Elderly Skin Conditions series – Incontinence Associated Dermatitis

Adult Diaper Skin Rash Incontinence Dermatitis This is another 4-part series, focusing on elderly. For those of you who have been following this blog, you know I’ve been passionately persevering in bringing you information for eczema children. This month, however, I’m inspired to focus on elderly because (i) I see a desire among elderly ladies in the eczema support group meeting to care for their skin and (ii) I am ashamed that I can’t convince my own elderly parents of the right skincare. Hopefully, with this series, elderly who surf the internet and found this blog will find the series useful and adult kids (yes, you and me included!) will be empowered to help their aged parents with the correct skincare. So here we go!

Last week, we covered a very common skin condition affecting elderly, Stasis Dermatitis. For those of you with aged parents with hyper-pigmented, itchy, swollen/ulcerated skin on the legs, coupled with varicose vein condition, read more in last week’s post. This week, we’re covering another common skin condition affecting elderly with incontinence issue who have to wear adult ‘diapers’. They may be too embarrassed to share with you their skin problem at the genital area, so it’s good to know so that you can ask gently about it.

What is Incontinence Associated Dermatitis (IAD)?

It is an inflammatory skin condition that affects elderly who wear absorptive products to manage their urinary or fecal incontinence issues. Incontinence associated dermatitis is also known as perineal dermatitis. Its prevalence range from 5% to as high as over 20% in various studies. It is characterized by skin damage, inflammation and erythema (skin redness).

Is it Eczema? If not, what causes IAD?

Eczema is atopic dermatitis, meaning there is atopy/allergic reaction involved that triggered the skin reaction. In the case of incontinence associated dermatitis, it is the constant contact to the urine/stool in the adult diaper that damages the skin. This skin damage weakens the skin barrier and leads to deteriorating skin functions, mainly protective and moisture retention functions.

The skin barrier becomes less protective and more susceptible to penetration of irritants (urine/stool), thus more likely to suffer from irritant dermatitis (vs atopic dermatitis).

The skin barrier’s ability to retain moisture already weakens with age and further exposure to urine/liquid stool/sweat increases the rate of this water loss (known as trans-epidermal water loss TEWL).

Skin damage via friction with absorptive products is higher in elderly with IAD and it is possible that the constant exposure to urine raises the skin pH level which makes it more susceptible to damage from friction/pressure.

For elderly with both urine and fecal incontinence (known as double incontinence), there is higher likelihood of skin damage as the liquid stools/stools mixed with urine, leads to higher volume of digestive enzymes that breakdown the fats and proteins of the skin layer.

Just the genital area?

No, incontinence associated dermatitis can extend beyond the genital area to the buttocks and upper thighs.

Complications of Incontinence Associated Dermatitis

A frequent complication of skin inflammation is skin infection. The other complication is candidiasis (fungal infection from yeast called Candida albicans) that appears like a red/brownish red rash with ‘satellite’ lesions. Incontinence associated dermatitis should be differentiated from skin ulcers, which is pressure ulcer/deep tissue damage from pressure (sometimes at area of bone prominence).

Prevention of IAD

  • Minimize time wearing absorptive products, for instance use of hand-held urinal or catheter
  • Frequent change of the adult diapers to minimize the amount of time the skin comes into contact with urine
  • If there is diarrhea or liquid stools, be sure to change adult diaper frequently
  • Daily proper cleaning (without using harsh soap) of genital area at each change of absorptive products and protection with moisturizer (non-fragrance and without common irritants). An ointment containing zinc oxide, similar to baby diaper cream/ointment can also be used to protect against irritant/urine/stool.
  • Similar to baby skin care, frequent washing, use of hot water, rubbing dry with towel should be avoided to minimize drying and wear and tear of skin.

Other methods to manage the incontinence issue can be explored, such as diet/fluid management, pelvic muscle and bladder training and toileting technique. Surgical procedure is often presented as an option, but the pros and cons have to be weighed properly given that no surgical procedure is 100% risk-free. Particularly for an elderly, being subject to a surgical procedure so as not to have to wear ‘diaper’ may end up with more complications (This is outside the scope of this skin post, but more can be read here and here).

For those of us with elderly family members with continence issue, maybe tactfully drop reminder of extra skincare when they are wearing the absorptive products. Share your experience in the comments too, we all need support!

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