Prevention and Treatment of Perineal Skin Breakdown Due to Incontinence

Denise Nix, RN, MS, CWOCN

Pathology and Risk Factors of Perineal Skin Breakdown

Perineal skin breakdown secondary to incontinence can range in severity and may present as one or all of the following symptoms: erythema, swelling, oozing, vesiculation, crusting, and scaling in the groin, perineum, and buttocks region.1
Multiple potentially harmful variables work together to cause perineal skin breakdown. Moisture from incontinence alters the skin’s protective pH and increases the permeability of the stratum corneum. An intense irritant such as feces contains bacteria that can permeate the stratum corneum, allowing for secondary infections. The need for frequent cleansing can lead to further pH changes and damage from friction.1,2 In addition to exposure to urine and feces, intensity of irritant, duration of exposure, and factors that cause diarrhea are potential threats to perineal skin integrity.3

Significance

In long-term care, the prevalence of incontinence has been reported to be as high as 46.4% for urinary incontinence, 29.5% fecal incontinence, and 25.6% for combination urinary and fecal incontinence.4 In hospitalized elderly, fecal incontinence is estimated to affect 16% to 66%.1 Even though painful and preventable, perineal skin damage occurs in as many as 33% of hospitalized adults and 41% of adults in long-term care.5,6
Perineal skin damage may progress rapidly to ulceration and secondary infection, including bacterial (staphylococcus) and yeast (Candida albicans) infections that increase discomfort and treatment costs.7 Additional significant problems associated with perineal skin damage include pressure ulcer development, pain, and compromised quality of life (QOL).8
Incontinence, perineal skin breakdown, and pressure ulcer development are linked.5,9–11 Maklebust and Magnan9 reported that 56.7% of patients with pressure ulcers had fecal incontinence and were 22 times more likely to have pressure ulcers than patients without fecal incontinence. Studies have shown that when a comprehensive preventive skin care program includes appropriate perineal skin care, incidence of sacral/buttock pressure ulcers is significantly reduced.5,10,12
Regulatory entities such as the Joint Commission for Accreditation of Health Care Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (CMS) recognize skin breakdown as a key indicator for quality care.13–15 Federal and state survey agencies use “tags” F-314 and F-315 of the CMS Guidance to Surveyors for Long-Term Care Facilities to assess the quality of pressure ulcer and incontinence care provided to residents in long-term care facilities. Inherent to these documents is the expectation that appropriate interventions will be implemented for patients with incontinence. For example, F-314 identifies moisture from incontinence as one of the risk factors that must be minimized to prevent pressure ulcers.14 F-315 guides surveyor evaluation of efforts regarding appropriate cleansing, rinsing, drying, and protective moisture barrier application to prevent skin breakdown from incontinence.15

Plan of Care

The plan of care must be individualized for the patient with incontinence and should include the following components:
  • assessment and management of incontinence etiology
  • perineal skin and risk assessment
  • gentle cleansing and moisturization
  • application of skin barriers
  • use of containment devices if indicated.
Assessment and management of incontinence etiology. Although perineal skin care will minimize potential damage from exposure to urine or stool, the ultimate goal of perineal skin care is the management of the underlying incontinence. Each patient who is incontinent should be assessed and provided appropriate treatment and services to achieve or maintain as much normal function as possible. Interventions may be behavioral, pharmacologic, and surgical.16
Perineal skin and risk assessment. Perineal skin should be assessed on admission and periodically. Initially, perineal skin assessment will help drive prevention and treatment choices; ongoing skin assessments will help determine if the interventions are effective. The skin assessment must include identification of secondary infection (eg, staphylococcus or Candida albicans) that will require antifungal or antibiotic agents.8,17
Identifying risk factors that can contribute to perineal skin breakdown such as loose stools and frequent incontinent episodes can assist with intervention and product selection. For example, the patient with incontinence and diarrhea may require a more durable skin barrier (eg, containment device or barrier paste); the patient with incontinence and formed stools may use a barrier lotion to prevent perineal skin breakdown.3,18 Assessments must be documented. Documentation tools with specific cues for documentation perimeters will promote standardized and accurate documentation. Decision-making tools that match assessment findings with treatment options have been useful in clinical practice.19
Gentle cleansing and moisturization. Perineal skin cleansing should be performed promptly after each incontinent episode. The cleanser selected should be indicated for perineal skin cleansing. Perineal cleansers may be packaged as a liquid, emulsion, foam, or towelette. Bar soap and products intended for routine skin cleansing or antibacterial handwashing should not be used because they can dry the skin, raise its pH, and contribute to the erosion of the epidermis.2,17
The perineal skin of a patient with incontinence requires moisturization to replace the natural moisturization factors that have been removed due to urine, feces, and frequent cleansing. Humectants such as glycerin, methyl glucose esters, lanolin, or mineral oil replace the oils in the skin and can be found in many perineal skin care products. In proper concentrations, cetyl or stearyl alcohol also may be incorporated in skin care products as emollients. No-rinse perineal cleansers minimize drying if they contain humectants because they are left on the skin rather than rinsed away.2
Application of skin barriers. Moisture barriers, sometimes called skin barriers or skin protectants, shield the skin from exposure to irritants or moisture. Active ingredients in moisture barriers include petrolatum, dimethicone, lanolin, or zinc oxide. A moisture barrier may be incorporated into skin cleansers or applied separately as a cream, ointment, or paste. Creams are water-based preparations; ointments are oil-based preparations and have a longer-lasting effect than creams because they are more occlusive. A paste is an ointment with powder added for durability and absorption.7,17 Some of the newer products on the market have the properties of a paste and are formulated to be clear or transparent for skin inspection.
Liquid-barrier films or skin sealants consist of a polymer combined with a solvent. When applied to the skin, the solvent evaporates and the polymer dries to form a barrier. A liquid film barrier should not be combined with a barrier cream or paste because these products are often incompatible. Some solvents may irritate compromised perineal skin; therefore, liquid-barrier films for perineal skin care should be limited to products that do not sting.17
Use of containment devices. Underpads or absorbent briefs can be used as long as they wick moisture away from rather than trap the moisture against the skin. External urinary catheters and fecal incontinent collectors (external pouches) can be utilized to contain urine and feces.11,18 If products are used properly, they can prevent and treat perineal skin breakdown. Rectal tubes should not be used to contain fecal incontinence because they can perforate the bowel and damage the anal sphincter. FDA-approved indwelling fecal containment devices on the market can be used safely.20 Due to the incidence of urinary tract infections, indwelling (ie, Foley) catheters should not be routinely used for skin protection and should be discontinued if they are not medically necessary.15,21

Conclusion

Incontinence care should be coordinated with treatment of the causative condition. Perineal skin problems can be prevented and perineal skin breakdown reversed with appropriate perineal skin care. Caring for perineal skin begins with a thorough assessment that identifies potential for or actual skin injury as well as factors that may exacerbate perineal skin injury. Perineal skin care requires timely and appropriate cleansing and protection that minimizes or prevents exposure of the perineal skin to urinary or fecal incontinence. An appropriate product formulary specific to the patient population it serves is key to any successful skin health program. Professional and patient education is essential for knowledgeable approaches to incontinence and subsequent perineal skincare.
The Skin Matters series is made possible through the support of the Skin Health Division of Coloplast Corp., Marietta, Ga.

References: 

1. Brown DS, Sears M. Perineal dermatitis: a conceptual framework. Ostomy Wound Manage. 1993;39:2–26.
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3. Nix DH. Validity and reliability of the Perineal Assessment Tool. Ostomy Wound Manage. 2002;48(2):43–46,48–49.
4. Sgadari A,Topinkova E, Bjornson J, Bernabei R. Urinary incontinence in nursing home residents: a cross-national comparison. Age Ageing. 1997;26(suppl 2):49–54.
5. Lyder C, Clemes-Lowrance C, Davis A, Sullivan L, Zucker A. A structured skin care regimen to prevent perineal dermatitis in the elderly. J ET Nurs. 1992;12:12–16.
6. Lyder CH. Perineal dermatitis in the elderly. A critical review of the literature. J Gerontol Nurs. 1997:23(12):5–10.
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8. Nix D, Ermer-Seltun J. A review of perineal skin care protocols and skin barrier product use. Ostomy Wound Manage. 2004;50(12):59–67.
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11. Wound, Ostomy and Continence Nurses Society. Guideline for Management of Pressure Ulcers. WOCN Clinical Practice Guideline Series #2. Glenview Ill: WOCN Society;2003.
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13. Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals: The Official Handbook (CAMH). JCAHO 1999. Available at: www.jcaho.org/standard/pm_mpfrm.html and www.jcaho.org. Accessed February 21, 2006.
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16. Ermer-Seltun J. Assessment and management of acute or transient urinary incontinence. In: Doughty D (ed). Urinary and Fecal Incontinence, Current Management Concepts, 3rd ed. St. Louis, Mo: Mosby Elsevier Inc.;2006:72–73.
17. Donovan A, Ratliff C, Gray M. Perineal skin care for the incontinent patient. Adv Skin Wound Care. 2002;15(4):170–175.
18. Nix D. Prevention and treatment of perineal skin breakdown. In: Milne C, Corbett L, Dubuc D, eds. Wound, Ostomy, and Continence Nursing Secrets. Philadelphia, Pa: Hanley & Belfus, Inc.:2002:373–377.
19. Letourneau S, Jensen L. Decision making tools — impact of a decision tree on chronic wound care. J WOCN. 1998;25(5):240–247.
20. Kim J, Shim M, Choi B, et al. Clinical application of continent anal plug in bedridden patients with intractable diarrhea. Dis Colon Rectum. 2001;44:1162–1167.
21. Newman DK, Fader M, Bliss DZ. Managing incontinence using technology, devices and products. Nurs Res. 2004;53(6 suppl):42–48.

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