Authors

  1. Lim, Yvonne Siew Ling
  2. Carville, Keryln

Abstract

An integrative review was conducted to synthesize evidence on prevention and management of incontinence-associated dermatitis (IAD) in the pediatric population. A 5-step integrative process was used to guide the review. Articles published from January 2000 to April 6, 2017, were identified and retrieved from CINAHL, PubMed, ProQuest (MEDLINE), and Scopus; key terms were associated with IAD, pediatric, prevention, and management. Supplemental and manual searches were carried out to identify other relevant studies. The studies' findings were extracted and summarized in a table of evidence, with their quality evaluated using the Joanna Briggs Institute's Critical Appraisal Checklist. Sixteen articles were included in the review. Articles explored prevention and management strategies including skin cleansing technique, diaper selection, and the application of topical skin care products. Inconsistent and limited evidence was found regarding the benefits of using disposable wipes in preference to water-moistened washcloths in the cleansing process and on the use of superabsorbent polymer diapers with breathable outer lining in IAD prevention. Findings were inconclusive with regard to the best topical skin care product for IAD care. However, the application of skin protectants was encouraged by the authors, as well as promoted in various clinical guidelines. The development of a structured skin care regimen supplemented by a comprehensive patient education program was advised to enhance the prevention and management of IAD.

 

Article Content

INTRODUCTION

Incontinence-associated dermatitis (IAD) is one of the conditions described under the constellation of moisture-associated skin damage.1 It is characterized by inflamed, erythematous, and occasionally eroded skin due to excessive exposure to urine, stool, or both.2 The skin is the largest organ in the human body and functions as the main deterrent to irritants and pathogens.3 Its primary protective and barrier properties are conferred by the outermost epidermal layer, the stratum corneum.4 A damaged stratum corneum is more permeable to irritants, triggering the inflammatory process clinicians label dermatitis.5,6

 

Infants and children who have not undergone potty training, and older pediatric patients with urinary or fecal incontinence who are subjected to ongoing contact with urine or stool of the skin underneath a diaper or absorbent product, are at risk for damage to the skin's epithelial barrier (stratum corenum).4,7,8 Apart from the damage caused by overhydration, changes in cutaneous pH also impair the barrier properties of the stratum corneum.6 A pH of 4 to 6 is crucial for maintaining the skin's acid mantle that enhances cohesion within the stratum corneum and impedes colonization by potentially pathogenic microorganisms.9 However, both urinary and fecal matters contain ammonia, which has a pH of 11.6 in its pure form. Prolonged exposure to ammonia can increase the skin pH.9,10 Fecal materials also contain digestive enzymes such as lipases and proteases that are activated at more alkaline pH ranges, causing further damage to the stratum corneum.6 Studies have been conducted to establish if skin contact with either urine or stool is of greater influence in predisposing the individual to risk of IAD development, but results are inconclusive.11,12 Nevertheless, clinical experience strongly suggests that that dual urinary and fecal incontinence or liquid stool is more damaging than urinary incontinence alone or incontinence of solid stool. This effect may be attributable to the higher pH range existing with these forms of incontinence, along with the higher concentration of fecal enzymes in liquid fecal materials such as active proteases and lipases, thus maximizing inflammation and damage to the stratum corneum.1,6,11,13

 

The prevalence of IAD in the pediatric population is not known.14 Diaper dermatitis is often used as a nonspecific term to describe a wider range of inflammatory, eroded, or ulcerated skin lesions that manifest in the diapered skin.14-16 The etiology of diaper dermatitis has been attributed to irritant contact dermatitis, psoriasis, fungal infections, nutritional deficiency, and immunodeficiency syndromes.14,16,17 Research suggest that diaper dermatitis contributes to 1 in 5 pediatric dermatology visits and that IAD specifically is the commonest presentation.14,18,19 A study of skin integrity of children after admission at a children's hospital in the United States reported a 10-fold higher IAD prevalence rate compared to pressure injuries.20 In the United Kingdom, an IAD prevalence rate of 16% was reported in the pediatric department of a large district general hospital.21 Li and colleagues22 evaluated 5 maternity and child health facilities in China and reported that at least 2 in 5 children experienced at least 1 episode of IAD during the 6 weeks preceding data collection.

 

Even though IAD is not a life-threatening condition, it causes unnecessary discomfort, pain, pruritus, and paresthesia in patients, which affect health-related quality of life, in addition to being costly and difficult to treat.1,6 It also puts individuals at risk of developing secondary infections and is potentially dangerous to patients who are immunocompromised.23,24 The overhydrated skin cells have a reduced endurance to pressure and friction, increasing the risk of developing pressure injuries.1 Additionally, restoration of skin barrier function in visibly healed IAD was found to be suboptimal on measurements of factors such as water flux and barrier integrity, indicating patients' susceptibility to recurrent IAD.15 Experts have advocated that prevention is the best management for IAD.1,6,25 However, a lack of robust clinical trials that are eclipsed by a vast range of skin care products has hindered clinicians' abilities to identify the best interventions to prevent and manage IAD.25-27 Moreover, there is a limited international consensus regarding the prevention and treatment in younger patients. This integrative review seeks to address this knowledge gap through synthesizing current best evidence within this domain.

 

METHODS

A 5-step integrative process was used to guide the review; they are (1) problem identification, (2) literature search, (3) data evaluation, (4) data synthesis, and (5) presentation of findings.28 The problem statement was: "What are current evidence-based practices for prevention and management of IAD in the pediatric population?" Inclusion criteria were research-based studies published in the English language from the year 2000 to April 6, 2017, involving pediatric patients and interventions to prevent or manage IAD. Studies that recruited subjects with preexisting skin disease such as eczema and psoriasis as well as studies looking at treatment of infectious dermatitis conditions such as candidal dermatitis were excluded. Four electronic databases, CINAHL, PubMed, ProQuest (MEDLINE), and Scopus, were searched using key terms related to these concepts (Table 1). Boolean operators and truncation were used to refine the search and identify most relevant articles. Limiters were set as "article published after 1st January 2000 till present" and "in English Language." Supplementary searches were carried out in the Journal of Wound Ostomy Continence Nursing and Pediatric Dermatology Journal. A manual search was also conducted and examined the reference lists of the eligible articles for further possible inclusions. The suitable studies were evaluated by the author using the Joanna Briggs Institute Critical Appraisal Checklist.29 Study findings were extracted and summarized in a table of evidence for comparison and analysis.

  
Table 1 - Click to enlarge in new windowTABLE 1. Key Search Terms

RESULTS

Seven hundred fifty-nine articles were retrieved from the 4 databases. After the removal of duplicates and the exclusion of articles that lack relevance to the focus of this integrative review, 22 articles remained. The remaining 22 articles were further assessed for eligibility, resulting in the exclusion of another 6 articles. Five of the excluded articles were reported in a previous literature review that is included in this study. The sixth article was a Cochrane review30 that contained a single study meeting inclusion criteria for this review. This study was also included in a more recent literature review,25 which was selected for this integrative review. No articles were found in the Journal of Wound, Ostomy and Continence Nursing and Pediatric Dermatology Journal that were not identified in our search of the electronic databases. Three other potential articles were found after examining the reference lists of the 16 eligible articles. However, 2 of them were reported in Chinese language (Mandarin) and 1 was written in the German language and therefore could not be included in this review. The literature search result was summarized using a PRISMA flow diagram adopted from Moher and colleagues and The PRISMA Group31 (Figure).

  
Figure. The PRISMA f... - Click to enlarge in new windowFigure. The PRISMA flow diagram outlines the literature search.

Five articles, 3 randomized controlled trials (RCTs) and 2 systematic reviews, reported on strategies to prevent IAD, and the remaining 11 elements comprised 10 RCTs and 1 systematic review that evaluated interventions for managing IAD. The systematic review conducted by Rowe and colleagues32 aimed to gather evidence to identify barrier preparations that were effective in the prevention and management of IAD but did not include any IAD prevention-related articles and therefore this review was classified as an IAD management-related study. The characteristic of the included studies are summarized in Table 2 and the results are presented in Table 3.

  
Table 2 - Click to enlarge in new windowTABLE 2. Characteristics of the Included Studies
 
Table 3 - Click to enlarge in new windowTABLE 3. Integrative Review Results

DISCUSSION

Incontinence-associated dermatitis can affect individuals of all ages, who require the use of containment devices for the management of incontinence, or in the case of infants and children prior to toileting training for urinary and fecal output.2 In the pediatric population, such devices, primarily diapers, are used until they acquire the cognitive ability to maintain continence (ie, complete toilet or potty training).33 Furthermore, children with certain neurological conditions such as spina bifida, cerebral palsy, paraplegia, and other sensory or cerebrospinal defects who experience incontinence require long-term containment of urine and stool. Parents with diapered children reported IAD as their top dermatological concern.14,18 However, most strategies currently employed by parents and caregivers for prevention and management of IAD tend to be based on popular opinion and anecdote rather than firm evidence.34,35 In the clinical setting, the lack of a standardized assessment tool and an intervention protocol also hinders the management of IAD.36

 

The assessment and diagnosis of IAD depend mainly on inspection and related observations. Nevertheless, the various assessment tools used by researchers lacked rigorous validation.34,37 Additional research establishing the validity and reliability of IAD assessment tools is needed. For example, a well-designed IAD assessment tool to enhance the ability of clinicians in differentiating IAD lesions from other forms of skin damage is needed to augment our ability to provide appropriate care and monitor outcomes.6,36

 

Incontinence-associated dermatitis management should also aim to prevent further skin damage.1,6,38 It is important to minimize irritant contact in at-risk patients and preserve their skin integrity and barrier function. Preventive and management strategies such as appropriate selection of the type of containment device used, skin cleansing techniques, and the application of topical barrier products can help either deter or hasten the development of IAD and aid in healing. The findings from this review indicate a lack of consensus for a consistent and effective solution for prevention and management of IAD. Previous literature reviews25,26,32,39 performed in both the adult and pediatric settings reported similar constraints. Nevertheless, similar to the recommendations by other authors,6,11,40 the review has highlighted the benefits of having an evidence-based structured skin care regimen for promoting healthy skin care habits and minimizing the development of IAD.

 

Absorbent Devices: Diaper Selection

The findings from the review were limited and inadequate to support or refute the use of disposable diapers over cloth diapers. Nevertheless, evidence was inclined towards diapers with a higher absorbent capacity and a breathable outer lining. Expert opinion and research-based evidence support the use of diapers containing superabsorbent polymers for prevention and management of IAD.15,21,38,41-43 Superabsorbent polymers aid in the rapid absorption and containment of fluids,42 thus reducing skin wetting and irritant skin contact. Furthermore, the breathable outer lining incorporated into some disposable diapers promotes vapor exchange, and dryness in the microenvironment between absorbent product and skin, thus minimizing overhydration of skin cells.42 In one study, 7 of 10 children using cloth diapers were found to have IAD in the perianal and intertriginous regions,41 further highlighting the importance of using diapers with a higher absorbent capacity. Moreover, neonates and infants using cloth diapers were found to have a higher risk of acquiring neonatal sepsis when compared to those using disposable diapers.44 The use of diapers impregnated with a skin protectant was also found to reduce IAD severity,15,45,46 although the cost of these diapers may restrict their use.

 

In addition, we found several clinical guidelines that recommended diaper-free periods to prevent and aid wound healing in those who have developed IAD.8,19,33 However, we did not find any studies that examined the benefits of diaper-free periods in managing IAD. While the diapered area was described as more hydrated that the nondiapered area (regardless of the extent of soiling), the optimal diaper-free duration is unknown and varies considerably depending on caregiver preference.34,35,47,48

 

Skin Cleansing Techniques

The use of disposable wipes for cleansing diapered skin was controversial. Preservatives in the wipes were proposed to cause skin irritation, but several manufacturers have attempted to minimize the type and number of preservative additives used.49,50 In the Ehretsmann and colleagues51 study, disposable wipes were found to be safe even for infants with atopic dermatitis. Even though there was a lack of consistency in the evidence reported from the reviewed articles, disposable wipes appeared to be able to maintain skin integrity to a level that was at least equivalent if not superior to water-moistened washcloths. The use of water-moistened washcloths or cotton products required more forceful scrubbing to remove contaminants, as water alone was reported to be inadequate in the removal of fat-soluble waste products.52 Conversely, most disposable wipes contain fat-soluble solvents that could aid in the removal of waste products.46

 

The influence of skin cleansers on cutaneous pH is important for maintenance of the integrity and cohesion of the stratum corneum and preservation of the skin's normal flora.11 Water has a pH of 7 and is neutral as compared to normal skin pH, which ranges from 4 to 6.53 Nevertheless, due to the immature and delicate skin of neonates and infants, disposable wipes used in the pediatric population should be selected with caution. A soft, nonwoven, nonfragrant, alcohol-free, pH-balanced wipe is preferred.11,25,54 In addition, a gentle cleansing technique that minimizes scrubbing is recommended.5,14,36 We did not find any studies that compared the effect of disposable wipes and water-moistened washcloths or cotton on damaged skin. No studies were found that explored the feasibility of using no-rinse skin cleansers in the pediatric population. In the adult setting, however, a no-rinse skin cleanser is highly recommended for use in lieu of soap and water or water alone.6 No-rinse cleansers have the benefits of being quick drying, which prevents unnecessary friction during drying of skin, are usually pH-neutral, and are able to remove contaminants more effectively than water alone.

 

Topical (Leave-on) Skin Care Products

Topical or leave-on skin care products minimize skin contact with chemical irritants, urine, and fecal material or help maintain and restore the skin barrier.6,11 The majority of the reviewed articles assessed the efficacy of topical skin care products in the prevention and management of IAD, but no conclusions could be drawn to recommend the most effective product. Experts and guidelines recommend the application of skin protectants containing active ingredients such as zinc oxide, petrolatum, and dimethicone after the cleansing of the perineum to protect high-risk patients from IAD.36,38,39 Nevertheless, the benefits of zinc oxide and petrolatum were not conclusively demonstrated in this review. In a literature review conducted in the adult setting, the efficacy of dimethicone-based no-sting barrier films was found to be comparable to zinc oxide- and petrolatum-based creams and they were also reported to be more cost-effective when used in IAD prophylaxis.55 However, there was a lack of data surrounding the efficacy of dimethicone in the pediatric population. Additionally, it was not clear whether the concentration of the active ingredients played a major role in the effectiveness of the skin protectants. This further increases the challenge of selecting a cost-effective, evidence-based product.

 

As the development of IAD is driven by an underlying inflammatory process, the use of products containing anti-inflammatory properties was favored among clinicians managing IAD. Topical steroidal products such as hydrocortisone are frequently prescribed for its anti-inflammatory effects on various dermatoses such as IAD.56 However, beyond the common side effects of steroid creams (cutaneous irritation and steroid atrophy), we identified a few case studies that reported the development of iatrogenic Cushing syndrome in children after prolonged and inappropriate usage of these creams in the diapered area.57,58 Breast milk may be as effective as hydrocortisone cream in reducing the severity of IAD, with no known reported side effects and may be a preferable option.59 However, breast milk does not possess the barrier function capability that other skin protectants confer, and it may not be readily available to all caregivers. We also identified a natural product commonly used in Iran (Calendula officinalis cream; Pharmaceutical, Hygienic and Food Industries, Dineh, Iran) with purported anti-inflammatory and antimicrobial effects. However, its benefits were not proven over conventional creams such as bentonite.

 

While the evidence surrounding the use of topical skin care products was limited and inconclusive, it is evident that the application of such products does help minimize the development of IAD and aid in skin recovery. The application of a thick layer of skin protectants was consistently advocated in clinical guidelines, and care providers were cautioned against total removal of leave-on skin products at every diaper change.14,36,38 Dabbing motions to remove soiled cream and topping up of the protectant as necessary were proposed, as these reduce unnecessary epidermal stripping.

 

Structured Skin Care Regimen

The authors of all the articles we reviewed also discussed the benefits of a structured skin care regimen and the importance of caregivers' education in the prevention and management of IAD. A structured skin care regimen comprising proper assessment, cleansing, and protection was recommended in multiple clinical guidelines.6,24,36,38,60,61 Because most IAD cases occur in the community, and more than half of them are managed without advice from a health care professional,14,21 providing IAD prevention and management education to caregivers of children of diapering age will be beneficial in reducing the occurrence of IAD.34

 

CONCLUSION

Incontinence-associated dermatitis is a prevalent and problematic condition of childhood that worsens health outcomes and causes distressing discomfort. Although multiple management and prevention strategies were identified in the review, we found a paucity of evidence-based and comprehensive research within this field. The 2 most consistent findings suggest the use of high absorbency, breathable diapers, as well as additive-free disposable cleanser wipes, with the caveat that the evidence for supporting their use remains conditional at best. Health care institutions should establish structured skin care regimens and patient and caregiver education programs. Further research is needed to enable clinicians to offer patients the best, most effective, and evidence-based care.

 

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66. Adib-Hajbaghery M, Mahmoudi M, Mashaiekhi M. The effects of bentonite and calendula on the improvement of infantile diaper dermatitis. J Res Med Sci. 2014;19(4):314-318.

 

67. Adib-Hajbaghery M, Mahmoudi M, Mashaiekhi M. Shampoo-clay heals diaper rash faster than calendula officinalis. Nurs Midwifery Stud. 2014;3(2), 1-4.

 

68. Gozen D, Caglar S, Bayraktar S, Atici F. Diaper dermatitis care of newborns human breast milk or barrier cream. J Clin Nurs. 2014;23(3-4):515-523.

 

69. Mahmoudi M, Adib-Hajbaghery M, Mashaiekhi M. Comparing the effects of bentonite & calendula on the improvement of infantile diaper dermatitis: A randomized controlled trial. Indian J Med Res. 2015;142(6):742-746.

 

70. Keshavarz A, Zeinaloo AA, Mahram M, Mohammadi N, Sadeghpour O, Maleki MR. Efficacy of traditional medicine product henna and hydrocortisone on diaper dermatitis in infants. Iranian Red Crescent Med J. 2016;18(5):e24809.

 

71. Nourbakhsh SM, Rouhi-Boroujeni H, Kheiri M, Mobasheri M, Shirani M, Ahrani S, Karami J, Hafshejani ZK. Effect of topical application of the cream containing magnesium 2% on treatment of diaper dermatitis and diaper rash in children: A clinical trial study. J Clin Diagn Res. 2016;10(1):WC04-WC06.

 

72. Qiao XP, Ge YZ. Clinical effect of hydrocolloid dressings in prevention and treatment of infant diaper rash. Exp Ther Med. 2016;12(6):3665-3669.

 

For 192 additional continuing education articles related to pediatrics, go to http://NursingCenter.com/CE.

 

Children; Diaper dermatitis; Diaper rash; Incontinence-associated dermatitis; Infant; Management; Pediatric; Prevention