Currently there is a wide range of differing practices relating to skin care. This document is aimed at standardising skin care in the management of adults with continence problems. This will help ensure best practice by all healthcare professionals involved in the patient’s care.

The aim of the guideline is to minimise the irritation and damage to the skin from moisture and chemical irritants thereby improving the quality and hydration of the skin.

Standard precautions in relation to infection control should be employed when delivering care. This includes the use of personal protective equipment and hand hygiene used in accordance with sections 1, 5, 6 and 7 of NHS Ayrshire and Arran Infection Prevention and Control Manual.

This document is relevant to all adult groups with urinary and/or faecal incontinence who are at risk of developing skin excoriation and who access nursing services throughout NHS Ayrshire and Arran.

Skin damage is a result of multiple causative factors such as an attack on the skin by physical, chemical, enzymatic and microbial factors¹. This can present as erythema where skin remains intact. Incontinence dermatitis is a result of further deterioration where the skin integrity is lost.

pH of the skin

The skin has an acid mantle of pH 4-6.8. It has a mean pH of 5.5 making it slightly acidic in nature, which is part of its barrier function. The barrier function is affected by the presence of urine and faeces. The skin therefore becomes more alkaline which further increasing the risk of bacterial colonisation². 

Excessive hydration of the skin

Excessive moisture comes from several sources including urine, perspiration and liquid stools. The effect of exposure of the skin to moisture results in maceration and an increase in skin permeability. Skin that is excessively hydrated is more vulnerable to damage by frictional forces. This in turn increases the patient’s risk of pressure ulcer development³.

Excessive hydration along with the increase in pH found with exposure to urine and faeces impairs the barrier function permitting faecal enzymes to attack the skin. The greater the frequency and volume of the incontinence, the greater the risk of skin damage⁴.

Microbial effects

When urine and faeces mix the bacteria present convert the urea in the urine to ammonia resulting in an increase in the pH of the skin. This destroys the acid mantle allowing irritants to more easily penetrate the skin causing inflammation⁵. Some microbes are part of the normal skin flora. However, when the barrier function of the skin has been impaired, the skin becomes more susceptible to infection. This includes an increased risk from the normal skin flora.

Occlusion of the skin

Many studies have been carried out on different types of continence pads. They concluded that pads containing super-absorbent materials reduce the wetness of the skin, maintaining the pH as near normal as possible.  These super absorbent materials separate the urine from the faeces thereby minimising the risk of faecal enzymatic activity which causes irritation of the skin⁶.

The use of plastics such as pants, sheets and furniture protectors cause occlusion of the skin as they allow the skin to become wet and cause sweating and excessive hydration. Breathable backed products will reduce this risk.

Holistic assessment of the patient should be undertaken. The patient’s continence status should be thoroughly assessed and investigated. When the cause of the incontinence has been identified, a proportion will be able to be cured or greatly improved ^6,7.

It is also important that patients are assessed properly for body worn pads and correct net pant size.

Patients should not be nursed on flat procedure pads.

Further advice on the promotion of continence and management of incontinence can be sought from the continence nurse advisors.

Skin assessment

Assessment of the patient’s risk of developing skin damage must be undertaken in order to identify the contributing factors. These include:-

• increase in the pH through exposure to urine and/or faeces
• increase in skin hydration through exposure to moisture
• exposure to faecal enzymes and urea
• repeated washing with soap and water.

Please see Appendices 1, 2 and 3 for information on how to use recommended skin care products.

Basic skin care principles

The principles of basic skin care are gentle handling of skin whilst keeping it clean and dry. Cleansing of the skin should take place after each episode of incontinence to preserve skin function⁸.

Detrimental effects on the skin can be caused by the following:

Urinary incontinence

Patients who are incontinent of urine and have no evidence of skin damage should have their skin cleansed with a pH balanced soap. Where skin damage has occurred, a foam cleanser should be used⁹.

It is imperative that pad assessment is carried out. In order to minimise episodes of pad leakage and excoriation, the correct size of pad and absorbency should be selected.

Faecal incontinence and double incontinence

Patients whose skin is exposed to faeces and urine should have their skin cleansed using a foam cleanser.

Regular skin inspection should be undertaken and if any evidence of skin damage occurs they will require the use of a barrier product. The severity of incontinence related dermatitis should be recorded in the SSKIN bundle / nursing notes following assessment using the excoriation and moisture related skin damage tool. (See Appendix 4).

Patients with temporary faecal incontinence where the faeces are liquid or semi-liquid may be considered for a faecal management system.

Skin care regimes

See Appendices 5a & 5b on skin care regimes.

Consider the use of barrier preparations to prevent skin damage in those at high risk of developing incontinence related skin damage, i.e. patients with incontinence, oedema, dry or inflamed skin¹⁰.

Problem solving tool for continence problems

Inappropriate selection and fitting of incontinence products may lead to skin damage. See Appendix 6 for additional information.

Employees are reminded that they may have patients/carers who require communication in an alternative format e.g. other languages or signing. Additionally, some patients/carers may have difficulties with written material. At all times, communication and material should be in the patient’s/carer’s preferred format. This may also apply to patients with learning difficulties.

In some circumstances there may be religious and/or cultural issues which may impact on clinical guidelines e.g. choice of gender of health care professional. Consideration should be given to these issues when treating/examining patients.

Some patients may have a physical disability or impairment that makes it difficult for them to be treated/examined as set out for a particular procedure requiring adaptations to be made.

Patients’ sexual orientation may or may not be relevant to the implementation of this guideline, however, non-sexuality specific language should be used when asking patients about their sexual history. Where sexual orientation may be relevant, tailored advice and information may be given.

1. Beeckman D, Schoonhoven L, Verhaeghe S, Heyneman A and Defloor T. Prevention and treatment of incontinence associated dermatitis: literature review J. Adv. Nurs. 2009 65(6):1141-1154. Available from: doi: 10.1111/j.1365-2648.2009.04986.x.
2. Beeckman D, Woodward S & Gray M. Incontinence-associated dermatitis: step-by-step guide prevention and treatment. Br. J. Comm. Nurs. 2011 16(8):382-389. Available from: https://pubmed.ncbi.nlm.nih.gov/21841630/. DOI:10.12968/bjcn.2011.16.8.382.
3. Runeman B. Skin interaction with absorbent hygiene products. Clin. Derm. 2008 26(1):45-51. Available from: https://pubmed.ncbi.nlm.nih.gov/18280904/. DOI:10.1016/j.clindermatol.2007.10.002.
4. Wishin J, Gallagher J and McCann E. Emerging options for the management of faecal incontinence in hospitalised patients. J. Wound, Ostomy Continence Nurs. 2008 35(1):104-111. Available from: https://pubmed.ncbi.nlm.nih.gov/18199946/. DOI:10.1097/01.WON.0000308626.53335.37.
5. Beeckman D et al. Proceedings of the Global IAD Expert Panel. Incontinence-associated dermatitis: moving prevention forward. Wounds International. 2015 Available from: https://www.woundsinternational.com/resources/details/incontinence-associated-dermatitis-moving-prevention-forward.
6. Le Lievre S. An overview of skin care and faecal incontinence. NT Plus 2002 98(4):58-59. Available from: https://www.nursingtimes.net/clinical-archive/continence/an-overview-of-skin-care-and-faecal-incontinence-24-01-2002/
7. NMPDU. Best Practice Statement on Adults with Urinary Dysfunction 2002. NMPDU Edinburgh.
8. Ousey K & O’Connor L. Incontinence-associated dermatitis made easy. Wounds UK 2017. Available from: https://www.wounds-uk.com/resources/details/incontinence-associated-dermatitis-made-easy.
9. All Wales Tissue Viability Nurse Forum and All Wales Continence Forum. All Wales best practice statement on the prevention and management of moisture lesions. Wounds UK 2014. Available from:https://www.wounds-uk.com/resources/details/awtvnf-prevention-and-management-of-moisture-lesions
10. NICE. Pressure ulcer prevention and management. CG179. 2014. Available from: www.nice.org.uk/guidance/CG179

Bibliography

NHS Ayrshire and Arran (2010) Control of Infection Manual.

NMPDU (2009) Best Practice Statement on Pressure Ulcer Prevention and Management NHS Quality Improvement Scotland Edinburgh.

Durable barrier cream is for use on intact skin only. Barrier creams are packaged as single patient use items therefore each patient must have a tube kept solely for their use and labelled with their identifying details. Within hospital sites some patients may use single use sachets as opposed to tubes.

1. Label tube with patient details.
2. Adhere to universal precautions for infection control.
3. Ensure the skin is clean and dry.
4. Apply a pea sized application of cream to the skin using downwards strokes that follow the growth of the hair.
5. The cream requires to be applied as necessary/according to manufacturer’s instructions.
6. Clean the tube with alcohol wipe after use.
7. Store tube where it can be accessed for patient’s use, e.g. in locker.

Very important:

Apply sparingly

If the "after-feel" is oily, you have applied too much.

If the tube becomes contaminated with urine, faeces or body fluids, it MUST be disposed of appropriately.

Barrier film is for use on broken skin. When skin becomes intact, but requires continued use of a barrier product, barrier cream should be used. Barrier films are packaged as single patient use items therefore each patient must have a bottle kept solely for their use and labelled with their identifying details.

1. Label bottle with patient details.
2. Adhere to universal precautions for infection control.
3. Skin should be clean and dry prior to application of the barrier film.
4. When using the spray bottle, hold the spray nozzle 10 to 15 cm from the skin and apply in a smooth even coating over the entire treatment area, whilst moving the spray in a sweeping motion.
5. If an area is missed, reapply to that area only after the first application has dried (approximately 30 seconds)
6. If the barrier film is applied to an area with skin folds or other skin-to skin contact, make sure that the skin contact areas are separated and allow the coating to dry before returning to normal positions.
7. Re-application should be carried out every 24-72 hours depending on skin condition, according to the manufacturer’s instructions. Can be applied more frequently if required. Removal of film is not necessary between re-applications.
8. Allow the product to dry completely before applying pads or clothing.
9. Clean the tube with alcohol wipe after use.
10. Store tube where it can be accessed for patient’s use, e.g. in locker.

If the bottle becomes contaminated with urine, faeces or body fluids, it MUST be disposed of appropriately.

Foam cleansers are packaged as single patient use items therefore each patient must have a can kept solely for their use and labelled with their identifying details.

1. Select the most appropriate can size for the patient in light of the anticipated length of care and frequency of incontinence.
2. Enter patient details on can label.
3. Adhere to universal precautions for infection control.
4. Remove excess faeces with a dry wipe before using the foam cleanser.
5. Shake can then apply a golf ball size application of foam onto the patient’s skin. The can and nozzle should not come into contact with the patient’s skin.
6. Cleanse skin with foam.
7. Dispose of soiled waste appropriately.
8. Clean can with alcohol wipe.
9. Store can where it can be accessed for the patient’s use e.g. in the locker.

If the can becomes contaminated with urine, faeces or body fluids, it MUST be disposed of appropriately.

Scottish excoriation & moisture related skin damage tool

Skin care regime for urinary incontinence algorithm

Despite following the above algorithm, some patients may continue to require to use a barrier cream or foam cleanser. The rationale for continued use should be documented in the care plan.

Skin care regime for faecal/double incontinence algorithm

Despite following the above algorithm, some patients may continue to require to use a barrier cream. The rationale for continued use should be documented in the care plan.

Problem solving tool for continence products

Note: Certain medication or moving & handling techniques should also be considered with regard to skin problems. Some odours may indicate underlying problems.