Treatment of Perianal Erythematous Rash from Incontinence
For perianal erythematous rash resulting from incontinence, use zinc oxide-based skin protectants as the primary treatment, not nystatin, unless there is confirmed fungal infection. 1
Primary Treatment Approach
Zinc oxide is the evidence-based first-line treatment for incontinence-associated dermatitis (IAD) affecting the perianal area. 1, 2
- Zinc oxide-based barrier creams or pastes should be applied to protect the skin from further exposure to urine and feces 1, 2
- Apply after each incontinence episode, particularly when feces are present 3
- Zinc oxide products create a physical barrier that prevents moisture and irritants from contacting damaged skin 2, 4
When to Consider Nystatin
Nystatin should only be used if fungal infection is confirmed or strongly suspected. 5
- Nystatin is indicated specifically for cutaneous mycotic infections caused by Candida albicans and other Candida species 5
- Consider fungal infection if there are satellite lesions, pustules, or if the rash fails to improve with barrier protection alone 1
- Local fungal skin infections may be associated with peristomal or perianal leakage and can be treated with topical antifungal agents 1
- Nystatin is NOT a skin protectant and will not prevent further irritation from incontinence 5
Complete Skin Care Protocol
Implement a structured three-step approach: cleanse, protect, and monitor. 6, 3
Step 1: Skin Cleansing
- Use a pH-neutral, no-rinse skin cleanser rather than soap and water 7, 6
- Soap and water can disrupt the skin's natural pH and worsen irritation 6
- Cleanse after each incontinence episode, especially with fecal incontinence 3
Step 2: Skin Protection
- Apply zinc oxide barrier cream or paste to the affected perianal area 1, 2, 4
- For severe cases, consider applying zinc oxide followed by petroleum jelly for enhanced protection 4
- Reapply after each cleansing 3
Step 3: Monitoring
- Assess daily for improvement or signs of secondary infection 7
- If satellite lesions or pustules develop, consider adding nystatin for confirmed fungal superinfection 1, 5
Common Pitfalls to Avoid
- Do not use nystatin as first-line treatment for simple irritant dermatitis from incontinence—it lacks barrier properties and is unnecessary without fungal infection 5
- Do not use soap and water for routine cleansing, as this worsens skin pH and increases irritation 6
- Do not delay barrier protection—apply zinc oxide preventively in high-risk patients with frequent incontinence 3
- Do not assume all perianal rashes are fungal—most incontinence-associated dermatitis is irritant contact dermatitis, not candidiasis 2, 3
Additional Considerations
- Foam dressings may be used to absorb drainage and lift moisture away from skin, whereas gauze can worsen maceration 1
- Optimize incontinence management with appropriate containment products to reduce skin exposure 3
- For patients with persistent symptoms despite proper barrier use, culture the area to identify fungal or bacterial superinfection before adding antimicrobials 1