By Debra Thayer, MS, RN, CWOCN
Incontinence can be a frustrating and worrisome condition to live with on a day-to-day basis. Fortunately, skin irritation and odor are not inevitable and you can prevent these unwanted problems.
Health care professionals have identified many factors that contribute to the skin irritation and soreness that can result from incontinence. They use the term “Incontinence-associated Dermatitis” (IAD) to describe this specific type of skin damage.
Skin can also become inflamed. In people with light-toned skin, the first sign of IAD is redness. If left unprotected, this can progress to a rash with small bumps or even tiny blisters. While skin exposed to urine can become irritated, stool has a greater potential to cause skin injury and individuals that suffer from fecal incontinence and especially diarrhea are at greater risk. This is because liquid stool contains large amounts of enzymes-these substances can quickly cause severe and painful skin damage because they trigger specific chemical reactions in the skin that cause breakdown. In addition to redness and rash, painful shallow open areas can develop if skin is not adequately protected. These are referred to as “erosions” and look like the moist, weepy painful skin found under a blister.
For those incontinent only of urine, the genital area, groin folds and inner thighs are primarily affected. With fecal incontinence, the skin around the anal opening, the buttocks and the backs and inner portions of the thighs are more at risk. For convenience, health care providers often collectively refer to these locations as the perineal area. Specifically, the perineal area is between the vulva and the anus in a woman and between the scrotum and the anus in a man.
Chronic wetness, fecal incontinence and IAD also make the skin more susceptible to infection. Skin care experts commonly call this a yeast infection or may refer to it as Candidiasis (Can-di-di-a-sis). It appears as a bright red rash that often has tiny pinpoint pimple-like bumps or spots around the edge. It can also look scaly and is typically itchy. People with certain conditions such as diabetes, cancer and other immune system disorders, or those that take immune-suppressive medications are at higher risk for developing this type of infection.
Fortunately, there are simple self-care activities that will help prevent skin damage. First, it’s important to gently wash your perineal area at least once per day and then promptly after an incontinent episode. Use of “no-rinse” liquid skin cleansers is preferred to regular bar soap. Soap can be drying and leave an irritating residue behind on the skin. In contrast, liquid cleansers are designed to gently loosen soil from the skin with a minimum of friction. Selecting a cleanser that is pH balanced will help to make sure it is compatible with the normal chemistry of the skin. It is ideal if the products are dye-free and fragrance-free as these components can be irritants for some individuals. Apply the cleanser to a soft cloth and gently wipe your skin to remove soil. After cleansing, skin should be patted dry. Never rub the skin vigorously. If a liquid cleanser is not an available choice, ask your Pharmacist to recommend a gentle Dermatology-quality soap.
Pre-moistened wipes (where a cleanser is saturated into a disposable soft cloth) can offer a convenient way to stay clean and fresh while away from home. Be sure to check the instructions though-many wipes are not flushable!
Next, it is important to protect the skin. To do this, you need to apply a “moisture barrier” product. These products are formulated with ingredients (e.g. Dimethicone) that are capable of repelling moisture and irritants from the skin. Look for a product that is labeled as a “moisture barrier” or “skin protectant”.
Many moisture barrier creams provide protection, but sit on the skin in a thick, sticky or greasy coating and can be uncomfortable to wear. Look for a moisture barrier that applies easily and vanishes into the skin. Because typical ointments are greasy, they generally are not well suited for incontinence skin protection in active people. Products labeled as a “moisturizer” or “emollient” can help with dry skin but do not contain the ingredients needed for skin protection.
While creams and ointments have a relatively long history of use in preventing and treating IAD, barrier films are a more recent option for skin protection. Barrier films are liquids that are painted or sprayed onto the skin to form a transparent, protective coating. They are durable, that is to say they will persist on the skin and are not washed off. Some of these products also help to minimize chafing. For incontinence care, it is important to select a barrier film that is alcohol-free.
Talcs and powders may help with chafing but will not provide skin protection. Follow manufacturer’s instructions and use sparingly within skin folds to prevent clumping. Most experts do not recommend use of cornstarch. Although inexpensive, it has been associated with skin infection and allergy.
When incontinence cannot be corrected, products that contain or divert urine or stool away from the skin should be considered. High quality products that feature modern absorption technology to wick and trap moisture away from skin are preferred. Products should fit well to avoid chafing in skin folds. Avoid use of products that are not intended to absorb urine such as paper towels or napkins.
It is important to inspect your skin frequently. Make sure to consult your physician for redness or irritation that does not resolve, or if you note a persistent rash or ulceration in the perineal area. A yeast infection will require treatment with an antifungal medication.
For individuals that are incontinent of urine a three-pronged approach will help prevent embarrassing odor. 1) Drink plenty of fluids* and especially water. This will keep your urine dilute and odor free. 2) Keep your perineal area clean and dry as described above and 3) Change your absorbent pad or garment regularly and before it is saturated. Disposable absorbent products should be promptly disposed of in the outside household garbage. If you are using reusable absorbent products, store the soiled item in a covered, odor proof plastic storage container in between washings.
Talk to your doctor if you notice persistent odor in your urine that does not respond to any of the measures above, as this can be a symptom of a urinary tract infection.
Fecal incontinence requires special strategies for odor control. Again, attention to good personal hygiene and proper disposal of absorbent products is essential. Most over the counter products merely mask odor with another scent. A product that is capable of neutralizing odor is a better solution. A medical supply store may be able to advise you on the best option for your situation. Some products are intended for room deodorization, others can be sprinkled on an incontinence garment. Again, it’s important to always understand the intended use of the product and read the manufacturer’s instructions carefully. Deodorant tablets that can be taken by mouth may be another alternative-be sure to talk to your physician before you take these to make sure they are appropriate for your medical situation.
Skin irritation and embarrassing odor do not have to go hand in hand with incontinence. Paying attention to the simple strategies described above can help avoid these troublesome problems. Of course, the best way to protect skin from IAD is to avoid exposure to urine and stool in the first place. Remember that many causes of incontinence are reversible or treatable, so it is very important to see a health care provider that specializes in incontinence for a thorough evaluation and exploration of treatment options.
* If you have been advised to restrict the amount of fluids you drink, do not increase this amount without talking with your physician
About The Author
Debra Thayer is a board certified Wound Ostomy and Continence (WOC) Nurse with over 20 years experience in the specialty. She currently works at 3M as a Senior Technical Service Specialist in their HealthCare-Skin and Wound Care Division.
She holds a Baccalaureate degree in Nursing from the University of Wisconsin, and a Master’s Degree in Nursing from the University of Minnesota. She has provided wound, ostomy and continence care as a clinical specialist in hospitals, nursing homes and home health care. She was a faculty member of the Abbott Northwestern Hospital WOC Nursing Education program for 9 years and served as clinical faculty at the University of Minnesota. Prior to joining 3M as a Skin and Wound Care Specialist, she had a private nursing practice that included patient care and industry consultation. Debra has participated in research and has published. Skin care, incontinence and wound infection are areas of special interest. Debra is a member of the Wound, Ostomy and Continence Nursing Society.
In her current role she has lectured on skin and wound related topics across the US, Asia/Pacific, Latin America and Europe.