Skin health can be an overlooked part of managing incontinence. However, maintaining the skin barrier and preventing breakdown is critical for your health. Your skin is the gateway to your entire body and serves many important functions. Incontinence can quickly break down the skin’s defensive barriers and cause a host of issues such as pain, itching, wounds, and serious infections. Prevention is always key when reviewing incontinence skin care tips, but knowing what to do if issues arise can be just as important.
As a nurse, I am always watching for changes in the skin or signs that could indicate damage is occurring. These are the things nurses are watching for when someone has incontinence.
Changes in Skin Color
Changes in skin color can be one of the first signs a nurse sees that indicates skin damage is already occurring. Changes in skin color vary based on ethnicity and race, so it is important not to assume that skin is healthy based on lack of redness or obvious discoloration. For darker skin tones, instead of seeing a dark reddened color, you may see a dusky, grayish, or purple discoloration. Darker skin tones have more melanin, which makes it harder for us to see the red color that can appear under or at the surface of the skin.
Color changes we see in the skin and what they can indicate
Pink/red- Pink and reddened skin areas are among the most commonly seen colors. They can indicate inflammation, rashes, dermatitis, or deeper issues such as a pressure injury. Anytime pink or reddened areas are seen on the skin, it is important to consult with a health care provider promptly.
Pink or red areas that blanch when gently pressed can be classified as blanchable or non-blanchable. This means that when you press on the colored area, the skin color will change to a lighter color (blanchable), or it will remain the same pink or red color (non-blanchable). This is important to note since non-blanchable areas indicate the development of pressure injuries. Blanchable areas that appear shiny, wet, and more rash-like and are not directly over bones are more likely to be dermatitis (a rash).
Purple/blue/red- These colorations will again vary by skin tone; on lighter skin, it can indicate bruising or a suspected deep tissue injury. On darker skin, it can indicate the same but may appear more purple and maroon or have a dusky or grayish appearance as well.
Determining whether it’s a bruise or a suspected deep tissue injury is important because one will heal on its own while the other can turn into a pressure injury. Suspected deep tissue pressure injuries can also present with an intact fluid-filled blister. Notify a healthcare provider immediately if you see these skin changes.
Moisture That Doesn’t Go Away
Moisture is a well-known risk factor for skin damage, and the risk is significantly increased with incontinence. Anytime urine or feces has direct and prolonged contact with the skin, it can change the skin’s natural pH, making it more permeable, fragile, and at risk for breakdown. When people are incontinent, they are likely to use incontinence products, which can cause further changes to the skin’s environment. Incontinence products, especially those that are not sized correctly or made of non-breathable materials, can increase the temperature, humidity, and friction of the skin in the perineal area (the area a diaper or incontinence product covers).
As a nurse, I watch for moisture that doesn’t go away because it often leads to incontinence-associated dermatitis (IAD), which can also lead to open skin and infections. The best way to reduce moisture against the skin is to use well-fitting and breathable protective underwear. Not all products are made the same, and the wrong one can cause skin issues and frustration from leaks. Products, such as those made by LivDry, offer an absorbent gel core covered by soft, breathable materials that draw moisture away from the body while providing a dry surface that is in direct contact with your skin. Even the best-made products need to be changed routinely to prevent moisture build-up.
Skin Breakdown and Open Areas
This one may be obvious, but skin breakdown can occur quicker than you think. Leaving open skin in the perineal area to see if it heals on its own increases the risk for further damage and infection. Open skin that is in constant contact with urine or feces can become infected quickly and be difficult to heal. As a nurse, I always make sure any open area or compromised skin (such as a rash or redness) is treated immediately and monitored until healed.
The Connection Between Pressure Injuries and Incontinence
Pressure injuries can occur when there is prolonged pressure on bony prominences. The pressure causes damage to the skin and underlying tissues. Incontinence-related skin issues and pressure injuries frequently happen together, as the skin can become damaged and deteriorate quickly when there is pressure and moisture involved. Pressure injuries related to incontinence typically occur over the sacrum (the triangular bone at the lower back) or the ischial tuberosity ( better known as the “sit bones”; they are the bones you feel when sitting down, especially on hard surfaces). These areas are impacted by incontinence and pressure injuries as they are prone to increased pressure and frequent moisture from incontinence.
What Nurses Do to Protect the Skin
Protecting the skin from incontinence is a multi-layered approach. It can also depend on how mobile the person is, how frequently they are incontinent, their overall health, and any other contributing factors to skin health such as chronic conditions that also impact the skin. In general, these steps can help maintain skin integrity, prevent skin issues, and also help manage skin breakdown if it occurs.
- Keep the skin clean and dry: This is easier said than done when someone is experiencing incontinence, but it is essential to limit how much time urine and feces have contact with the skin. Using absorbent tabbed incontinence briefs that wick moisture away from the skin can go a long way. Any time urine comes in contact with the skin, the skin needs to be gently cleansed to help restore a normal pH. This can be done by bathing, using adult cleansing wipes or non-rinse cleansers. It is important to be gentle with cleansing and avoid products the person is allergic to.
- Use barrier products: Barrier products are creams, wipes, and sprays that can be applied directly to the skin. They are used to create a waterproof barrier between the skin and any urine it comes into contact with. Barrier products should be left in place and not scrubbed off, as this can damage the skin.
- Use the correct incontinence products: Using the right product and size ensures the product can work correctly. This includes measuring the body and comparing it to the manufacturer’s sizing chart. It is also important to use the right product and absorbency level for each person’s needs. Consulting an incontinence product guide or product catalog can help you get a better idea of different options.
- Identify and address skin changes promptly: Ideally, skin should be assessed daily. Breakdown can occur quickly, and the sooner it is noticed, the better. Taking extra time while bathing and changing incontinence products to look at the skin in the perineal area will help identify small changes such as new red areas, spots that are staying moist, or any open areas. When even small changes are noticed, it is important to notify your healthcare provider to receive guidance on treatment.
Other Skin issues that can arise from incontinence
Determining what type of skin issue is occurring can be difficult; it is always best to consult with a healthcare provider before treating. Beyond skin breakdown and pressure injuries, several other skin conditions can arise from incontinence, and it can be helpful to understand them. Many of these skin issues fall under the umbrella term of moisture-associated skin damage.
Allergic contact dermatitis- This can be difficult to distinguish from incontinence-associated dermatitis, as the skin appearance may be similar. However, with IAD, the skin will quickly heal when urine and feces are no longer contacting the skin. With allergic dermatitis, the skin will take longer to heal, and healing only begins when the allergen is discovered and removed. Allergic dermatitis can frequently be caused by cleansers and wipes used to remove urine from the skin; because of this, it is always best to avoid anything scented or things not designed for the sensitive perineal area of the skin.
Yeast- This is a common infection that occurs along with incontinence-associated dermatitis, as yeast thrives in warm and moist environments. Yeast is a generalized term, as there are many different types, with Candida albicans being the most common. Yeast can appear as scaly white areas, sometimes with small pustules or fluid-filled bumps spreading away from the main area, and a foul odor.
Intertrigo- Intertrigo is similar to IAD, but it only occurs in skin folds versus covering a large area of the buttocks or perineal region. Skin folds can trap additional moisture and heat and also sustain friction from incontinence products, underwear, and clothing. Intertrigo can occur even without contact with urine as it forms from the body’s heat and moisture in the folds.
What Nurses Want Every Caregiver to Remember
Skin care is an important part of incontinence management. Prevention and early intervention for incontinence-related skin issues, if they arise, can help reduce the risk of more serious issues such as pressure injuries or infections. Remember to check the skin daily and notify a healthcare provider right away if any areas of concern are seen.
