What You Need To Know About Moisture-Associated Skin Damage

Skin is the body’s physical barrier to the environment and assessing skin condition is critical. When the epidermis (outer layer) of the skin is compromised, there is risk for pain, infection and delayed healing. Moisture-associated skin damage (MASD) is a skin condition caused by constant contact with moisture. The result is irritation and redness of the skin that may lead to breakdown, erosion, and pathogens. The most common pathogens are Candida albicans and Staphylococcus. MASD can occur anywhere on the body and from multiple sources of moisture (perspiration, saliva, fistulas, wound drainage, urine, and stool). Skin areas that are difficult to dry or get little exposure to air s are at higher risk for MASD. Older adults are at higher risk due to age-related thinning of the epidermis. Nurses are commonly the first to assess and identify skin problems. Therefore, it is important nurses understand the different types of MASD, as well as, interventions to prevent each type.

Incontinence Associated Dermatitis (IAD)

IAD occurs when urine or stool comes in direct contact with skin for a prolonged period of time. Skin moisture isn’t necessarily damaging, however, the alkaline nature of urine contributes to IAD. Stool has digestive enzymes that breakdown the skin’s protective barrier. Liquid stool contains more digestive enzymes than formed stool, increasing the risk of IAD. Fecal bacteria can also increase the risk of secondary skin infection.

Disposable adult incontinence diapers or briefs contain a superabsorbent polymer designed to wick and keep moisture contained. Unfortunately, these products can also trap in heat and moisture, which may lead to redness and inflammation.

Prevention

• Understand the type of incontinence the person is experiencing (stress, urge, overflow or mixed).
• Assess if patient is having symptoms of a urinary tract infection that could be contributing to new onset incontinence.
• Promptly provide incontinence care to prevent prolonged exposure to moisture. Use moisture barrier creams, sprays or similar products with each diaper/brief/pad change.
• Implement toileting schedules consistent with usual voiding pattern.
• In severe cases, urinary catheters or fecal containment devices may be used to prevent irritation and infection. These may also be used to assist in healing when the skin is excessively inflamed.

Intertriginous Dermatitis or Intertrigo

Intertrigo occurs when moisture is trapped between skin folds. Because air does not circulate well through these areas, there is often an excess of moisture. A common cause of intertrigo is moisture from perspiration. Risk is increased for persons who are bedridden, obese, diabetic or have been diagnosed with human immunodeficiency virus. As the skin becomes macerated, the epidermal skin is further damaged by increased friction within the skin fold. Intertrigo can progress to severe inflammation and breakdown, creating an entry point for secondary skin infections. A person can be asymptomatic or experience itching, burning and pain at the site.

Prevention

• Keep skin folds clean and dry.
• Do not use products that may trap moisture- talcum powder, gauze or towels.
• Use appropriate products in the skin fold to absorb moisture- soft absorbent pads, moisture wicking fabric products.
• Treat secondary fungal and bacterial infections.

Periwound-Associated Dermatitis

It is important to maintain a moist environment for wound healing. However, with prolonged contact with moisture, periwound areas are susceptible to erythema, irritation and skin breakdown. Periwound-associated dermatitis may delay or prevent healing of the actual wound.

Prevention

• Assess periwound area with each dressing change
• Assessment should focus on skin color, maceration, irritation and extent of skin damage
• Be sure dressing is appropriate for wound characteristics (type tissue and moisture)
• Dressing should flex with the patient’s movement to prevent excessive shear
• Promptly change dressing when it becomes saturated.

Peristomal Moisture- Associated Dermatitis

Ostomy patients frequently experience peristomal skin complications. Appliances may be poorly fitted causing leakage and skin irritation. Skin irritation may also be from moisture under the barrier or an allergy to products being used. Patients with an ostomy from an emergent situation are more likely to have complications.

Prevention

• Stoma products should be fitted for the patient.
• Select the most appropriate product based on work conditions, climate, financial situation and lifestyle.
• Select products based on the person’s body size, build and stoma location.
• Educate patient on cleaning, application and gentle and slow removal of appliance.

MASD is often an under-recognized form of skin complications. Nurses play a vital role in assessing skin and identifying skin issues. Prevention and treatment of MASD should focus on the underlying cause and protection of the skin.

Additional Resources:

Journal Article- Intertrigo and Secondary Skin Infections

Journal Article- Moisture Associated Skin Damage

Journal Article- Incontinence-Associated Dermatitis: State of the Science and Knowledge Translation