Management of Excoriation from Incontinence
A structured skin care program including gentle cleansing, moisturizing, and application of a skin protectant is the most effective approach for managing and preventing incontinence-associated dermatitis and excoriation.
Assessment of Incontinence-Related Skin Damage
Initial Evaluation
Assess the severity and extent of skin excoriation:
- Degree of erythema (redness)
- Presence of skin breakdown or erosion
- Signs of infection (increased warmth, purulence, odor)
- Pain or discomfort reported by patient
Characterize the incontinence pattern:
- Type: urinary, fecal, or both
- Frequency and timing of episodes
- Volume of leakage
- Consistency of stool (if fecal incontinence)
Treatment Protocol for Excoriated Skin
1. Cleansing
- Remove irritants promptly after each incontinence episode, especially after fecal incontinence 1
- Use a pH-balanced skin cleanser (pH 4-7) specifically designed for incontinence rather than soap and water 2
- Soap can be alkaline and further irritate damaged skin
- No-rinse cleansers are preferred as they maintain skin's acid mantle
- Gently cleanse without rubbing or friction which can further damage fragile skin 2
- Pat dry or allow to air dry rather than rubbing skin 1
2. Moisturizing
- Apply a moisturizer to rehydrate skin after cleansing 1
- Focus on areas prone to dryness but avoid over-moisturizing intertriginous areas
3. Skin Protection
- Apply a barrier product to protect skin from moisture and irritants 3, 4
- Choose appropriate barrier based on severity:
- For intact but erythematous skin: moisture barrier cream or ointment
- For moderate excoriation: zinc oxide-based products or dimethicone-containing barriers
- For severe excoriation: film-forming skin protectants that won't further irritate damaged skin 5
- Apply barrier product in thin layer to clean, dry skin 1
Prevention of Further Excoriation
Incontinence Management
- Implement a regular toileting schedule based on patient's voiding patterns
- Use appropriate containment products:
- Select absorbent products with rapid wicking properties
- Change promptly when soiled
- Avoid occlusive plastic-backed products that trap moisture against skin
Environmental Factors
- Minimize skin exposure to moisture:
- Change bed linens and clothing promptly when soiled
- Use moisture-wicking fabrics when possible
- Consider low-air-loss surfaces for bedbound patients with severe incontinence
Special Considerations
For Fecal Incontinence
- More aggressive skin protection is needed due to enzymatic damage from stool
- Consider fecal management systems for liquid stool incontinence
- Address underlying causes (constipation with overflow, infection)
For Mixed Urinary and Fecal Incontinence
- Highest risk for skin damage - requires most vigilant care
- May require more frequent application of barrier products
- Consider consultation with wound/ostomy nurse for severe cases
Monitoring and Reassessment
- Assess skin condition daily
- Document improvement or deterioration
- Adjust treatment plan based on response:
- If improving: continue current regimen
- If worsening or no improvement after 3 days: consider more aggressive barrier products or consult specialist
Common Pitfalls to Avoid
- Not removing previous barrier product before applying new layer (can lead to buildup and maceration)
- Confusing excoriation with pressure injury (assess location and presentation carefully)
- Inadequate cleansing after incontinence episodes
- Using products with sensitizing ingredients (fragrances, preservatives) on damaged skin
- Focusing only on treatment without addressing the underlying incontinence
By implementing this structured approach to managing excoriation from incontinence, skin integrity can be maintained or restored while working to address the underlying causes of incontinence.