Moisture-associated skin damage - American Nurse Journal

Moisture-associated

skin damage

The basics

Identification, prevention, and management

By Armi S. Earlam, DNP, MPA, BSN, RN, CWOCN, and Lisa Woods, MSN, BSN, RN, CWOCN

CNE

1.5 contact

hours

L EARNING O BJECTIVES

1. Describe causes and risk factors for moisture-associated

skin damage (MASD).

2. Describe the pathophysiology related to the four most

common types of MASD.

3. Define the prevention and management strategies for the

four most common types of MASD, including incontinenceassociated dermatitis, intertriginous dermatitis, periwound

MASD, and peristomal MASD.

The authors and planners of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining

to this activity. See the last page of the article to learn how to earn

CNE credit.

Expiration: 10/1/25

MOISTURE-ASSOCIATED SKIN DAMAGE (MASD),

inflammation and erosion of the skin, results from

prolonged exposure to different sources of moisture

such as feces, urine, sweat, saliva, wound exudate, mucus, perspiration, digestive secretions, and other bodily fluids. This prolonged exposure leads to irritant

contact dermatitis. Common manifestations include

local inflammation with erythema (pink or red color

or lighter or darker than usual skin tone), inflamed

skin with irregular borders, erosion of superficial skin

layers, and sometimes rash from fungal or bacterial

skin infection. Considered top down skin damage,

MASD begins with superficial damage to the epidermis (¡°bottom up¡± damage, such as pressure injuries

[PIs], begins with deeper tissue as a result of ischemia

and then progresses to the superficial tissue and skin).

(See MASD examples.)

The four most common types of MASD are incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD) or intertrigo, periwound MASD, and

peristomal (skin around stomas such as fecal and urinary ostomies, tracheostomies, and gastrostomies)

MASD. Other forms of MASD not covered in this article include irritant contact dermatitis caused by contact with saliva and irritant contact dermatitis related to

unspecified stoma or fistula.

In October 1, 2021, the Wound, Ostomy and

Continence Nurses Society (WOCN) spearheaded

American Nurse Journal. 2022; 17(10). Doi: 10.51256/ANJ102206

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Volume 17, Number 10



important updates in the International Classification of Diseases, Tenth Revision, Clinical

Modification (ICD-10-CM) related to differentiation and documentation of various

MASD. The ICD-10-CM codes, applied

worldwide for disease identification, are used

in the United States for insurance and healthcare supply reimbursements. The WOCN

added several codes under the category of

Contact Dermatitis, using different MASD

etiologies to make distinctions. To ensure consistent documentation, all clinicians should review and correctly use the new codes. (See

ICD-10-CM updates.)

MASD pathophysiology

Overhydration of the stratum corneum, the

outermost layer of the skin¡¯s epidermis, compromises the structure of the epidermal layer.

This allows penetration of the skin by irritants

that cause inflammation and skin erosion,

which can result in the entry of microorgan-

isms that lead to infection. Prolonged exposure

of the skin to moisture, such as from urine or

feces, changes the skin¡¯s pH, which makes it

more penetrable to irritants and infectious organisms. Skin exposed to excess moisture also

has reduced resistance to mechanical stresses of

pressure, shear, and friction.

Some interventions meant to address skin

moisture may cause further damage. For example, forcefully rubbing the perineal skin during

incontinence clean up can result in friction injury. Alkaline soap used for cleansing can reduce the stratum corneum thickness and alter

the skin¡¯s pH, which is naturally acidic (pH between 4 to 6.8). Excess moisture or alkaline

soap can destroy this acid mantle and allow irritants and pathogens to enter the skin.

Several factors increase a person¡¯s MASD

risk. These include advanced age, obesity, environmental factors, immobility, use of occlusive

containment products such as plasticized undergarments, diminished cognition, an inability

MASD examples

Moisture-associated skin damage (MASD) results from various causes and typically begins with superficial harm to the epidermis.

Following are examples of MASD.

Severe irritant dermatitis caused by

incontinence

The patient has a urinary catheter, but it

may have been inserted after the skin had

already broken down. Stool incontinence

also can cause this condition. Note the

erythema and skin breakdown (open

skin) over the buttocks. This extent of

breakdown qualifies it as severe. Likely

causes, given the location and severity, include prolonged exposure to an irritant

such as liquid stool or stool combined

with urine, which may occur if incontinent episodes aren¡¯t promptly addressed.

Mild irritant dermatitis

The skin on the inner buttocks and

medio-posterior thighs is discolored

(red), but intact. Red skin that¡¯s not open

qualifies this as mild irritant contact dermatitis due to fecal, urinary, or dual incontinence.

Periwound

This periwound MASD resulted from prolonged contact with proteolytic enzymes.

Photos of severe and mild irritant dermatitis courtesy of the Wound, Ostomy and Continence Nurses Society. Photo of periwound courtesy of Wounds Canada.



October 2022

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ICD-10-CM updates

The 2022 International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) includes these codes for

irritant contact dermatitis.

Codes

Description

Exemplars for code use

L24.A0

?

Irritant contact dermatitis due to

friction or contact with body fluids,

unspecified

Inner thighs with irritant contact dermatitis due to friction and

moisture (body fluids associated with the dermatitis aren¡¯t

determined)

L24.A1

?

Irritant contact dermatitis due to saliva

Skin breakdown on the chin of patient unable to control leaking

saliva from the mouth or a wound from which saliva is leaking

L24.A2

?

Irritant contact dermatitis due to fecal,

urinary, or dual incontinence

Dual incontinence of feces and urine in a patient unable to

control leaking or elimination resulting in skin breakdown on

the inner buttocks

L24.A9

?

Irritant contact dermatitis due to

friction or contact with other specified

body fluids

Patient with a leg wound that drains heavily causing skin

breakdown around the wound

L24.B0

?

Irritant contact dermatitis related to

unspecified stoma or fistula

Signs of contact dermatitis present, but type of stoma

(surgically created opening) or fistula (abnormal opening)

associated with the dermatitis is not specified

L24.B1

?

Irritant contact dermatitis related to

digestive stoma or fistula

Irritant contact dermatitis on the abdomen related to a

digestive stoma (e.g., gastrostomy tube)

L24.B2

?

Irritant contact dermatitis related to

respiratory stoma or fistula

Irritant contact dermatitis around a tracheostomy

L24.B3

?

Irritant contact dermatitis related to

fecal or urinary stoma or fistula

Patient with ileostomy has a leaking pouch causing peristomal

skin erosion

Table adapted from Bliss et al.

to perform personal hygiene, fever, medications

such as antibiotics and immunosuppressants,

poor nutrition, and critical illness.

Incontinence-associated dermatitis

Skin inflammation from prolonged exposure to

urine or stool, particularly liquid stool, can result in IAD. Signs include redness, swelling,

pain, and in some cases, pruritus. In people with

darker skin, IAD may present with subtle redness or discoloration of the surrounding area.

Anyone with IAD may have blistering and confluent or patching lesion distribution with irregular edges and erythema. The lesions may be

shallow, denuded, and macerated. Most IAD lesions occur in the perineal area, buttocks, inner

thighs, groin, and the lower part of the abdominal skin folds. If the lesions are draining, typical

exudate is clear, serous, weepy, or sanguineous.

IAD can place an individual at increased

risk for PI. In fact, IAD frequently is misidentified as superficial (stage 1 or 2) PI.

Prevention and management

When possible, IAD prevention starts with a

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bowel and bladder program (timed or prompted toileting). Identifying the cause of the incontinence also is key. For example, a resident

in a nursing home who reports being incontinent at night may not be able to reach the

bathroom in time because of mobility and visual issues. A bedside commode and a clap-activated bedside lamp may help solve the issue.

Depending on circumstances, other IAD interventions may be appropriate. For example, patients with stage 3 or 4 PIs may benefit from an

indwelling urinary catheter. In hospital units, patients with liquid stool may benefit from internal

or external fecal management or containment

systems. Absorptive wearable incontinence garments can be used; however, these products create an occlusive environment that increases skin

temperature and humidity, which contribute to

IAD development. Instead, most hospitals use

nonwearable absorptive products (disposable

pads) and limit wearable incontinence garments

to physical therapy or ambulation. In the community setting, caregivers and patients frequently choose wearable incontinence garments to

promote dignity. To help avoid IAD, advise

tients to select products that wick wetness from

the skin, schedule regular cleaning, and promptly change soiled or wet garments.

A landmark systematic literature review by

Beeckman and colleagues identified a structured skin care protocol that helps decrease

IAD incidence. The three-step process includes gentle cleansing, moisturizing, and protection of the skin. No-rinse cleansers containing surfactants are recommended over

standard soap and water for clean-up. Moisturizers that replace the lipid on the skin and

products that coat the skin to protect it from

overhydration, irritants, and urinary/fecal

pathogens also are recommended. Advise patients to avoid products with fragrance and

dyes, which may cause irritation.

Intertriginous dermatitis

ITD Lesions are erythematous, moist red or

red-brown, and beefy. Linear erosions also occur. Pruritus, pain, and foul odor frequently are

reported. ITD can occur anywhere on the body

where skin opposes skin and traps moisture.

Common locations include the axillae, inguinal

areas, abdominal skin folds, inframammary

folds, and the intergluteal cleft. Lesions also occur in the umbilicus, neck folds, and web spaces

of fingers and toes. Patients with limb contractures may develop ITD in the antecubital and

popliteal fossae. Risk factors include immobility, obesity, hyperhidrosis, immune deficiencies,

diabetes, and malnutrition.

Prevention and management

To prevent and manage ITD, provide careful

and diligent skin care, wick or absorb trapped

moisture from skin folds, and separate skin

folds to prevent skin damage from friction.

Recommended skin care regimens include using pH-balanced skin cleansers, gentle cleansing (without scrubbing), using soft cloths (not

washcloths), and patting (not rubbing) the skin

dry. Avoid talc, cornstarch, antiperspirants, and

placing bed or bath linens in skin folds.

Other interventions to treat ITD include

drying the affected area with a hair dryer on the

cool setting, using absorptive clothing such as

cotton to separate skin folds, applying a skin

sealant, and applying preservative- and fragrance-free moisture barrier ointments combined with soft folded sponges to maintain skin

fold separation. Commercially available wicking

textiles, some impregnated with antimicrobial



agents, can help decrease the risk of developing

skin infections. Weight loss and diabetes treatment, as applicable, also can help manage ITD.

Common ITD complications include secondary infections such as candidiasis and

Staphylococcal infections. To treat candidiasis,

lightly dust the affected area with antifungal

powder. Avoid excessive use of powder, which

can lead to caking and increased skin damage

caused by friction. If applicable, the provider

may prescribe azole antifungal creams (such as

miconazole), which have antifungal, anti-inflammatory, and antibacterial effects. For patients with significant pruritus, a low-potency

corticosteroid may help.

Periwound MASD

Periwound MASD occurs when wound exudate, containing proteolytic enzymes, comes

into prolonged contact with skin. Compared

to acute wounds, chronic wounds have higher

levels of these enzymes and are more likely to

cause periwound MASD. Chronic wounds also tend to be infected and thus more exudative.

Associated irritation and pruritus cause the patient to scratch skin, leading to further damage.

Signs of periwound MASD include erythema, maceration, and skin loss. Macerated skin

is soggy and soft, and it may be whiter than

usual. Among darker-skinned patients, maceration presents as gray-white and wrinkled skin.

Prevention and management

Prevention and management of periwound

MASD include selecting dressings with adequate absorptive capacity, changing dressings

before they become saturated, and using moisture barrier products to protect periwound

skin. Commonly used products include skin

sealants, skin barrier ointments or paste, and

solid-wafer skin barriers. Ensure periwound

skin is kept clean and dry. For seriously ill patients with wounds that have large surface areas, consider obtaining a low air loss mattress.

Peristomal MASD

Peristomal MASD¡ªinflammation or erosion

of the skin around ostomies¡ªresults from exposure to fecal or urine drainage. Peristomal

skin starts at the beginning of the stoma-skin

junction and extends outward in an approximately 4-inch radius. Common clinical signs

of peristomal MASD include maceration, erythema, and superficial skin loss. Around fecal

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Infections and contact dermatitis

Complications of moisture-associated skin damage (MASD) include

fungal and bacterial infections and allergic contact dermatitis.

Fungal infections

Fungal infections typically are found in moist, warm areas on the body, including skin folds where MASD is likely to occur. The most common fungal

skin infection, candidiasis, may appear with redness, scaling, itching, creamy

exudate, yeast odor, and satellite lesions. Other types of fungal infections include tinea (dermatophyte), and its appearance may vary based on body location. Fungal infections require appropriate antifungal products.

Bacterial infections

Bacterial skin infections frequently present with intense erythema, pain,

pustules or blisters, warmth, swelling, and serous or purulent drainage

or weeping. Suspected bacterial infections require diagnosis by a medical provider, who may prescribe topical or systemic antimicrobials.

Allergic contact dermatitis

First-line treatment for allergic contact dermatitis is to remove the offending allergen. Topical steroid creams can help reduce skin inflammation,

but they should be used cautiously and avoided in areas of suspected skin

infection. Topical steroid¨Cassociated risks and side effects include epidermal thinning and increased chance of or exacerbating skin infections.

and urine ostomies, if the skin barrier is cut too

large or isn¡¯t correctly fitted around the ostomy, the peristomal skin can be exposed to stool

or urine, leading to skin damage.

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Prevention and management

To help prevent peristomal MASD provide ostomy care education that focuses on correct

sizing of the barrier opening and skin barrier

selection. In addition, assess the patient¡¯s technique in applying and removing their pouch to

ensure they¡¯re following the correct procedure.

Depending on the source of the peristomal

MASD, management may include modifying

the pouching system, educating the patient

about proper ostomy care, or increasing the frequency of ostomy appliance changes. Consider

consulting with a certified ostomy nurse

(COCN?) or certified wound, ostomy and continence nurse (CWOCN?), who may implement a convex skin barrier, ostomy accessories

(ring barriers or ostomy belts), the ¡°crusting

method¡± (applying powder and a no-sting skin

barrier film to create a dry surface for pouch adhesion), or a cyanoacrylate-based product as a

protective layer over the skin.

In cases of high stool output or runny consistency that undermines the skin barrier, diet

modifications and medications to thicken

stool or slow peristalsis may be prescribed. If

the patient has diarrhea as the result of an infection, the infection should be treated with

antibiotics as appropriate.

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For peristomal MASD resulting from leakage around tubes, for example a leaking feeding gastrostomy tube, consult a physician (in

this case an interventional radiologist) to help

determine the cause of the leak, confirm proper tube placement, and to stabilize the tube.

Other interventions include applying a skin

sealant, skin barrier ointment or paste, or a

solid-wafer skin barrier to protect the skin

around the tube. Also consider using a dressing with appropriate absorptive capacity, increasing the frequency of dressing changes as

needed, and gently cleansing and drying the

peristomal skin.

Complications

MASD complications include fungal and

bacterial skin infections that require identification and treatment by a provider. Viral

skin infections aren¡¯t associated with moisture, but some, such as herpes simplex and

varicella-zoster viruses, may be found in areas

where IAD is common. Some patients may

develop localized allergic responses (allergic

contact dermatitis). (See Infections and contact dermatitis.)

Improve outcomes

MASD can cause pain and discomfort, secondary infections, and further debilitation.

Management requires identifying and treating

the cause. Cleansing, moisturizing, and protecting the skin aid in skin repair, help keep

the skin intact, and prevent breakdown. Other

crucial steps include educating and involving

the patient and caregivers in management

steps, as well as collaborating with other disciplines, such as physicians, dietitians, and

physical therapists. Consulting a wound care

specialist, such as a CWOCN, is especially

important if MASD worsens or fails to improve after initial interventions. Additionally,

for assistance in selecting incontinence garments, consider consulting a wound and incontinence specialist. Addressing contributing

health issues, such as diabetes and obesity, also

may help improve patient outcomes.

AN

Access references at ?p=337447.

At the time of manuscript submission through to acceptance, Armi

Earlam worked as a clinical trial recruiter for Indegene. Her background includes working as a lead certified wound, ostomy, and

continence nurse. Lisa Woods is a wound, ostomy and continence

nurse and nurse educator residing in Littleton, Colorado.



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