their bladders and bowels and to collect, absorb and contain leaked urine or faeces. The incontinence product market is large and growing, and ongoing developments in materials and technologies should lead to improvements in these products and devices. Engineers and designers who work in this field - or who plan to do so - need to recognise the breadth of factors that affect the effectiveness and acceptability of products. The primary functions of products for managing bladder and bowel dysfunctions are the collection and containment of urine or faeces - and the associated engineering and design challenges may be considered in terms of flow rates and volumes and methods of acquisition and containment. But products will fail if they do not take into account other factors, some of which relate less directly to these primary functions and some not at all. This article aims to highlight the product characteristics that are most important to the people who use them, and areas where user-centred innovation and development may lead to improvements.

Specific dermatological benefits associated with quantities of lotion transferred to the skin

BACKGROUND

A growing number of manufacturers are taking advantage of the ability of absorbent consumer products to deliver lotion to the skin. The lotion is included on these products to help protect the skin from adverse skin effects that can occur, including: (1) irritation, (2) over hydration of the stratum corneum, (3) dryness that can occur from extended exposure to highly absorbent consumer products, and (4) changes in pH.

OBJECTIVE

This manuscript presents results of a quantitative lotion transfer study of adult incontinence products. Resulting lotion transfer is compared to the results of several separate experiments in which specific skin benefits have been correlated to lotion concentrations.

METHODS

The behind-the-knee (BTK) lotion transfer protocol was used to quantitate lotion transfer from adult incontinence (AI) test products constructed using 2 lotion formulations and 2 configurations of lotion application. A modified arm patch protocol, in which skin sites of a measured dimension were pre-treated with specific volumes of lotion, was used to evaluate protective effects of lotion against exposure to irritants, and over hydration from wetted absorbent products.

RESULTS

After a 6-hours continuous exposure in the BTK the 5-stripe lotion configuration products transferred (adjusted mean ± SE) 94 ± 11-104 ± 11 μg/cm² lotion. After 24 hours of wear, transfer had increased to 127 ± 22 and 149 ± 24 μg/cm² , respectively. The single-block configuration products transferred 289 ± 10-316 ± 10 μg/cm² (P = .04). Transfer after 24 hours of wear was 328 ± 23 and 472 ± 21 μg/cm² , respectively (P < .0001). Several protocols were used to evaluate the concentration of lotion required to provide four specific skin benefits. In studies evaluating protection against irritants, skin site pre-treated with lotion were patched with 0.5% sodium lauryl sulfate (SLS). Protective effects were assessed by visual assessment of erythema and trans-epidermal water loss (TEWL). In the first experiment, lotion pre-treatment concentrations as low as 165 μg/cm² exhibited significantly (P < .05) lower erythema and TEWL compared to the positive irritant control (ie, no lotion pre-treatment and SLS only). In the second experiment, lotion pre-treatment concentrations of 80 μg/cm² (P = .018) exhibited significantly (P = .018) lower TEWL. In two studies on protection from over hydration, lotion pre-treatment sites were subsequently patched with wetted absorbent consumer products. The change in TEWL was used as a measure of over hydration. Lotion concentrations significantly reduced the increase in TEWL at 80 μg/cm² (P = .007) and 70 μg/cm² (P ≤ .05). A BTK study was used to evaluate the ability of lotion to prevent dryness. After 6 hours of wear, test products transferring lotion concentrations of 110 or 133 μg/cm² produced significantly lower scores for dryness compared to products transferring 48 or 69 μg/cm² . Using collagen sheets to mimic the stratum corneum, an in vitro study was conducted to measure the ability of lotion to prevent passage of high pH buffer solution. Results demonstrated that the lowest concentration of lotion that was tested (110 μg/cm² ) interfered with passage of the high pH buffer through the collagen sheet, delaying the rise in pH.

CONCLUSIONS

We can conclude that pretreatment with 110 μg/cm² lotion acts as a barrier to high pH fluids such as urine. Using the measurement of lotion transfer from the AI products, together with the results of studies conducted to determine the concentration of lotion required to provide specific skin benefits, we conclude that the five-stripe lotion configuration AI test products transferred enough lotion (ie, ≥80 μg/cm² ) to provide skin protection with regard to: (1) irritant effects and (2) excess moisture. The single-block AI test products also transferred enough lotion to provide these skin benefits (ie, ≥165 μg/cm² ), and the additional benefits of skin protection against: (3) dryness, and (4) changes in pH.

Clinical Evaluation of a Skin Protectant for the Management of Incontinence-Associated Dermatitis: An Open-Label, Nonrandomized, Prospective Study

PURPOSE:

The purpose of this study was to evaluate the efficacy of an investigational skin protectant product at managing severe skin breakdown associated with incontinence.

DESIGN:

Open-label, nonrandomized, prospective study.

SUBJECTS AND SETTING:

The sample comprised 16 patients; inclusion criteria were: patients older than 18 years, cared for in the intensive care unit of a level I trauma center hospital or in long-term care facilities in the northeast region of the United States, and had incontinence-associated dermatitis (IAD). Twelve of the patients had epidermal skin loss and 4 had severe redness.

METHODS:

The investigational product is a formulation based on acrylate chemistry. The skin protectant application schedule was twice weekly for up to 3 weeks for a maximum of 6 applications during the study period. The skin was evaluated via a skin assessment instrument specifically designed for use in this study; this instrument has not undergone validation studies. The main outcome measure was changes in the instrument score over time. In addition, complete reepithelialization was recorded when observed, and pain scores (associated with IAD) were noted in participants who were able to report pain.

RESULTS:

The IAD score improved in 13 of 16 patients, remained unchanged in 1 patient, and deteriorated in 2 patients. The median percent improvement in the skin assessment instrument was 96% (P = .013). Four of the patients with epidermal skin loss had complete reepithelialization of the skin surface with 4 to 6 applications of the skin protectant, and 5 had substantial improvement. The 4 patients with severe red skin returned to healthy normal skin with 2 to 4 skin protectant applications. Substantial pain reduction was reported by all 9 patients who reported pain at enrollment. No adverse events associated with the skin protectant application were reported during data collection.

CONCLUSION:

Results of this study suggest that an acrylate-based product, evaluated here for the first time in patients, may be effective as a protective barrier in the presence of continued incontinence. Additional research is needed to confirm these findings.

Incontinence Briefs Containing Spiral-Shaped Fiber Acidify Skin pH of Older Nursing Home Residents at Risk for Incontinence-Associated Dermatitis

PURPOSE

The study's purpose was to assess the pH of the skin of older (aged ≥75 years) incontinent nursing home residents after exposure to an incontinence brief containing spiral-shaped fiber wet with an alkaline solution mimicking urine or fecal pH and compared to skin pH after exposure to an industry standard brief wet with the same solution and various controls.

DESIGN

The design was experimental, as conditions were applied to skin and skin pH was measured in random order, and subjects served as their own controls.

SETTING AND SUBJECTS

The setting was a Midwestern nonprofit nursing home. The sample was 26 nursing home residents; their mean age was 87 years (SD = 6 years); 77% were female. Most (69%) had urinary incontinence alone, and 31% had dual urinary and fecal incontinence.

METHODS

Skin pH was measured in duplicate on 6 areas of the inner thighs and 6 areas of the volar surface of the forearms. Each area was exposed to 1 of 6 conditions applied in random order: an incontinence brief containing spiral-shaped fiber wet with an alkaline solution and one that was dry; a standard incontinence brief (without spiral-shaped fiber) wet with the same alkaline solution and one that was dry; the alkaline solution alone; and normal skin.

RESULTS

On both the thighs and the forearms, skin pH was significantly lower (more acidic) after exposure to the incontinence brief containing spiral-shaped fiber wet with an alkaline solution compared to the wet standard brief and all other control conditions (P < .001). On thighs, the mean skin pH was 5.7 (SD = 0.5) after exposure to the wet brief with spiral-shaped fiber versus 6.4 (SD = 0.5) after exposure to the wet standard brief. On forearms, the mean skin pH was 5.3 (SD = 0.4) after exposure to the wet brief with spiral-shaped fiber versus 6.0 (SD = 0.4) after exposure to the wet standard brief.

CONCLUSIONS

Incontinence briefs containing a spiral-shaped fiber significantly acidify the pH of the skin exposed to an alkaline solution, while industry standard briefs do not. Since alkaline skin pH is a risk factor for incontinence-associated dermatitis (IAD), results suggest that briefs with spiral-shaped fiber may help prevent IAD. Findings encourage further research.

Skin Health Connected to the Use of Absorbent Hygiene Products: A Review

Over the past 50 years, absorbent hygiene products such as baby diapers and incontinence products have become essential features of modern day life. Through innovation and enhanced technology, their design, composition and performance have been dramatically upgraded from their early forms, and they have transformed the lives of millions of people, improving their quality of life. Skin health related to the use of absorbent hygiene products has accordingly also greatly improved. Still, the wearing of absorbent hygiene products will affect the skin, and for some users the changes in microclimate, mechanical interactions and the exposure to urine and faeces may result in irritant contact dermatitis, i.e. diaper dermatitis (DD) or incontinence-associated dermatitis (IAD). Babies with developing skin and the elderly with deteriorating skin functions who are the most frequent users of absorbent hygiene products are more vulnerable to the causal factors. Although irritant reactions are the most common, allergic contact dermatitis should be considered if a DD/IAD fails to improve by recommended actions. There is also a connection between IAD and pressure ulcer development of which it is important to be aware. A holistic approach of using high-quality absorbent hygiene products in combination with appropriate skin care will help maintaining good skin health.

Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System

Our understanding of pressure injury etiology and development has grown in recent years through research, clinical expertise, and global interdisciplinary expert collaboration. Therefore, the National Pressure Ulcer Advisory Panel (NPUAP) has revised the definition and stages of pressure injury. The revision was undertaken to incorporate the current understanding of the etiology of pressure injuries, as well as to clarify the anatomical features present or absent in each stage of injury. An NPUAP-appointed Task Force reviewed the literature and created drafts of definitions, which were then reviewed by stakeholders and the public, including clinicians, educators, and researchers around the world. Using a consensus-building methodology, these revised definitions were the focus of a multidisciplinary consensus conference held in April 2016. As a result of stakeholder and public input, along with the consensus conference, important changes were made and incorporated into the new staging definitions. The revised staging system uses the term injury instead of ulcer and denotes stages using Arabic numerals rather than Roman numerals. The revised definition of a pressure injury now describes the injuries as usually occurring over a bony prominence or under a medical or other device. The revised definition of a Stage 2 pressure injury seeks to clarify the difference between moisture-associated skin damage and injury caused by pressure and/or shear. The term suspected has been removed from the Deep Tissue Pressure Injury diagnostic label. Each definition now describes the extent of tissue loss present and the anatomical features that may or may not be present in the stage of injury. These important revisions reflect the methodical and collaborative approach used to examine the available evidence and incorporate current interdisciplinary clinical expertise into better defining the important phenomenon of pressure injury etiology and development.

Effectiveness of topical skin products in the treatment and prevention of incontinence-associated dermatitis: a systematic review

BACKGROUND

Incontinence-associated dermatitis (IAD) is inflammation of the skin resulting from repeated contact with urine and/or feces. It causes pain, redness, swelling and excoriation, and may lead to complications such as fungal skin infections and pressure injuries. It is important to prevent and treat IAD to avoid complications and improve patient outcomes. A number of products are available for protecting skin, but evidence on their effectiveness is limited.

OBJECTIVES

The current review aimed to establish the effectiveness of topical skin products in reducing the occurrence and/or severity of IAD.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Adult patients over the age of 18 years with incontinence and/or diarrhea.

TYPES OF INTERVENTION

Topical skin products as individual interventions or part of a skin care regimen.

TYPES OF STUDIES

Both published and unpublished study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after, prospective and retrospective cohort, case-control, analytical cross-sectional, descriptive study designs including case series, individual case reports and descriptive cross-sectional studies across all care settings for inclusion.

OUTCOMES

The primary outcome of interest was the absence or non-development, reduction or resolution, new development or increase in the occurrence of IAD or the increase in severity of IAD. The secondary outcome was any adverse effect caused by the skin care products used.

SEARCH STRATEGY

A three-step search strategy to find both published and unpublished papers was utilized in this review. Studies were limited to those published in English from 1980 to 2016.

METHODOLOGICAL QUALITY

Papers selected were assessed by two independent reviewers using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).

DATA EXTRACTION

Data were extracted using the standardized data extraction tool in JBI-MAStARI. The data extracted included specific details about the interventions, populations, study methods and outcomes.

DATA SYNTHESIS

Studies were assessed for methodological quality and statistical significance to determine validity and generalizability of study results. It was not possible to pool studies to conduct meta-analysis or test for heterogeneity.

RESULTS

There were a limited number of clinical trials that compared products for efficacy in preventing and treating IAD. Assessment tools and severity scores used to measure skin damage outcomes were dissimilar and prone to subjectivity. It was difficult to ascertain superiority of any individual product.

CONCLUSION

Information on barrier protective efficacy, side effects and cost can be valuable to both clinicians and care providers. More randomized controlled trials on product effectiveness for prevention and treatment of IAD are highly recommended.

Evaluation of a new topical skin protectant (RD1433) for the prevention and treatment of incontinence-associated dermatitis

Context Incontinence-associated dermatitis (IAD) is a type of moisture-associated dermatitis caused by repeated skin exposure to urine or stool. A product that could mitigate such symptoms would have a significant impact on cost of care and patients' quality of life. Objective This study compared the clinical efficacy of RD1433 and a comparator product (Vaseline®) in preventing and treating experimental IAD skin lesions. Materials and methods For the "prevention" part of the study, skin sites in eight human volunteers were treated daily for 5 d with either RD1433 or Vaseline® immediately prior to synthetic urine exposure. In the "treatment" part, exposure to synthetic urine was substituted for Vaseline® or RD1433 application on the first 2 d to promote the development of skin lesions prior to the application of the products from day three. Product efficacy was quantified by visual scoring and an array of biophysical instruments. Results Both RD1433 and Vaseline® significantly reduced lesion progression when applied as a prophylactic. When applied as a treatment (following establishment of skin lesions), RD1433 demonstrated a statistically significant improvement in several measures of skin function whereas there was no statistically significant improvement following treatment with Vaseline®. Conclusions The findings of this study suggest that RD1433 may be superior to Vaseline® in the prevention and treatment of experimental IAD lesions. Clearly, further work is required to establish the efficacy of RD1433 with patients in a clinical environment.