Diretrizes para Prevenção e Tratamento da Dermatite Associada à Incontinência

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J Wound Ostomy Continence Nurs. 2012;39(3):303-315.
Published by Lippincott Williams & Wilkins
CONTINENCE CARE
Incontinence-Associated Dermatitis
Consensus Statements, Evidence-Based Guidelines for 
Prevention and Treatment, and Current Challenges
Dorothy Doughty � Joan Junkin � Peter Kurz � Joan Selekof � Mikel Gray � Mandy Fader � 
Donna Z. Bliss � Dimitri Beeckman � Susan Logan
In 2010, an international consensus conference was held to re-
view current evidence regarding the pathology, prevention, 
and management of incontinence-associated dermatitis (IAD). 
The results of this literature review were published in a previ-
ous issue of this Journal. This article summarizes key consensus 
sta tements agreed upon by the panelists, evidence-based 
guidelines for prevention and management of IAD, and a dis-
cussion of the major challenges currently faced by clinicians car-
ing for these patients. The panelists concur that IAD is clinically 
and pathologically distinct from pressure ulcers and intertrigi-
nous dermatitis, and that a consistently applied, structured, or 
defi ned skin care program is effective for prevention and man-
agement of IAD. They also agreed that differential assessment 
of IAD versus pressure ulceration versus intertriginous dermati-
tis remains a major challenge. Panel members also concur that 
evidence is lacking concerning which products and protocols 
provide the best outcomes for IAD prevention and treatment in 
individual patients. Issues related to differential assessment, 
product labeling and utilization, staff education, and cost of 
care are the primary focus of this article.
■ Report of Consensus Conference on 
Incontinence-Associated Dermatitis: 
Clinical Implications
In 2010, an international consensus conference was con-
vened to review the current evidence base regarding prev-
alence, pathology, prevention, and management of 
incontinence-associated dermatitis (IAD). The results of 
the literature review have been reported previously.1 
Consensus statements from that article are summarized in 
Box 1. This article pro vides a summary of evidence-based 
guidelines for prevention and management of IAD, ad-
dresses current challenges in the assessment and manage-
ment of IAD, and reviews implications for practice and 
research.
IAD is a prevalent condition with signifi cant negative 
impact; it is painful, it places the patient at increased risk 
for secondary infection and for pressure ulcer develop-
ment, and it can be costly and diffi cult to treat. Fortunately, 
the increased recognition of IAD has led to additional re-
search focusing on strategies for prevention and manage-
ment, design and validation of assessment tools, and 
development of IAD-related products. While additional 
research is needed to determine specifi c elements of an 
evidence-based practice guideline for prevention and 
treatment of IAD, existing evidence supports implementa-
tion of a defi ned or structured skin care regimen that in-
corporates consistent and appropriate use of cleansers, 
moisturizers, and skin protectants.1,2
■ Evidence Gaps
Despite progress in recognition, prevention, and manage-
ment of IAD, signifi cant gaps remain in both our evidence 
base and current practice that have implications for future 
� Dorothy Doughty, MSN, Director of Emory University WOC Nursing 
Education, WOC Nursing Education Center, Emory University, Atlanta, 
Georgia.
� Joan Junkin, MSN, RN, CWOCN, Wound Consultant at The Healing 
Touch, Bryan LGH Medical Center, Lincoln, Nebraska.
� Peter Kurz, WPM Wund Pfl ege Management, Managing Director, 
Graduate Nurse for Wound Management, Vienna, Austria.
� Joan Selekof, BSN, RN, CWOCN, Coordinator -Wound Ostomy 
Continence Nursing, University of Maryland Medical Center, Columbia.
� Mikel Gray, PhD, FNP, PNP, CUNP, CCCN, FAANP, FAAN, Professor and 
Nurse Practitioner, University of Virginia Department of Urology 
and School of Nursing, Charlottesville.
� Mandy Fader, PhD, Research Fellow, University College London, 
Centre for Clinical Technology & Science, London, England.
� Donna Z. Bliss, PhD, RN, FAAN, Research Professor, University of 
Minnesota School of Nursing, Minneapolis.
� Dimitri Beeckman, PhD, RN, SEANS, Assistant Professor, University 
of Ghent, King’s College London and Florence Nightingale School 
of Nursing & Midwifery, London, England.
� Susan Logan, BSN, RN, CWS, FACCWS, Clinical Consultant, Kindred 
Healthcare, Inc, Louisville, Kentucky.
The authors declare no confl ict of interest.
Correspondence: Dorothy Doughty, MSN, Emory University WOC 
Nursing Education Program, 1762 Clifton Rd NE Ste 2200, Atlanta, 
GA 30322 (ddought@emory.edu).
DOI: 10.1097/WON.0b013e3182549118
CE
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304 Doughty et al J WOCN ■ May/June 2012
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research, caregiver education, and classifi cation and use of 
products for IAD prevention and management. Gaps iden-
tifi ed during the consensus conference included (1) dif-
ferential assessment of IAD, intertriginous dermatitis 
(ITD), and pressure ulcers; (2) appropriate classifi cation 
and use of products for prevention and management of 
IAD; (3) the critical importance of caregiver education, to 
include knowledge defi cits to be addressed and potential 
strategies for providing this education; and (4) direct and 
i ndirect costs of IAD treatment and prevention.
Differential Assessment
For many years clinicians made no attempt to differentiate 
between lesions caused by moisture or moisture and fric-
tion (top-down lesions) and those caused by pressure and 
shear (bottom-up injuries). As a result, moisture-related 
lesions were classifi ed as superfi cial (stage II) pressure ul-
cers. In the last 2 revisions of the pressure ulcer staging 
system, the National Pressure Ulcer Advisory Panel 
(NPUAP) added a caveat to the defi nition of stage II ulcers: 
“This category should not be used to describe skin tears, 
tape burns, IAD, maceration, or excoriation.”3,4 This state-
ment refl ects the growing consensus that differentiation 
between pressure ulcers and other types of lesions, such as 
moisture-related lesions, is clinically necessary.
One challenge in the assessment and management of 
IAD is the accurate differential classifi cation of IAD versus 
other forms of moisture-associated skin damage, specifi -
cally intertriginous dermatitis, versus a stage 1 or stage II 
pressure ulcer.5-8 As noted in the literature review summa-
rized by Gray and colleagues,1 IAD is frequently misclassi-
fi ed as a pressure ulcer despite the fact that IAD is not caused 
by ischemia; studies indicate poor agreement among clini-
cians in terms of differential classifi cation of pressure ulcers 
and moisture lesions such as IAD. In 2006, DeFloor and col-
leagues6 evaluated interrater reliability of nurses when cat-
egorizing pressure ulcers and differentiation of pressure 
ulcers versus IAD based on photographs. Four hundred 
seventy-three nurses assessed 56 photographs and classifi ed 
each wound as “normal skin,” “blanchable erythema,” 
“pressure ulcer grade 1, 2, 3, or 4,” or “incontinence lesion.” 
The overall kappa was 0.37, and the investigators noted 
that incontinence lesions were frequently classifi ed incor-
rectly.6 Beeckman and colleagues5 conducted a large study 
involving 1452 nurses in 5 European countries, using pho-
tographs of normal skin, blanchable erythema, each grade/
stage pressure ulcer, moisture lesions, and combined le-
sions. They reported that only 22% of the moisture lesions 
were classifi ed accurately although accuracy was slightly 
higher among experienced nurses and those whohad at-
tended wound care training programs. In a separate study, 
Beeckman and associates9 evaluated baseline accuracy in 
pressure ulcer classifi cation and compared an e-learning 
program and a 1-hour lecture in terms of improved accu-
racy. Their sample included 212 nurses and 214 senior nurs-
ing stu dents. Preintervention scores revealed low accuracy 
in classifi cation; scores improved signifi cantly following 
educational intervention. The levels of agreement prior to 
the educational program are consistent with those of 
Mahoney’s group,10 who conducted a study in the United 
States evaluating the level of agreement among WOC 
nurses when asked to classify pressure, moisture and mix 
moisture, and pressure lesions based on photographs; they 
reported an overall kappa score of 0.1708.
BOX 1.
Summary of Consensus Statements From the Incontinence-Associated Dermatitis (IAD) Consensus Conferencea
IAD is now the accepted term for skin damage caused by exposure to stool or urine.
Variability in reported prevalence and incidence rates of IAD may be attributable to differences in care setting, the prevalence and character 
 of the underlying incontinence (urine, fecal double urinary, and fecal incontinence), and lack of a fully developed assessment tool to 
measure IAD.
Clinical observation and histopathologic analysis suggest that IAD is the result of “top-down” injury.
The major etiologic factors for IAD are exposure to urine or stool, with liquid stool identifi ed as a particularly potent irritant.
Factors contributing to the development and severity of IAD include high levels of Staphylococcus aureus or Candida albicans
The role of absorptive products in the pathogenesis of IAD is not well understood. The use of occlusive absorptive products has been 
 associated with an increased likelihood of IAD; the use of modifi ed products that provide enhanced water vapor transmission may reduce 
the risk of IAD.
Differential assessment of IAD, pressure ulcers, and other forms of skin damage is diffi cult for both staff nurses and wound care nurses; 
 accuracy in differential assessment is positively impacted by education and by the use of structured differential assessment tools.
There is a dearth of evidence regarding best regimens for prevention and treatment of IAD, although most studies do support consistent use 
 of a well-defi ned skin care regimen.
Current clinical consensus supports the following as key components of an effective program for IAD prevention:
 Gentle cleansing with a no-rinse cleanser with pH range similar to normal skin.
 Moisturization to maintain normal levels of intercellular lipids and the skin’s normal barrier function.
 Application of moisture barrier product (petrolatum-based, dimethicone-based, zinc oxide–based, or liquid fi lm-forming acrylates).
a From Gray et al.1
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Houwing and associates11 suggest that a ccurate dis-
tinction between IAD and pressure-induced ulcers is nei-
ther feasible nor important. However, members of the 
IAD consensus document concur that misclassifi cation is 
a problem, for several reasons: (1) effective treatment of 
any type of skin breakdown must include correction of 
etiologic factors, and measures to protect against pro-
longed pressure are quite different from those designed to 
correct exposure to urine and stool; (2) misclassifying IAD 
as a pressure ulcer increases the agency’s risk for litiga-
tion, since pressure ulcers are now considered to be med-
ical errors; (3) misclassifi cation of IAD lesions as pressure 
ulcers compromises the integrity and validity of preva-
lence and incidence data and makes meaningful bench-
marking impossible; and (4) incorporation of IAD lesions 
in pressure ulcer prevalence data prevents accurate mea-
surement of the prevalence and incidence of both condi-
tions and does not allow comparison of data for 
benchmarking purposes.10
Given differences in etiology and pathophysiology, ac-
curate classifi cation of IAD versus pressure ulceration ap-
pears straightforward on initial consideration. Pressure 
ulcers are ischemic lesions, caused by tissue and vessel de-
formation that leads to progressive tissue hypoxia and 
death. Pressure ulcers are characterized as bottom-up inju-
ries, because they originate in deep tissue layers and prog-
ress toward the surface.10-12 They typically present as 
full-thickness wounds located over bony prominences or 
under medical devices, are characterized by signifi cant tis-
sue necrosis and tissue loss, and are often associated with 
undermining and tunneling.3,13,14 In contrast, IAD is an 
infl ammatory response to prolonged exposure of the skin 
to stool and/or urine; the lesions are characterized as top-
down injuries that initially present as erythema of intact 
skin but may progress to vesicle formation and epidermal 
loss, especially when the area is also exposed to fric-
tion.7,15,16 Thus the location, depth, and characteristics of 
pressure ulcers and IAD differ considerably; Table 1 high-
lights these differences.
So why is accurate classifi cation of IAD lesions and 
pressure ulcers such a challenge? Several factors contribute 
to the diffi culty clinicians experience when classifying le-
sions as IAD or pressure ulcer. Many patients who are at 
risk for IAD are also at risk for pressure ulcer development; 
indeed, some patients are very likely to have mixed etiol-
ogy lesions. Another is the fact that both stage 1 pressure 
ulcers and mild to moderate IAD present clinically as ery-
thema of intact skin, even though the underlying etio-
logic factors differ. The erythema associated with stage 1 
pressure ulcers represents an infl ammatory response to 
ischemic damage involving the subdermal tissues, while 
the erythema associated with IAD represents an infl amma-
tory response to irritant exposure that is confi ned to the 
epidermis and dermis. A lesion that is exposed to both 
pressure and stool or urine presents a diagnostic dilemma, 
because visual inspection and palpation may not allow the 
clinician to accurately determine the depth of the injury 
and magnitude of infl ammation. In these cases, clinical 
experience suggests that assessment of the lesion’s blanch-
ability may help clarify etiology. Wounds that are associ-
ated with a pressure/shear etiology are characterized by 
nonblanchable erythema. Therefore, the clinician can be 
taught to gently press on the erythematous area to deter-
mine whether or not it blanches. Lesions that do not and 
are located over a bony prominence should be classifi ed as 
a stage I pressure ulcer.3 Adequate environmental lighting 
and clear exposure of the involved area are critical to ac-
curate assessment of erythema and determination of 
blanchability. Skin pigmentation also infl uences assess-
ment accuracy; erythema is especially diffi cult to detect in 
TABLE 1.
Differential Classifi cation of Pressure Ulcers, Incontinence-Associated Dermatitis (IAD), and Intertriginous 
Dermatitis (ITD)
Pressure Ulcer IAD ITD
Location Over bony prominence or under
 medical device
Perineum; perianal area; inner 
 thighs; buttocks
Intergluteal cleft 
Groin creases
Associated factors Reduced mobility 
May have reduced sensory 
 awareness
Urinary and/or fecal incontinence Diaphoresis
Depth Initially may present as stage I or 
 sDTI; ultimately usually full 
thickness (III/IV)
Usually partial thickness Usually partial thickness, at least 
 initially
Shape/distribution Typically round; if shear involved, 
 may be oval/elongated; distinct 
borders
 Irregular and indistinct borders 
common
Linear break in skin
Associated fi ndings May have necrotic tissue; may 
 have undermining or tunneling
Surrounding skin typically 
 macerated
Surrounding skin frequentlymacerated
Abbreviations: IAD, incontinence-associated dermatitis; ITD, intertriginous dermatitis.
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darkly pigmented skin. In this case, accurate assessment 
requires palpation of the tissue to determine changes in 
fi rmness or temperature.
Partial-thickness skin loss also may result in confusion 
with differential classifi cation of IAD versus pressure ul-
cers. Pressure ulcers are ischemic lesions that begin in the 
deep tissue layers and progress toward the surface, and 
partial-thickness lesions represent epidermal loss with 
preservation of deep dermal and underlying tissue layers. 
Therefore, it seems unlikely that partial-thickness lesions 
represent pressure-induced injuries. Nevertheless, stage II 
pressure ulcers are defi ned as “partial thickness loss of der-
mis presenting as a shallow open ulcer with a red pink 
wound bed, without slough [that]… may also present as 
an intact or open/ruptured serum fi lled or serosanguinous 
fi lled blister.”3
Differentiation between IAD and intertriginous der-
matitis also may lead to confusion in classifi cation. 
Intertriginous dermatitis is defi ned as skin damage caused 
by trapped perspiration and frictional forces between op-
posing skin surfaces and typically presents as infl amma-
tion and linear lesions occurring at the base of skin folds 
(eg, beneath the pannus, underneath pendulous breasts, 
or in the groin crease).16,17 It involves skin damage from 
internally produced moisture (perspiration); thus, preven-
tion and management of these lesions involves strategies 
to wick moisture away from skin creases and to keep the 
skin dry and supple. In contrast, IAD involves skin damage 
caused by exposure to external moisture sources, specifi -
cally stool and urine, and management involves the use of 
skin protectant products.15,17
Tools that may aid clinicians in the accurate classifi ca-
tion of IAD and ITD versus pressure ulcers include diag-
nostic instruments designed to detect early changes in the 
skin layers and soft tissues that correspond to superfi cial 
and deep tissue damage. Bates-Jensen and colleagues18 
used electrical capacitance testing to evaluate subepider-
mal moisture content (SEM) as a predictor of pressure 
ulcer development, especi ally in patients with darkly pig-
mented skin. In their pilot testing, higher SEM levels were 
associated with PU development, but no instrument for 
clinical measurement of SEM measurement is currently 
available. Andersen and Karlsmark19 evaluated 4 diagnos-
tic instruments for their ability to detect changes in the 
soft tissue characteristic of pressure ulcer development: 
(1) a handheld spectrometer for assessment of erythema, 
deemed especially useful in darkly pigmented skin; (2) a 
handheld infrared scanner capable of detecting small dif-
ferences in skin temperature; (3) a device involving a suc-
tion cup and photosensors that was designed to detect 
changes in skin elasticity; and (4) a 20-MHz ultrasonic 
scanner designed to detect changes in the soft tissue con-
sistent with edema formation and/or tissue damage/ne-
crosis. In their study of 11 patients with 15 pressure ulcers, 
they reported that the ultrasonic scanner provided the 
most defi nitive and consistent indicators of deep tissue 
damage. Specifi c ultrasound fi ndings indicative of under-
lying tissue damage included hypoechogenic layers or 
pockets consistent with edema formation, and loss of clear 
differentiation of the various skin layers.12,19,20 Aoi and col-
leagues12 used a 10-MHz ultrasonic scanner and identifi ed 
discontinuity of the fascia layer as an additional indicator 
of deep tissue damage. Deprez and colleagues21 suggest 
that pressure ulcer development is characterized by stiff-
ening of the involved tissue, and that this stiffening can 
be detected through anot her ultrasound measurement, 
tissue elastography. Further study is needed to elucidate 
the value and clinical utility of tissue elastography for dif-
ferential assessment of pressure ulcers versus other lesions.
One ultrasound system is available for use in the clini-
cal setting; the EpiScan I-200 (Longport Digital Scanner, 
Glen Mills, Pennsylvania) uses a 20-MHz probe to image 
the skin and 2 cm of underlying tissue. An observational 
study compared ultrasonic images of healthy volunteers 
with images of patients deemed at risk for pressure ulcer-
ation. Fifty-fi ve percent of the ultrasonic images from pa-
tients deemed at risk for pressure ulceration revealed 
fi ndings consistent with early pressure-induced changes 
in the soft tissues, whereas images from the healthy vol-
unteers revealed only normal fi ndings. The investigators 
in this study also evaluated the ability of the Epi-Scan to 
determine differences in skin and soft tissues exposed to 
friction and those exposed to pressure. They found that 
friction lesions were associated with subepidermal edema 
but no changes in the deeper tissues. In contrast, pressure 
injury was associated with edema that extended into the 
subdermal tissues. These fi ndings suggest that ultrasonic 
imaging may hold signifi cant potential for improving our 
capacity for both early detection of skin and soft tissue 
injury and differential assessment of superfi cial and deep 
tissue damage.20 However, this device has not gained wide-
spread clinical use and a literature search revealed no con-
trolled studies verifying initial observations.
The Thermographic Imaging System (Wound Vision, 
Indianapolis, Indiana) has also been investigated for its 
ability to detect pressure damage to tissue before ulceration 
occurs. The device employs infrared thermography to visu-
alize the skin and subcutaneous tissue. This instrument is 
newly available to clinicians but not yet widely used. 
Additional research is needed to determine its role in early 
detection of pressure injury to subcutaneous tissues.22
Despite progress in the development of technologic 
aids to early diagnosis, clinicians currently must rely on 
visual and palpatory assessment of damaged skin to deter-
mine probable etiology. In addition, limited tools are 
available to aid clinicians in reliably differentiating pres-
sure/shear injuries from moisture-related lesions such as 
IAD and ITD. The European Pressure Ulcer Advisory Panel 
(EPUAP) developed and published a guidance document 
titled “Pressure Ulcer Classifi cation: Differentiation 
Between Pressure Ulcers and Moisture Lesions.”15 This 
document provides a chart that compares pressure ulcers, 
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moisture lesions, and mixed lesions in terms of causative 
factors, location, shape of the lesion, anatomic depth of 
the lesion, presence of necrosis, edge characteristics, and 
color of the lesion and surrounding skin.
Guidelines for differential assessment and classifi ca-
tion of IAD and pressure ulcers have been incorporated 
into EPUAP’s Pressure Ulcer Classifi cation Self-Assessment 
Tool (PUCLAS). This document provides instruction to the 
clinician along with a self-evaluation exercise designed to 
improve skills classifying (grading) pressure ulcers and dif-
ferentiating pressure ulcers from moisture lesions. 
Beeckman and colleagues23 conducted a randomized con-
trolled trial to evaluate the effi cacy of the PUCLAS tool in 
improving nurses’ ability to accurately differentiate be-
tween pressure ulcers and IAD. They enrolled 1217 nurses 
from 4 European countries. Participants were asked to 
classify 20 photographs as either IAD, pressure ulcer, or 
mixed etiology wound; the etiology of thewounds in the 
photographs were determined by unanimous consensus 
from a panel of wound care experts. Participants received 
no feedback regarding the accuracy of their baseline clas-
sifi cations. Following baseline data collection, participants 
allocated to the intervention group received education on 
differential assessment that included lecture, PowerPoint 
photos, video, and exercises. The control group received a 
15-minute review of the various grades of pressure ulcers 
according to the EPUAP classifi cation system. Participants 
were then asked to classify 40 photographs for etiology. 
Baseline classifi cation accuracy was 44.5%, with no differ-
ence between the control and intervention groups. Nurses’ 
ability to accurately differentiate between IAD and pres-
sure ulcers was improved signifi cantly when results of the 
intervention group were compared to those of control 
subjects (70.7% vs 35.6%, P � .001).23 While the fi ndings 
of this study provide evidence that PUCLAS is effective for 
differentiation of IAD versus pressure ulcers, the tool has 
not been widely disseminated in the United States. 
Instead, the only tool available in the United States for 
improving accuracy in wound classifi cation is the NEOCS 
(N. E. One Can Stage, NE Solutionz, LLC, Las Vegas, 
Nevada). The effects of this tool were evaluated in a single 
pilot study that enrolled 101 clinicians who were asked to 
classify 10 wound photos accompanied by brief case de-
scriptions.24 Young and colleagues24 reported that the 
NEOCS, combined with a 5-minute scripted education in-
tervention, increased accuracy in pressure ulcer staging by 
37.7%. The NEOCS is not yet widely available and its con-
tribution to differentiating pressure ulcers from IAD has 
not been thoroughly evaluated.
■ Implications for Research and Practice
These observations clearly illustrate that differential diag-
nosis of pressure ulcers, IAD, ITD, and mixed-etiology 
wounds has tremendous signifi cance for the clinician. The 
consensus panel, therefore, strongly supports utilization 
of the PUCLAS tool or a comparable instrument to guide 
the clinician in differential assessment. Consistently ac-
curate differential assessment requires agreement among 
clinicians regarding the pathology and presentation of 
pressure ulcers, IAD, ITD, and mixed lesions, and current 
data indicate that obtaining consensus on these issues will 
be a major challenge. Results of studies based in the United 
States and Europe5,6,9,10,25 consistently reveal that accurate 
classifi cation remains a challenge. A consensus session 
sponsored by the WOCN Society revealed that inclusion 
of partial-thickness lesions in the NPUAP staging system 
for pressure ulcers contributes signifi cantly to confusion 
among clinicians.25 Based on these fi ndings, consensus 
panel members recommend that the WOCN Society and 
NPUAP collaborate on a consensus statement regarding 
guidelines and tools for differential assessment of pressure 
ulcers, IAD, ITD, and mixed etiology lesions.
■ Product Selection and Classifi cation
Effective prevention or management of IAD requires the 
appropriate use of incontinence care products, which re-
quires the clinician to be knowledgeable regarding the 
various products and the indications, contraindications, 
and guidelines for their use. Clinicians have access to a 
robust range of products, variously labeled as cleansers, 
moisturizers, moisture barriers, skin protectants, moisture 
barrier pastes, and antifungals. The variety of available 
products indicates the availability of a product for almost 
all of the skin care problems commonly encountered by 
clinicians seeking to prevent and manage IAD. However, 
this variety may render it diffi cult for the bedside nurse to 
select the optimal product for a given patient. This chal-
lenge is exacerbated by a lack of consistency in product 
names and absence of a grading scale designed to aid clini-
cians when selecting products based on severity of IAD, 
irritant source, and presence of complications. For exam-
ple, patients with dry, fl aky, and rough-textured skin, 
those with macerated and overhydrated skin, persons 
with denuded skin, or patients with candidiasis require 
different products. The patient with very dry rough skin is 
best managed with a highly effective moisturizer that con-
tains both emollients and humectants.26 Such a product 
would be inappropriate for a patient with macerated over-
hydrated skin. In this case, the clinician should select a 
nonocclusive emollient that softens the skin; the addition 
of a humectant is contraindicated in this case because it 
attracts further moisture to the area, exacerbating rather 
than alleviating maceration. Emollients and humectants 
are also not indicated for the patient with damaged de-
nuded skin; this person requires a skin protectant that 
adheres to the moist damaged skin, and provides absorp-
tion of moisture. Finally, the patient with candidiasis re-
quires a product with an effective antifungal agent. 
Selection of the best product in this case must be com-
bined with the optimal delivery vehicle for the antifungal, 
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either a powder, cream, or ointment, depending on the 
presence of factors discussed earlier.
Consensus panel members identifi ed 4 primary prob-
lems related to product labeling. Skin care products are 
classifi ed and regulated by the US Food and Drug 
Administration based on the following 3 categories: (1) 
prescription products, such as topical antifungal prepara-
tions; (2) over-the-counter drugs such as zinc oxide protec-
tant pastes; and (3) cosmetic products, including many of 
the moisturizing agents. The rules for labeling and the 
order in which ingredients are listed vary based on cate-
gory. For example, inactive ingredients in over-the-coun-
ter drugs must be listed alphabetically, while the 
ingredients in cosmetic products must be listed in de-
scending order of predominance.27 This makes direct 
product comparisons diffi cult. While 2 products appear 
similar based on the list of inactive ingredients, the rela-
tive amounts of these ingredients may signifi cantly differ 
owing to the Food and Drug Administration classifi cation 
and its effect on product labeling. In addition, many clini-
cians select skin care products based on the category listed 
on the front of the tube (eg, moisturizer, moisture barrier, 
etc) rather than individual ingredients. Product labels pro-
vide broad categories, but they may not provide suffi cient 
information for clinical decision making. For example, to 
many clinicians, the term moisturizer means that the 
product adds moisture (water) to the skin, and they reason 
that such products are unnecessary or even inappropriate 
for an incontinent patient with overhydrated skin. 
However, the term moisturizer describes products that 
provide oils or dimethicone to replace lost lipids and slow 
transepidermal water loss.28,29 Clinicians may not under-
stand the importance of replacing lost intercellular lipids 
when the skin is overhydrated. This confusion is increased 
because moisturizers may contain emollients, humec-
tants, or both. Consensus panel members noted that 
many clinicians may be unaware of the difference between 
emollients and humectants, because these terms are pri-
marily used by dermatologists and manufacturers rather 
than by nurses who typically deliver this care.
Similarly, the product category skin protectant (some-
times labeled moisture barriers) provides general guidance 
but does not substitute for consideration of individual in-
gredients. Some moisture barriers are occlusive and there-
fore contraindicated for overhydrated skin, while others 
(such as zinc oxide paste) are somewhat astringentand 
contraindicated for dry skin. Skin protectants also vary in 
the magnitude of protection from exposure to irritants, 
but we have inadequate evidence to rank these products 
based on their barrier function while preventing macera-
tion of underlying skin. In addition, we have inadequate 
evidence to determine the effect of the concentration of 
active ingredients. For example, dimethicone is classifi ed 
as a nonocclusive emollient and skin protectant, but some 
products contain 1% dimethicone, while others contain 
3% or 5% dimethicone.
Because of these defi cits in knowledge and clinical evi-
dence, it is not surprising that product selection remains a 
challenge for clinicians when preventing and managing 
IAD. Failure to recognize IAD as a specifi c clinical diagno-
sis, combined with absence of clear guidelines for manage-
ment, may lead to ineffective or inappropriate application 
of a variety of topical agents. This confusion is refl ected in 
recommendations from multiple blogs and Web sites pro-
moting a variety of questionable and unsubstantiated 
claims concerning the prevention and management of 
IAD or diaper dermatitis.30-32
■ General Recommendations
The consensus panel concurs that the solution to the chal-
lenges associated with the appropriate use of skin care 
products should be addressed by changes in product label-
ing and caregiver education. The panel recommends that 
industry leaders work together to standardize terminology 
and product classifi cation. There is precedence for this ap-
proach; approximately 10 years ago, the NPUAP convened 
a task force charged with standardizing the language and 
criteria used to describe support surfaces such as overlays, 
mattresses, and chair cushions.33 Their work has revolu-
tionized the way in which healthcare facilities evaluate 
and make product decisions related to support surfaces. 
More recently, the National Association for Continence 
has convened a task force to identify and defi ne key per-
formance characterist ics for absorptive products.34 The 
panel believes that such an initiative could be equally ben-
efi cial in the arena of incontinence-related skin products.
The consensus panel recommends creation of stan-
dard defi nitions and performance characteristics for each 
skin care product category, including a pH-balanced no-
rinse cleanser, emollient moisturizers, humectant mois-
turizers, moisture barrier/skin protectant, skin barrier 
paste, and antifungal skin protectant. When applicable, 
members further recommend that products list the con-
centration of key active ingredients (eg, dimethicone 3%) 
and pH range (eg, 5.5-6.0) on product labels.
Consensus panel members also advocate creation of 
educational materials that list commonly used ingredients 
in each category of products. It would be most benefi cial to 
clinicians if it clearly indicated the primary purpose of 
each category and individual ingredient. For example, the 
document should indicate that a humectant (hydrating) 
moisturizer is indicated for treatment of rough dry scaly 
skin (xerosis) while an emollient (softening) moisturizer is 
indicated for maintenance of an intact skin barrier. Ideally, 
panel members recommend that these recommendations 
are added to individual product labels. In addition, the 
panel encourages the WOCN Society to consider publica-
tion of clinical guidelines for the use of various products 
that WOC nurses could use to educate their staff. The panel 
also asks that industry partners consider establishing a rat-
ing scale for selected products, much like the SPF factor 
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used to indicate the level of protection provided by a spe-
cifi c sunscreen product. For example, a moisture barrier 
that has been proven resistant to liquid stool and to re-
petitive cleansing episodes might be rated as “5” on a scale 
of 1 to 5. A rating scale might also be used to indicate the 
relative effi cacy of various humectant moisturizers or as-
tringent “paste” products. The panel acknowledges that 
promulgation of such a rating scale will require develop-
ment of objective testing measures and individual product 
testing. In addition to the general recommendations listed 
earlier, specifi c recommendations pertaining to product 
categories are listed in Table 2.
Skin cleansers
Soap and water cleansing using a washcloth and bath 
basin are associated with multiple infection control issues 
as well as increased risk of skin damage.36 Studies indicate 
that no-rinse cleansers are just as effective as soap and 
water in reducing bacterial counts on the skin, and clinical 
consensus now supports no-rinse nonionic “pH-balanced” 
cleansers and soft disposable washcloths as a preferred ap-
proach to cleansing following an incontinent episode.37--39 
However, the meaning of the term “pH-balanced” is am-
biguous; it is meant to imply that the product has a pH 
consistent with the acid mantle of healthy skin (5.5), but 
some clinicians interpret the term as indicating a neutral 
pH (7.0) and others are unsure of the term’s meaning.40 
Therefore, consensus panel members suggest a standard-
ized defi nition of pH-balanced, coupled with a label that 
states the pH range of that product.
While the use of pH-balanced cleansers and soft 
washcloths is clearly preferable to soap and water 
cleansing, panel members acknowledged limitations to 
this approach. Specifi cally the clinician must fi rst 
cleanse the skin and then must apply a protectant prod-
uct, which requires an additional product and cost. 
Consensus panel members also noted that while cleans-
ing is consistently provided in clinical practice, applica-
tion of moisturizers or a skin protectant product is not 
consistent,41 possibly due to lack of knowledge, access 
to appropriate products, or lack of time. Therefore, the 
panel recommends the use of a disposable cloth impreg-
nated with both acidic no-rinse cleansers and with a 
protectant such as dimethicone. This recommendation 
is consistent with Institute for Healthcare Improvement 
guidelines for pressure ulcer prevention that advocate 
the use of a disposable cloth with cleansers and moistur-
izers when caring for patients with urinary or fecal in-
continence.42 This approach is also consistent with a 
Belgian study comparing the incidence of IAD among 
patients managed with soap and water cleansing 
and those managed with the impregnated disposable 
cloth containing both cleansers and protectants. In this 
study, the incidence among the soap and water group 
was 27.1% as compared to 8.1% in the treatment group 
(P � .003).43
Moisturizers
Products labeled as moisturizers typically contain emol-
lients, which are designed to promote moisture barrier 
function by replacing intercellular lipids and slowing 
water loss from the skin. The water content of healthy 
epidermis is approximately 10%; when it falls below this 
level, the skin becomes rough and fl aky, rendering it more 
vulnerable to friction and penetration by irritants such as 
stool and/or urine.44 Moisturizers are available as “stand-
alone” products, but they are also incorporated as ingredi-
ents in most perineal and incontinence cleansers and 
disposable cleansing wipes. Since studies indicate that 
stand-alone moisturizers may not be used consistently, the 
panel recommends the use of products that combine a 
cleanser and a emollient-based moisturizer.41
Moisturizers may also contain humectants, which are 
designed to treat extremely dry skin by attracting and 
holding water within the skin cells. High concentrations 
of humectants are not appropriate for hyperhydrated skin; 
thus, the panel members recommend clear labeling of the 
level of humectant (hydrating) moisturizers to prevent in-
appropriate use.
Skin protectantsSkin protectants, also referred to as moisture barriers or oc-
clusive moisturizers, provide a protective fi lm that protects 
the skin against penetration by chemical irritants and 
pathogens contained in stool and urine. These combina-
tion products are available either as stand-alone products 
or as an ingredient in disposable cleansing wipes. Evidence 
suggests that a disposable wipe that combines a cleanser, 
moisturizing agent, and skin protectant is more effective 
for prevention of IAD than a skin care regimen combining 
neutral soap and water.1,43 Therefore, the Consensus Panel 
recommends use of combination cleansing-moisturizing-
protectant wipes for prevention of IAD when feasible. 
Because barrier products vary signifi cantly in the level of 
protection provided (based on the ingredients), the panel 
recommends that the industry consider labeling that indi-
cates degree of effi cacy/protection.
■ Implications for Education
Education regarding prevention and management of IAD 
is a high priority; enhanced knowledge is key to accurate 
differential assessment of IAD and to implementation of 
appropriate preventive care and management protocols, 
including the appropriate use of available products. Thus, 
it is important to consider the current level of knowledge 
and education related to IAD, barriers to IAD care that 
must be overcome, aspects of IAD prevention and man-
agement that represent “essential information,” and effec-
tive strategies for providing the needed information.
While there are no available studies specifi cally ad-
dressing nurses’ knowledge related to IAD, observations 
that both staff and wound care nurses frequently 
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TABLE 2.
Prevention and Treatment Incontinence-Associated Dermatitis (IAD) via a Defi ned Skin Care Regimen Product Selection
Recommendation SORT Strength of Recommendationa 
A consistently applied, defi ned, or structured skin care regimen is recommended for prevention 
 and treatment of IAD.
A
Product Selection
Skin care products used for prevention or treatment of IAD should be selected based on 
 consideration of individual ingredients in addition to consideration of broad product categories 
such as cleanser, moisturizer, or skin protectant.
C
Select a pH-balanced skin cleanser (one whose pH range approximates the acid mantle of 
 healthy skin). 
B
No rinse skin cleansers are preferred over towel drying. B
Gentle cleansing is preferred over scrubbing techniques; use a soft cloth to minimize friction 
 damage.
C
Routine use of a moisturizer is recommended to replace intercellular lipids and promote moisture 
 barrier function of the skin.
C
A moisturizer or combination product with a high concentration of humectants is not 
 recommended for hyperhydrated skin. 
C
A moisturizing product or combination product with an emollient moisturizer is recommended to 
 prevent IAD in intact skin. 
C
A product that combines a cleanser and emollient-based moisturizer ensures application of both 
 products in a single step.
C
A skin protectant or disposable cloth that combines a cleanser, emollient-based moisturizer, and 
 skin protectant is recommended for prevention of IAD in persons with urinary or fecal 
incontinence and for treatment of IAD, especially when the skin is denuded. 
B
Commercially available skin protectants vary in their ability to protect the skin from irritants, 
 prevent maceration, and maintain skin health. Additional research is needed to establish a 
benchmark for measuring various skin protectants’ ability to block exposure to a specifi c irritant, 
maintain hydration of underlying skin, and prevent maceration.
B
Timing
Cleansing should occur as soon as possible following an episode of incontinence to limit contact 
 with urine and stool.
C
Timely cleansing, moisturizing, and application of a skin protectant are especially important 
 following an episode of fecal incontinence.
C
Treatment
Treatment of IAD includes consistent application of a defi ned skin care regimen based on principles
 of cleansing, moisturizing, and application of a skin protectant similar to those advocated for 
prevention of IAD. 
B
Antifungal products should be used only when a cutaneous fungal rash is present; they are not 
 recommended for routine treatment of IAD.
B
Steroidal-based topical anti-infl ammatory products should not be used for routine treatment 
 of IAD.
C
Topical antimicrobials should not be used for the routine treatment of IAD. C
Patients who do not respond to treatment within 2 weeks should be referred for additional 
 evaluation.
C
Atypical presentations of IAD should be referred for additional evaluation and treatment. C
Supporting interventions for prevention and treatment
When used correctly, absorptive or containment products may aid in the prevention of IAD. C
In selected cases, urine or stool may be transiently diverted from the skin via an indwelling device 
 such as a urinary catheter or indwelling fecal diversion system to restore or maintain skin integrity.
C
Referral to a continence specialist should be considered for assessment and treatment of the 
 underlying incontinence. 
C
aStrength of Recommendation (SORT) grades are based on the following taxonomy35:
A: recommendation based on consistent, good-quality patient-oriented evidence evaluating clinical outcomes, symptom improvement, impact on quality of life, 
and costs.
B: recommendation based on inconsistent or limited-quality patient-oriented evidence.
C: recommendation based on consensus among experts, disease-oriented evidence, or case series studies.
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misclassify IAD as pressure ulcers and the confusion re-
garding appropriate use of available products refl ect a 
clinically relevant knowledge defi cit.9,10 While inconti-
nence management is included in most nursing texts, the 
focus on prevention and management of IAD is usually 
limited and frequently subsumed under pressure ulcer pre-
vention. This is somewhat understandable since most edu-
cation and focus on preventive skin care has been 
concentrated on pressure ulcers; IAD has sometimes been 
treated as a much lesser problem. However, there is in-
creasing evidence that macerated skin and IAD signifi -
cantly increase the risk for pressure ulcer development.45-47 
In addition, IAD can be painful. Thus, we need to broaden 
clinicians’ focus on prevention to include all types of skin 
damage, including IAD.
For both professional and lay caregivers, incontinence 
is frequently a taboo subject, associated with embarrass-
ment and disgust; this is particularly true of fecal inconti-
nence. Thus, most caregivers try to minimize the time 
spent providing or focusing on management of inconti-
nence; Consensus panel members speculate that this may 
contribute to the dearth of research and education related 
to IAD. Consensus panel members based in the Europe 
and the United Kingdom observed that this avoidance be-
havior extends to specialty nurses; they note that nurses 
specializing in both stoma management and incontinence 
care prefer to focus on stoma care.
When considering care of the incontinent individual, 
many caregivers focus primarily on containment (a care-
giver concern) and voice little awareness of the issues re-
lated to skin protection until breakdown has already 
occurred. Even at that point, many caregivers are unaware 
that IAD is painful and that each incontinent and cleans-
ing episode is associated with further pain and with em-
barrassment. Thus, a very criticalaspect of caregiver 
education is to sensitize them to the impact of inconti-
nence and IAD on the patient. Statistics can be used to 
convey the prevalence and signifi cance of the problem, 
but it is also essential to educate caregivers more about the 
impact of IAD on comfort and dignity.48
When planning an educational intervention, 
Consensus panel members recognize the need to identify 
essential information that forms a framework for presenta-
tions, handouts, and protocols. Unfortunately, a literature 
search retrieved no studies that identifi ed essential knowl-
edge related to prevention and management of IAD. As a 
result, panel members’ recommendations are based on our 
collective experience as clinicians and educators. The con-
sensus panel recognizes that clinical practice patterns and 
availability of continence care experts vary from country 
to country and from setting to setting. Thus, the panel has 
identifi ed educational content that we consider to be es-
sential for all levels of caregivers, and a second level of 
content that is critical for continence care experts or for 
the clinical leaders in a setting where there is no conti-
nence expert (Box 2).
The continence expert or clinical nursing leader obvi-
ously must be knowledgeable in all of these areas; how-
ever, this clinician must also be skilled in the differential 
assessment of pressure ulcers, IAD, and mixed etiology le-
sions. In addition, the clinical expert/leader needs an in-
depth understanding of the various products used for IAD 
prevention and management (in order to make appropri-
ate product decisions for the agency, and also as a basis for 
developing guidance documents and protocols to be used 
by the bedside caregivers).
Although few studies focusing on IAD education were 
identifi ed, Consensus panel members concur that a pri-
mary goal of education is to promote the integration of 
current best evidence into practice. Several studies have 
demonstrated that clearly defi ned evidence-based guide-
lines and algorithms are effective in promoting appropriate 
clinical decision-making for a wide variety of clinical con-
ditions.49-51 Beeckman and colleagues have demonstrated 
the effi cacy of the PUCLAS tool in improving accuracy in 
IAD assessment. Haslinger-Baumann an d colleagues52 re-
port similar fi ndings in the area of IAD prevention and 
management; they developed a practice guideline based on 
a literature review and used this guideline as a basis for 
educating staff and advancing practice in both the acute 
care and long-term care settings.
A promising tool for educating staff and guiding prac-
tice is the IAD-IT (Incontinence Associated Dermatitis 
Intervention Tool).53 This tool was designed by Junkin53 to 
promote accuracy in assessment and management; the 
tool provides a pictorial guide that allows clinicians to 
“match” their patients’ clinical presentation to photo-
graphs depicting “early IAD,” “moderate IAD,” “severe 
IAD,” and “fungal appearing rash” (Figure 1). The tool 
then provides guidance to the clinician as to appropriate 
management. The panel believes that such a tool has the 
potential to assist clinicians to translate “evidence-based 
guidelines” into actual practice. Initial studies have been 
BOX 2.
Essential Information for Educating Caregivers About 
Incontinence-Associated Dermatitis (IAD) Assessment, 
Prevention, and Treatment
Importance of intact skin barrier and characteristics of healthy skin
 (acidic, soft, dry)
Overview of IAD: prevalence; impact on patient; impact on staff; 
 link between IAD and increased risk of pressure ulcer development
Defi nition, risk factors, and pathology of IAD
Assessment of IAD, including differential assessment of wounds 
 with similar clinical appearance such as stage I and II pressure 
ulcers
Preventive care guidelines for cleansing, moisturizing, and 
 protecting skin, to include basic discussion of product categories 
and indications for each
Treatment of IAD using an established decision tree (and ideally a 
 pictorial guide)
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312 Doughty et al J WOCN ■ May/June 2012
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FIGURE 1. Incontinence-associated dermatitis intervention tool.
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done in Europe, demonstrating reliability of this tool, and 
further study is underway.54 The Consensus panel recom-
mends additional testing among US clinicians and in-
creased utilization of the tool in educational programs 
regarding prevention and management of IAD.
Effective staff education requires innovative strategies 
as well as clinically relevant tools; in many settings, it is 
unrealistic to expect signifi cant numbers of staff nurses to 
attend a lecture-based educational event. Fortunately, fi nd-
ings of several studies indicate that eLearning strategies are 
equally effective and are actually preferred by some subsets 
of learners.23,55 eLearning programs that utilize active ap-
plication of content to case study scenarios may be particu-
larly effective for clinical conditions such as IAD.
■ Cost
We have limited data regarding the cost of various proto-
cols for prevention and management of IAD. However, 
the annual estimated cost for skin conditions related to 
incontinence in the United States was $136.3 million in 
1995, so it is clear that IAD is a costly condition.56 Panel 
members agree that a focus on prevention of IAD is indi-
cated, from both an economic and quality-of-care stand-
point. Palese and Carniel57 reported on the impact of a 
multidimensional quality improvement program involv-
ing both product modifi cations and intensive staff educa-
tion on the incidence of IAD and the cost of care in a 
long-term care facility in Italy. The study involved 63 pa-
tients with incontinence, all of whom had IAD at base-
line. Following a data collection phase, the authors 
introduced a new line of absorbent products that were 
designed to minimize hyperhydration of the skin, and a 
structured skin care program that incorporated a pH-bal-
anced no-rinse cleanser and moisture barrier creams. In 
addition, continence nurse advisors provided a 3.5-hour 
educational program for the fi rst-line caregivers (nursing 
assistants); they also provided input as to the best absor-
bent product for each patient and strategies for preven-
tion and management of IAD and met with the nursing 
assistants weekly to discuss continence care issues. The 
incidence of IAD decreased from 100% at baseline to 
31.7% following introduction of the new skin care pro-
gram and absorbent products; the addition of education 
and consultation provided by the continence nurse advi-
sors resulted in a further reduction (from 31.7% to 3.1%). 
The estimated annual cost of care was reduced by almost 
50% (from £653.35 to £354.05 per resident). Eigsti58 re-
ported on a similar approach to quality improvement in 
the United States. Nurses in a critical care unit used evi-
dence-based protocols for IAD prevention along with in-
tensive staff education. Eigsti reported improved clinical 
outcomes and reductions in nursing time required for in-
continence care. These studies underscore the positive 
impact of evidence-based protocols coupled with inten-
sive staff education.
Two US studies compared the cost of soap and water 
cleansing versus the use of a pH-balanced, no-rinse 
cleanser and found that the no-rinse product saved an av-
erage of 9 minutes per episode, resulting in a signifi cant 
reduction in staff time and labor costs.59,60 In addition, re-
cent evidence supports the use of pH-balanced no-rinse 
cleansers as being preferable to soap and water for preven-tion of IAD.1,37
A limited number of studies have demonstrated both 
cost benefi ts and improved clinical outcomes related to 
simplifi ed protocols with fewer steps and product deci-
sions. Bale and colleagues61 evaluated savings in product 
costs and labor when a structured 2-step skin care protocol 
was compared to a nonstructured protocol and demon-
strated both a statistical ly signifi cant reduction in IAD in-
cidence and associated costs. Warshaw and colleagues62 
compared a 2-step skin care procedure (cleansing with ei-
ther soap and water or an incontinence cleanser followed 
by application of a protective barrier) to a 1-step proce-
dure, using a cleanser-protectant combination product. 
The 1-step procedure was associated with a reduction in 
nursing time and product costs as well as a reduction in 
skin pain and erythema. Clever and colleagues41 demon-
strated similar outcomes; they found an 89% reduction in 
incidence of skin breakdown and an estimated annual sav-
ings of $3700 with the use of a one-step skin protection 
program (Comfort Shield, Barrier Cream Cloths, Sage 
Products, Cary, Illinois), as opposed to a “multistep” inter-
vention program. Several studies have addressed the eco-
nomic and clinical effi cacy of a prevention protocol 
incorporating the use of a spray acrylate clear barrier fi lm 
applied 3 times weekly (Cavilon, 3M, St Paul, Minnesota) 
as the moisture barrier, as opposed to petrolatum or zinc 
oxide–based ointments applied after each incontinent 
episode. The barrier fi lm was found to be as clinically ef-
fective and more cost-effective in all studies, due in part to 
the signifi cant difference in frequency of application.63,64
While more studies are needed in the area of cost-effec-
tive IAD care, it seems evident that clearly defi ned proto-
cols that minimize steps and time involved are both 
clinically effective and cost-effective. Additional research 
should focus on the comparative effi cacy and cost of 
1-step and 2-step systems for both prevention and treat-
ment of IAD.
■ Summary
IAD is recognized as a clinical entity that is distinct from 
pressure ulcers and other forms of moisture-associated 
skin damage. Current evidence strongly suggests that a 
defi ned or structured skin care program is benefi cial for 
prevention and management of IAD. Nevertheless, the ex-
isting evidence base remains sparse, and Consensus panel 
members identifi ed a number of unresolved issues related 
to the assessment, prevention, and management of IAD. 
They include problems with differential assessment of IAD 
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314 Doughty et al J WOCN ■ May/June 2012
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versus pressure ulcers, challenges related to appropriate 
product utilization, a lack of effective education for all lev-
els of caregivers, and the need for care protocols that are 
cost-effective as well as clinically appropriate. The 
Consensus panel recommends a conference jointly spon-
sored by the WOCN Society and the NPUAP to develop 
consensus regarding parameters for differential assess-
ment; wide dissemination and utilization of the PUCLAS 
tool or a similar instrument to guide differential assess-
ment; clear labeling of continence care products to in-
clude product category, indications for use, and 
concentration of active ingredients; increased education 
for all caregivers that includes sensitization to the impact 
of IAD as well as current guidelines for prevention and 
management; use of a photographic tool such as the 
IAD-IT to guide appropriate management of IAD; in-
creased research on the cost-effectiveness of various proto-
cols for prevention and management of IAD; and a focus 
on simple protocols (1-step or 2-step) that provide both 
cost savings and time savings.
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