Incontinence- associated dermatitis - aca.uk.com

This Nursing Times Clinical Collection has been collated for the ACA Conference 2021

Clinical Collection

1: Risk factors for skin damage 3

2: Assessment, diagnosis and management 8

3: Systems for reporting skin damage 13

Practical procedures: Selecting and applying emollients to manage dry skin conditions 17

Incontinence-associated dermatitis

Incontinence-associated dermatitisContinence care is an essential nursing skill and all

nurses need to be aware of their vital role in continence

assessment and management. Nursing Times has had a

long association with the Association for Continence

Advice (ACA) and this year we have worked together to

produce a range of clinical articles. A selection of these

have been reproduced here in this special collection on

incontinence associated dermatitis (IAD).

It is estimated that 20-25% of people with continence

problems in hospital will experience IAD and it affects

around 41% of adults in long-term care (Page 3). It is

important that nurses understand this condition and this

collection provides a practice overview of the risk factors for

IAD (Page 3), the underlying pathophysiology and how to

assess and treat affected skin (Page 8). We also look at

current reporting systems for pressure ulceration and explain

the link between pressure damage and IAD (Page 13).

Finally, we have included a practical guide to application

of emollients which is an important part of the treatment

of IAD (Page 17).

The joint working relationship between the ACA and Nursing

Times ensures that general nurses have regular access to

articles on continence-related topics. We hope this clinical

collection will not only support you but also your team in

providing expert continence care for patients.

© EMAP Publishing 2021. This article is only for distribution to members of the Association for Continence Advice3 Nursing Times | Clinical Collection | Continence

Citation for this article: Yates A (2020) Incontinence-associated dermatitis 1: risk factors for skin damage. Nursing Times; 116: 3, 46-50

Moisture-associated skin damage (MASD) describes a group of skin conditions caused by contact between the skin and

excessive moisture including wound exu-date, perspiration, and urine and faeces. Common types of MASD are:l Incontinence-associated dermatitis

– chemical irritation caused by contact between the skin and urine and/or faeces;

l Intertriginous dermatitis – skin damage associated with sweat trapped in skin folds in areas with minimal air circulation;

l Peri-wound moisture-associated dermatitis – skin maceration and breakdown caused by excessive wound exudate;

l Peristomal moisture-associated dermatitis – inflammation and erosion of skin caused by moisture at the stoma/skin junction and extending outward (Dowsett and Allen, 2013). The pathophysiology of MASD is not

fully understood but multiple factors including moisture, skin-care regimens, changes in skin pH, presence of micro-organisms, and skin damage associated with pressure and friction all play a role. More

research is needed to establish how these fac-tors combine to result in skin damage and to inform prevention and treatment strategies.

Incontinence-associated dermatitis (IAD) has been described as a type of “irritant con-tact dermatitis” (Beeckman et al, 2015). It may be associated with infection and can occur on intact or damaged skin (Iblasi et al, 2019; Beeckman, 2017). IAD occurs in people who are incontinent of urine and/or faeces (Beeckman et al, 2015) and is one of the most common skin problems in this group (Iblasi et al, 2019; Van Damme et al, 2017; Van den Bussche et al, 2017). IAD is also known as per-ineal dermatitis, diaper rash, diaper/napkin/nappy dermatitis, napkin/nappy rash, irri-tant dermatitis, moisture lesions, or per-ineal rash (Beeckman et al, 2015).

Extent of the problemContinence problems are the main cause of IAD; NHS England (2018) estimates that: l 14 million adults in the UK are affected

by urinary incontinence;l >6.5 million adults experience

problems with bowel control. It also identified that one in ten of the UK

population experience faecal incontinence, with over half a million adults affected (NHS England, 2018). Nearly two-thirds of

Keywords Skin damage/Incontinence-associated dermatitis/Continence This article has been double-blind peer reviewed

Key points Moisture-associated skin damage describes a group of skin conditions caused by contact between the skin and excessive moisture

Incontinence-associated dermatitis falls into the overarching category of moisture-associated skin damage

Incontinence-associated dermatitis is caused by prolonged contact between the skin and urine and/or faeces

The precise pathophysiology of incontinence-associated dermatitis is not fully understood

Patients with suspected incontinence-associated dermatitis require a comprehensive continence and skin assessment

Incontinence-associated dermatitis 1: risk factors for skin damage

Author Ann Yates is director of continence services, Cardiff and Vale University Health Board.

Abstract Moisture-associated skin damage has many causes including contact with urine, faeces, perspiration and wound exudate. Incontinence-associated dermatitis occurs when there is contact between the skin and urine and/or faeces. This article, part 1 of a three-part series, explores the reasons why urine and faeces cause skin damage and outlines the risk factors for incontinence-associated dermatitis.

Citation Yates A (2020) Incontinence-associated dermatitis 1: risk factors for skin damage. Nursing Times; 116: 3, 46-50.

In this article...l Definitions of moisture-associated skin damage and incontinence-associated dermatitisl How urine and faeces damage the skinl Risk factors for incontinence-associated dermatitis

Clinical PracticeReviewMoisture-associated skin damage



Clinical PracticeReview

The corneocytes keep the skin hydrated, enhancing flexibility and elasticity. When incontinence occurs, excess water from urine and/or faeces is pulled into, and held within, the corneocytes (Beeckman et al, 2015), causing the skin to become overhy-drated, macerated and waterlogged.

At 4.6-5.5, the pH level of the skin is usu-ally acidic (Voegeli, 2016); this creates an acid mantle that helps to protect the body against infection. Exposure to urine makes the skin more alkaline. Urea, which is found in urine, is converted by skin bacteria to ammonia – this is alkaline breaking down the acid mantle, making the skin more susceptible to infection and/or IAD. Fig 3 outlines the skin changes caused by incontinence.

pathogens and excessive fluids (Woo et al, 2017). Other functions of the skin are detailed in Table 1. It is made up of three main layers: the epidermis, dermis and hypodermis (sub-cutaneous fatty tissue) (Fig 1). The outer layer of the epidermis, the stratum corneum, con-tains the protective building blocks often described as the ‘bricks and mortar’ of the skin. The bricks are protein-rich corneocytes, held together by lipid-rich matrix (mortar) and protein structures called desmosomes, which act as rivets (Voegeli, 2016) (Fig 2). The corneocytes are dead cells that start life as keratinocytes. These cells are formed in the basal epidermal layer of the skin; they migrate through the epidermis and differen-tiate before they degenerate and die.

people with faecal incontinence also have urinary incontinence – this is known as ‘double incontinence’ (National Institute for Health and Care Excellence, 2007).

Faecal incontinence is closely associated with age, and is more prevalent in residen-tial or nursing homes: one in three individ-uals in residential homes and two in three in nursing homes are affected (NHS Eng-land, 2007; NICE, 2015). However, these sta-tistics are likely to be underestimates given the stigma associated with the condition and its consequent under-reporting (Bedoya-Ronga and Currie, 2014).

Patients with a urinary catheter are not classified as incontinent, but leakage and the bypassing of urine can lead to them experiencing the symptoms of IAD.

Exact figures of individuals who experi-ence IAD are unknown but estimated preva-lence rates range from around 6-50% across different healthcare settings, patient popu-lations and age ranges (Woo et al, 2017). Beeckman (2017) estimated that 20-25% of people with continence problems in hos-pital will experience IAD, while Nix and Haugen (2010) suggested that IAD affects as many as 41% of adults in long-term care.

IAD can cause pain, considerable dis-comfort and distress (Yates, 2018); it can be difficult to diagnose, and time consuming and expensive to treat.

Why does IAD occur?The skin is the largest organ in the human body and provides a semi-permeable barrier that protects the body against mechanical damage, harmful irritants, infectious

Funded by an unrestricted educational grant from Essity

Fig 1. Structure of the skin

Epidermis

Dermis

Fat layer

Hair follicle

Nerve

Blood vessels

Sweat gland

SweatCapillaries

Hair

Oil

Sebaceous gland

Basement membrane

Melanocytes

Stratum corneum(keratin)

Table 1. Functions of the skinFunction Explanation

Protection l Acts as a protective barrier, preventing internal tissues being damaged by trauma, ultraviolet light, temperature changes, toxins, pathogenic microbes and chemical agents

Barrier to infection l Intact skin creates a physical barrier to infectionl The skin produces sebum, which is antibacterial and has an acidic pH of 4.6–5.5 (Voegeli, 2016);

this is known as the ‘acid mantle’l Corneocytes found in the stratum corneum – the outer layer of the epidermis – contain

substances that actively attract and hold water; this keeps the skin hydrated so it can function as a flexible barrier (Voegeli, 2016)

Production of vitamin D l This is produced by the skin in response to sunlight and is important for bone health

Maintenance of body temperature

l Heat is retained and lost from the body by vasoconstriction and vasodilation of blood vessels in the skin

Pain receptor l Nerve endings respond to painful stimuli and act as a protective mechanism to prompt the individual to move away from pain or discomfort

Production of melanin l This is responsible for skin colouring and protects against radiation damage from sunlight

Communication l The physical appearance of the skin can give us information about a patient’s health and wellbeing – for example, a yellow tinge can indicate jaundice

Source: Adapted from Yates (2018), Wounds UK (2012) FRAN

CESC

A CO

RRA



Patients with faecal incontinence are more likely to develop IAD compared with those who have urinary incontinence (Gray and Giuliano, 2018). This is because faeces contain biolytic (lipid-digesting) and prote-olytic (protein-digesting) enzymes that are damaging to the skin. Liquid faeces contain higher levels of digestive enzymes than formed stools, so patients with diarrhoea and faecal overflow are at increased risk of IAD (Beeckman et al, 2015). Those with double incontinence are at greatest risk of IAD (Gray and Giuliano, 2018); Fig 4 illus-trates how urine/faeces affects the skin.

Associated risk factors Although the key risk factor for IAD is incontinence, the factors determining risk of incontinence are multiple and complex. These can include: l Immobility;l Cognitive impairment;l Age.

The ageing process also affects the skin, and bowel and bladder function. As the skin ages, several physiological changes make it more prone to damage (Table 2).

Age-associated changes to bladder func-tion include decreased urinary flow as a result of conditions such as prostate enlargement, prolapse, poor detrusor con-traction and recurrent urinary tract infec-tions. Bowel function is affected by increased susceptibility to diverticular dis-ease or constipation with faecal impaction/overflow. These risks, while associated with ageing, are not exclusive to older people.

Continence issues can manifest at any time of life making anyone who is inconti-nent at risk of IAD (NHS England, 2018). The risks factors associated with IAD are sum-marised in Table 3.

Confusion between IAD and pressure ulcersAlthough the anatomical sites and general appearance of pressure ulcers and IAD are similar, the aetiology and treatments are dif-ferent. In practice, IAD is often misdiagnosed as pressure damage, which can lead to inap-propriate management (Iblasi et al, 2019) (see case study in Box 1). This year, NHS England and NHS Improvement (2020) published their patient safety CQUIN indicator for 2020-2021, one of which addresses the assessment and documentation of pressure ulcer risk in community hospitals and NHS-funded resi-dents in care homes. It aims to ensure that 60% of residents have a pressure ulcer risk assessment that meets NICE guidance with evidence of actions being taken to address identified risks. To ensure correct reporting,


Fig 3. Changes in the skin caused by incontinence

Fig 4. How urine/faeces affects the skin

Sources: Yates (2018), Beeckman et al (2015)

Sources: Yates (2018); Voegeli (2016); Beeckman et al (2015)

MacerationOver-exposure to moisture

(waterlogged)Once skin is macerated even gentle

rubbing with bed linen or washing can cause damage

Bacterial infectionIncontinence exposes the skin to

bacteria found in urine and faeces. Cracks and fissures associated with dry skin provides an ideal environment for

bacterial growth

Exposure to caustic agentsAmmonia found in urine increases skin

pH causing irritation and provides a nutritional source for bacteria

Fungal infectionDamp, warm skin associated with

incontinence is ideal for proliferation of pathogenic fungi

Fig 2. Structure of corneocytes

Intracellular lipid layers between the corneocytes

Corneocyte

Desmosome

FRAN

CESC

A CO

RRA

Incontinence-associated dermatitis

Breakdown of the skin due to over exposure to urine and

faeces

IAD

Water from urine/faeces is pulled in and held in

the corneocytesThis leads to

overhydration and damage to the acid mantle of the skin,

which is usually pH4.6-5.5

Causes disruption to the structure of the skin leading to macerationIrritants penetrate the

stratum corneum leading to inflammation

Skin becomes prone to injury

Skin becomes more alkaline due to

formation of ammonia

Liquid faeces is more damaging than solid stools as it has higher

levels of digestive emzymes

Double incontinence is more damaging than urine or faeces alone





Table 3. Contributory risks factors for the development of incontinence-associated dermatitis Incontinence l Urinary – incontinence or leakage from a device, such as an indwelling urinary catheter

l Faecal – diarrhoea/formed stool l Double – faecal and urinary

Frequent incontinence episodes Risks are higher in people who have faecal or double incontinence

Prolonged exposure to urine and faeces

This may be due to:l Infrequent change of incontinence products l Poor skin cleansing l Ineffective equipment/appliance, such as an indwelling catheter or faecal-management system

that regularly leaks

Poor initial continence assessment

This leads to: l Mismanagement of symptomsl Inappropriate interventionsl Over-reliance on containment products

Inappropriate assessment for pad products

Problems include selecting the wrong absorbency: absorbency that is too high can be just as damaging as absorbency that is too low

Inappropriate use of pad products

This includes practices such as: l Double padding l Infrequent changes of pad products Absorbent products or incontinence-containment devices (especially if plastic-backed) may cause over-hydration by holding moisture against the skin surface

Use of incorrect products on skin

Thick, occlusive skin protectants (such as petroleum jelly and zinc oxide) may inhibit urine/faeces uptake by absorbent incontinence products, causing over-hydration of the stratum corneum

Frequent skin cleansing with water and soap

This damages the corneocytes, removing lipids, increasing dryness and creating friction, which leads to damage in the skin barrier function

Inability to perform personal hygiene

This is a particular issue if patients are reliant on carers to cleanse their skin and change pad products after incontinence episodes

Compromised mobility Patients who are immobile are significantly more likely to experience IAD than those who are mobile (Iblasi et al, 2019)

Diminished cognitive awareness

Patients with dementia may no longer recognise the need to go to the toilet or be able to identify the toilet, leading to a potential risk of continence problems

Medication Antibiotics can cause diarrhoea, which can increase risk of IAD. Immunosuppressants and steroids can cause skin fragility, skin thinning and increased risk of bruising

Poor nutritional status This has a negative effect on skin health, hydration and healing

Critical illness This can lead to increased risk of incontinence and poor overall skin condition

Source: Adapted from Gray and Giulano (2018), Yates (2018) and Beeckman et al (2015)

Table 2. Effects of ageing on the skinPhysiological change Effect on the patient

Thinning of epidermis and dermis l Skin becomes more delicate/fragile and prone to damage from friction, moisture and trauma (Wounds UK, 2012; Voegeli, 2007)

l Thinning of the dermis leads to a reduction of blood vessels, nerve endings and collagen, which results in a decrease in sensation, rigidity and moisture retention, as well as poor temperature control (Wounds UK, 2012)

Decrease in production of sebum l Skin becomes itchy and dry, with cracks and crevices (Watkins, 2011), and is more susceptible to damage from washing, rubbing and drying

20% decrease in volume of skin layer l Skin has a paper-thin appearance (Wounds UK, 2012). Damaged skin takes longer to repair so healing time is increased

Flattening of dermo-epidermal junction between the epidermis and dermis (Wounds UK, 2012; Voegeli, 2007)

l A decrease in elasticity causes skin to stretch (Wounds UK, 2012; Voegeli, 2007). Sweat and blood vessels respond less well to heat and individuals may become more susceptible to cold/hypothermia (Wounds UK, 2012; Voegeli, 2007). The skin bruises easily

Decrease in underlying fat l Decreased protection against ultraviolet light

Source: Adapted from Yates (2018)



Management. nice.org.uk/cg49 Nix D, Haugen V (2010) Prevention and management of incontinence-associated dermatitis. Drugs and Aging; 27: 6, 491–496.Van Damme N et al (2017) Independent risk factors for the development of skin erosion due to incontinence (incontinence-associated dermatitis category 2) in nursing home residents: results from a multivariate binary regression analysis. International Wound Journal; 14: 5, 801–810.Van den Bussche K et al (2017) CONSIDER – Core Outcome Set in IAD Research: study protocol for establishing a core set of outcomes and measurements in incontinence-associated dermatitis research. Journal of Advanced Nursing; 73: 10, 2473–2483. Voegeli D (2016) Incontinence-associated dermatitis: new insights into an old problem. British Journal of Nursing; 25: 5, 256–262.Voegeli D (2007) Factors that exacerbate skin breakdown and ulceration. In: Voegeli D et al (eds) Skin Breakdown: The Silent Epidemic. Hull: Smith and Nephew Foundation.Watkins J (2011) Early identification of skin problems in older patients. British Journal of Healthcare Assistants; 5: 9, 424–428.Woo KY et al (2017) Management of moisture-associated skin damage: a scoping review. Advances in Skin Wound Care; 30: 11, 494-501. Wounds UK (2012) Best Practice Statement: Care of the Older Person’s Skin. London: Wounds UK.Yates A (2018) Preventing skin damage and incontinence-associated dermatitis in older people. British Journal of Nursing; 27: 2, 76–77.

impairment. The nature of normal skin ageing and the potential problems associ-ated with that, along with additional risk factors, means IAD is often misdiagnosed and mismanaged as the underlying conti-nence problem is often not addressed. Edu-cation in the fields of IAD and continence is lacking but needs to be improved. NT

ReferencesBedoya-Ronga A, Currie I (2014) Improving the management of urinary incontinence. Practitioner; 258: 1769, 21–24.Beeckman D et al (2015) Proceedings of the Global IAD Expert Panel. Incontinence-associated Dermatitis: Moving Prevention Forward. Bit.ly/IADPanelBeeckman D (2017) A decade of research on incontinence-associated dermatitis (IAD): evidence, knowledge gaps and next steps. Journal of Tissue Viability; 26: 1, 47–56.Dowsett C, Allen L (2013) Moisture Associated Skin Damage. Made Easy. Wounds UK; 9: 4, 1-4.Gray M, Giuliano KK (2018) Incontinence-associated dermatitis, characteristics and relationship to pressure injury: a multisite epidemiologic analysis. Journal of Wound, Ostomy and Continence Nursing; 45: 1, 63-67.Iblasi A et al (2019) Incontinence-associated dermatitis: a gap in practice. Wounds Middle East; 6: 2, 6-10.NHS England (2018) Excellence in Continence Care: Practical Guidance for Commissioners, and Leaders in Health and Social Care. Bit.ly/NHSContinenceCare NHS England, NHS Improvement (2020)Commissioning for Quality andInnovation (CQUIN). CCG indicator specifications for 2020-2021. Bit.ly/NHSCQUINNational Institute for Health and Care Excellence (2007) Faecal Incontinence in Adults:

staff must be able to distinguish between IAD and pressure ulcer damage as part of a rou-tine skin assessment and provide an appro-priate individualised plan of care.

It is important to be aware that those who experience IAD are also prone to pressure damage, especially in the sacral and peri-neum areas. This will be covered in detail in part 3 of this series.

ConclusionIAD is caused by continence problems but many factors contribute to its development, such as poor mobility and cognitive

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Incontinence-associated dermatitis series

Part 1: Risk factors MarPart 2: Prevention and treatment AprPart 3: Reporting skin damage May

CLINICAL SERIES

Box 1. Case studyWendy Simmonds is community team leader, tissue viability nurse, Cardiff and Vale University Health Board

Grace Simpson, aged 82, lives alone and is confined to a wheelchair or bed as a result of spina bifida. She has a urostomy, type 2 diabetes and has had an above-ankle amputation. Management of her bowels comprises daily manual evacuations and use of an anal plug to prevent faecal leakage. Formation of a stoma is not possible due to Ms Simpson’s condition and she was reluctant to have surgery. Poor mobility and other comorbidities have also resulted in a history of pressure ulcers to her labia and left ischial tuberosity.

Following a recent hospital admission, Ms Simpson’s bowel-care regimen was changed: use of the anal plug was discontinued and care reduced to alternate days as she had developed an anal fissure. This resulted in an increase in faeces leaking onto the surrounding skin, with subsequent moisture damage, increased skin maceration and contamination of the pressure ulcer on the left ischial tuberosity. The skin surrounding the pressure ulcers, anal fissure and labia showed evidence of moderate-to-severe moisture damage; the pressure ulcers became clinically infected and leaked copious amounts of exudate, which added to the moisture-associated skin damage.

Following our local pathway for incontinence-associated dermatitis (IAD), the aim of treatment was to repair and restore the integrity of the skin using a foam incontinence cleanser and skin-protectant ointment after each episode of incontinence. We protected the skin around the wounds with barrier film and, once

skin hydration was restored to normal, we aimed to maintain this with a barrier cream or ointment, depending on further risks of exposing the skin to moisture. Additional actions included: lTreating the pressure ulcers with topical antimicrobial of

flamazine and hydrofibre dressing twice daily to manage the exudate. Bed rest was advised, with frequent repositioning and limited time sitting in a chair

lReviewing the bowel-management regimen with the local continence service, and reinstating daily bowel care and use of an anal plug

lReviewing pressure redistribution equipment and seating lArranging a referral to the nutrition and diabetic teams to

review Ms Simpson’s diet intake and diabetic management, especially as her dietary intake had significantly reduced in the community and her blood-glucose control was poor.Reverting back to Ms Simpson’s daily manual evacuations

and use of the anal plug resulted in an improvement in her skin. The moisture damage was resolved and her skin is now managed with a skin cleanser and barrier film. The pressure ulcers are still present but are no longer infected or at risk of contamination from faeces. *The patient’s name has been changed

Points for reflectionlWhat was the direct cause of IAD in this case study?lUsing the information in Table 2 and Table 3 explain the

contributing factors for IADlWhat steps would you take to avoid this situation occurring?


Citation for this article: Flanagan M (2020) Incontinence-associated dermatitis 2: assessment, diagnosis and management. Nursing Times; 116: 4, 40-44

The most important function of the skin is to provide a semi- permeable barrier to protect the body from the external environ-

ment. After episodes of incontinence, effective skin care is essential to maintain skin integrity; however it is often taken for granted that nursing staff know how to care for skin and the topic is not given enough attention in undergraduate and postgraduate education. There is a growing body of evidence to support skin-care regimens that are based on gentle cleansing, moisturisation and applying a skin protectant as part of a structured protocol (Woo et al, 2017a; Beeckman et al, 2015).

Prevention of skin damage The prevention and management of incon-tinence-associated dermatitis (IAD) involves the following interventions:l Continence assessment and

management to minimise the risk of skin coming into contact with urine and/or faeces;

l Use of a structured skin-care regimen to protect vulnerable skin and help replenish the skin’s barrier function.

Both preventive and management inter-ventions for IAD should focus on main-taining or restoring an optimal skin condi-tion. In 2015, Beeckman et al – on behalf of a global IAD expert panel – recommended three integral components of a healthy skin-care regimen: l Skin cleansingl Skin protection;l Restoration of skin barrier function

(Fig 1). They emphasised that the presence of

urinary and/or faecal incontinence, even without other risk factors, should immedi-ately trigger the implementation of an IAD prevention protocol to protect the skin from exposure to irritants (Beeckman et al, 2015).

Continence promotion Continence promotion is a fundamental part of an IAD preventive strategy; it starts with a detailed assessment of the patient to identify the likely cause and to establish an appropriate treatment plan. The correct use of continence devices, such as body-worn pads, urinary sheaths and stool-diversion systems, is also essential.

Body-worn absorbent pads may be required as a short- or long-term measure

Keywords Incontinence-associated dermatitis/Assessment/Management This article has been double-blind peer reviewed

Key points Incontinence-associated dermatitis results from exposure of the skin to urine and/or faeces and is not caused by pressure or shear

Skin breakdown is largely preventable if effective and relatively inexpensive interventions are implemented

The impact of skin breakdown on quality of life is often ignored by policy makers and health professionals

Skin-care regimens that include cleansing, hydration and protection are beneficial as they help to restore and maintain the skin’s barrier function

There is a lack of high-quality clinical evidence to guide the use of skin-care protocols in clinical practice so further research is urgently required

Incontinence-associated dermatitis 2: assessment, diagnosis and management

Author Madeleine Flanagan is principal lecturer and programme lead, MSc clinical dermatology and MSc skin integrity and wound management, University of Hertfordshire.

Abstract Incontinence often has a detrimental effect on skin integrity as a variety of factors including moisture, increased humidity, alkaline skin pH, incontinence and use of antibiotics can contribute to the development of incontinence-associated dermatitis. This article, the second in a three-part series, focuses on strategies to maintain and support skin function, and minimise the effect of incontinence on skin health. Risk factors for incontinence-associated dermatitis are discussed in part 1.

Citation Flanagan M (2020) Incontinence-associated dermatitis 2: assessment, diagnosis and management. Nursing Times; 116: 4, 40-44.

In this article...l Strategies to prevent skin damage associated with incontinence l Diagnosing incontinence-associated dermatitis l How to manage incontinence-associated dermatitis if it occurs





extent and colour of any skin problem and the sites involved. Using touch can be helpful to gather information about the skin that may not always be obvious – for example, skin will feel warmer than the surrounding healthy tissue in the presence of early pressure damage (induration), inflammation (dermatitis) or localised infection (cellulitis) (Table 1).

Identifying IAD It is important to accurately differentiate between varying types of moisture-associ-ated skin damage to be able to make effec-tive management decisions and imple-ment appropriate interventions promptly (see part 1). Although specific IAD assess-ment tools exist, they do not adequately predict risk of IAD development (Beeckman et al, 2015); clinicians therefore need to develop a heightened awareness of risk factors contributing to this type of skin damage as it can occur rapidly in indi-viduals ranging from neonates to older people who are incontinent.

Observing the distribution and location of dermatitis on the body will help clini-cians differentiate IAD from other types of skin damage such as pressure injury and intertrigo (inflamed skin folds caused by exposure to perspiration, friction and bac-teria and fungi). Attention should be paid to skin folds or areas where moisture resulting from incontinence may be in contact with the skin for prolonged periods, such as the perineum, buttocks, gluteal fold, groin, thighs, lower back, lower abdomen and underneath containment devices. The skin should be inspected for signs of: l Erythema;l Maceration;l Erosion;l Oedema;

If the patient’s incontinence is not con-tained or resolved, specialist advice should be obtained from continence advisers (Palese and Carniel, 2011).

Skin examination It is essential to conduct a daily skin exami-nation to identify signs of IAD in patients who are incontinent of urine and/or faeces. Patients at high risk of IAD, such as those with diarrhoea, should have their skin exam-ined more frequently. Findings should be documented, with appropriate actions noted in the patient’s records and communicated to the multidisciplinary team (Woo et al, 2017b).

Some simple methods can help ensure members of the multidisciplinary team identify and describe skin problems in a consistent manner. For example, check for dry skin, signs of scratching (excoriation), rashes, skin tears and any signs of pressure damage. It is important to gain an idea of the shape, symmetry and distribution,

to manage symptoms. In recent years, new technology has greatly improved the fluid-handling properties of these products and they can form part of a structured skin-care regimen; they help to avoid occlusion and overhydration of the stratum corneum by drawing fluid away from the skin sur-face. However, it is vital to apply according to manufacturers’ instructions and patients are not positioned on several large absorbent pads as these may: l Wrinkle, causing localised pressure;l Increase skin humidity and perspiration;l Reduce the effectiveness of pressure-

relieving support surfaces (Beeckman et al, 2014). Some patients with IAD may benefit

from temporary use of an indwelling uri-nary catheter to protect the skin on a short-term basis. This should be discussed with the multidisciplinary team as it places the patient at risk of catheter-associated uri-nary tract infection and should only be implemented when non-invasive interven-tions have failed. If a catheter is considered necessary, it should be reviewed daily and removed as soon as clinically appropriate.

Skin excoriation caused by lipase and protease is associated with diarrhoea, which can cause sudden and extensive skin breakdown (see part 1); within a short time, the epidermis can become erythematous and inflamed (Park and Kim, 2014). Factors that might exacerbate liquid stool should be reviewed; these include antibiotic therapy and constipation with overflow diarrhoea, which should be managed appropriately before reverting to the use of faecal-management systems or a faecal pouch as they can be uncomfortable for patients and difficult to apply (Beeckman et al, 2015; Morris, 2011).


Fig 1. The principles of skin care

Table 1. Assessing skin changes Area of change Points to consider

Texture Is the skin rough, scaly, dry, cracked? Is there induration? Think about possible causes of damage

Maceration Are there signs of perspiration, incontinence, wound exudate?

Pain How does the patient describe the pain – for example, burning, stinging, sore?

Oedema Is the oedema pitting, non-pitting, dependent (gravity-related)?

Warmth Are there signs of inflammation, infection, non-blanchable erythema (early pressure damage)?

Coolness Are there clinical signs of ischaemia/necrosis and deep-tissue pressure damage?

Skin sensitivity Does the patient have a rash? Does the patient have prickling, tingling, itching?

Skinrestoration

Skincleansing

Skinprotection



l Blisters (vesicles, papules);l Cracking;l Signs of bacterial or fungal skin

infection (Zulkowski, 2012). Skin damage occurring on the sacrum

or the trochanters (hips) may be due to a combination of factors, including pres-sure injury, which is made worse if the skin is moist; this means the exact cause can be difficult to determine (Woo et al, 2017b).

Distinguishing between IAD and pressure ulcersA systematic review confirmed that indi-viduals with IAD are five times more likely to develop pressure ulcers than those who are continent; this is due to the combined effects of incontinence and high humidity, which affect the microclimate of the skin and increase vulnerability of the soft tis-sues to pressure, friction and shear (Beeckman et al, 2014).

NHS England and NHS Improvement’s (2020) patient safety Commissioning for Quality and Innovation indicator, which addresses the assessment and documenta-tion of pressure-ulcer risk in community hospitals and NHS-funded residents in care homes, highlights why staff must be able to distinguish between IAD and pres-sure-ulcer damage as part of a routine skin assessment and provide an appropriate individualised plan of care. Differentiating between the two can be difficult; a study of 100 wound care nurses found they could not consistently agree on the cause of skin damage in the gluteal cleft/buttocks when presented with a series of photographs (Mahoney et al, 2011). These differences can be subtle in clinical practice and a dif-ferential diagnosis may not be possible until a management protocol has been in place for several days and the response to treatment has been monitored.

If the aetiology of a patient’s skin damage is not clear, a standard bundle of skin-care interventions to manage both IAD and pres-sure-ulcer prevention should be imple-mented and regularly monitored. The use of a structured skin-care protocol for IAD can be very effective, resulting in a visible improvement in patient discomfort and skin condition within several days. Pressure ulcer and IAD reporting will be discussed in more detail in part 3 of this series.

Structured skin-care protocolSkin cleansingThere is no evidence to confirm the optimum frequency of skin cleansing for patients who are incontinent but Beeckman et al (2015) recommended that the skin of


patients who are incontinent should be cleansed at least once daily and after each episode of faecal incontinence. However, frequent and repeated skin cleansing can disrupt the skin’s barrier function so a bal-ance needs to be maintained between removing skin irritants and stripping the skin surface of its protective barrier.

Soap and water. Soap and water should be avoided for skin cleansing after an episode of incontinence as soap contains a mixture of alkalis and fatty acids that cause skin damage in several ways. The alkalis in soap are known to increase skin pH, which damages the acid mantel on the skin’s sur-face and increases the likelihood of skin breakdown. Both soaps and detergents are known as surfactants (short for surface-active agents) and contain lipophilic (fat-loving) molecules that strip dirt and lipids from the skin, thereby disrupting the deli-cate skin barrier function and allowing the skin to dry out and become itchy. These cumulative effects cause pruritus and dis-comfort, and initiate the itch-scratch cycle (Fig 2), which causes further excoriation and allows for the additional entry of path-ogens and irritants. One of the most effec-tive ways to treat itchy skin is to apply emollients frequently to build up intra-dermal lipids and rehydrate the skin, which soothes irritated sensory nerve end-ings (Langøen and Bianchi, 2013).

Perineal skin cleansers. Perineal skin cleansers are less damaging than soap and water, and help maintain a pH level that minimises disruption to the skin barrier (Woo et al, 2017a). They are available as: l Liquid solutions or lotions that may be

delivered using a spray bottle;

l A foam cleanser;l Impregnated cloth.

These liquid cleansers combine gentle detergents and surfactants to loosen and remove skin irritants, and usually have a pH range similar to that of normal skin (Gray et al, 2002). Many are designed not to be rinsed off the skin as they contain mois-turising agents to restore or preserve optimal barrier function; and are now con-sidered the treatment of choice (Beeckman et al, 2015). Liquid cleansers also eliminate friction caused by manual drying and save time (Beeckman et al, 2010).

Continence-care wipes. Convenient to use, continence-care wipes replace the need for water, soap and separate moisturisers (Voegeli, 2008). Made of smooth, non-woven material, they are impregnated with advanced formulations that can cleanse, moisturise and deodorise. Most contain dimethicone (an emollient-containing silicone), which forms a protective layer on the skin, sealing out moisture.

If skin needs to be dried it should always be gently patted, taking care to avoid mechanical injury. Vigorous massage should also be avoided as it can damage the micro-circulation.

Skin protection The mainstay of treatment for IAD is the restoration and maintenance of barrier function, avoidance of irritants and treat-ment of inflammation. The most effective way of achieving this is to apply bland (colour- and fragrance-free) emollients. The terms ‘emollient’ and ‘moisturiser’ are often used synonymously to describe top-ical substances applied to the skin to main-tain or repair barrier function; although

Fig 2. Disruption to the barrier function cycle of the skin

Irritant

Barrier damage

Scratch and excoriation

Irritationand itch Inflammation



both are lipids, emollients primarily work by occluding the epidermis and preventing water loss, while moisturisers add humec-tants (substances that bond with water molecules to increase water content) to the skin surface to improve hydration. Glyc-erin, sugars and collagen are effective water-binding agents that typically draw water from a humid environment; they enhance water absorption from the outer layer of skin (Voegeli, 2012) (Fig 3).

Moisturisers and emollients come in var-ious formulations: creams, ointments, gels, sprays, foams and lotions. Many people are sensitive to fragrances and preservatives in topical skin products; lanolin is frequently associated with skin sensitivities and should be avoided (Draelos, 2010). Generally, the more ‘greasy’ the topical product, the more effective it is at trapping moisture in the epi-dermis, thereby providing a better emol-lient effect. However, some moisturisers contain a mixture of emollients and humec-tants, and not all are able to restore the skin barrier function. In particular, humectants should not be used on wet, macerated skin as they will attract further moisture to the area. Box 1 (page 44) lists the principles of emollient and moisturiser use.

Complete emollient therapy is a skin-care regimen that uses emollient soap sub-stitutes, leave-on emollients and moistur-isers such as creams, lotions and ointments to moisturise the skin and maintain its bar-rier function. It is beneficial for any indi-vidual at high risk of skin breakdown.

Skin protectants aim to prevent skin breakdown after cleansing by isolating exposed skin from irritants and excess moisture. Liquid barrier films and mois-ture barrier creams or ointments are often used. The introduction of synthetic barrier products – which leave a thin, conform-able, protective polymer layer on the skin that is water repellent for several days – has proven cost effective at protecting skin from high levels of moisture (Woo et al, 2017a; Guest et al, 2011). Barrier films are convenient as they: l Can be applied to skin that is damaged

or intact;l Reduce maceration;l Do not sting as they are alcohol-free.

In the past, traditional skin barrier creams were applied in thick layers and not removed effectively, which could increase skin humidity and maceration, and reduce the absorbency of continence pads. Modern formulations of topical skin bar-rier creams minimise this problem and should be used in accordance with the manufacturer’s instructions.

Fig 3. How emollients/moisturisers affect the barrier function of the epidermis 3a. Intact and healthy barrier function

Keratinocytes formed in the skin’s basal epidermal layer migrate to the epidermis and mature before they degenerate and die. The dead cells (corneocytes) are surrounded by natural lipids, which maintain the skin’s barrier function and help minimise water loss.

3b. Failed barrier function

Failed barrier function due to incontinence-associated dermatitis disrupts sebum and intracellular lipids at the surface of the epidermis, allowing irritants to enter between the corneocytes and stimulate an inflammatory response in the dermis. Skin barrier dysfunction increases the risk of colonisation by micro-organisms and may lead to secondary infection.

3c. Restored barrier function

Barrier function of the epidermis has been restored due to treatment with emollients and moisturisers. The intracellular lipid layer has been temporarily substituted by moisturisers, which contain humectants, allowing the skin to recover its protective function to resist damage caused by contact with urea and ammonia.

Environmental hazards

Corneocyte

Desmosome

Sebum natural oil

Intercellular lipid matrix


Corneocyte

Desmosome

Sebum washed away

Intercellular lipid matrix dissolved


Corneocyte

Desmosome

Sebum natural oil

Intercellular lipid matrix

FRAN

CESC

A CO

RRA

Adapted from Flanagan M (2013)





Once the barrier function of the skin is damaged, micro-organisms may penetrate to increase the risk of secondary skin infec-tion. Topical antibacterial products should only be used in patients with IAD if there are clinical signs of secondary infection. Signs of infection include more pain and discomfort than previously, while the skin will be red, feel hot and be prone to breakdown. Anti-fungal creams or powders should only be used if candidiasis has been identified; this usually presents as a sore, red rash (Fig 4).

Managing skin lossIn severe IAD, superficial skin loss may be present; this can be extremely painful but will improve if a semi-occlusive dressing is applied. Dressings that absorb wound fluid but promote moist wound healing should be used. Many modern dressings are for-mulated with advanced adhesives to mini-mise skin trauma; among the most effec-tive are silicone dressings, which have been proven to reduce skin stripping to preserve the skin barrier function (Woo et al, 2017a).

Some modern dressings are specifically shaped to better conform to the anatomical profile of the sacrum, but successful dressing application in the perineal area is made more problematic by the presence of skin folds, creases, continuous moisture and soiling. Wound dressings that are soiled or saturated with exudate should be changed to avoid increasing skin humidity and keeping moisture in direct contact with the skin.

ConclusionThere is a growing body of evidence to sup-port the use of structured skin-care proto-cols that focus on cleansing, the applica-tion of emollients and the use of skin protectants. This approach should be rou-tinely adopted for individuals at risk of IAD to reduce the likelihood of skin damage. Nurses need to work closely with members of the multidisciplinary team who have the relevant expertise – such as dermatology and continence specialists – to raise aware-ness of the importance of skin health. Fur-ther research is urgently needed to

establish the effectiveness of specific skin-care interventions and to validate best practice so carers can effectively support and maintain skin integrity. NT

References Beeckman D (2015) Incontinence-associated Dermatitis: Moving Prevention Forward. Wounds International.Beeckman D et al (2014) A systematic review and meta-analysis of incontinence-associated dermatitis, incontinence, and moisture as risk factors for pressure ulcer development. Research in Nursing and Health; 37: 3, 204-218.Beeckman D et al (2010) What is the most effective method of preventing and treating incontinence-associated dermatitis? Nursing Times; 106: 38, 22-25.British Dermatological Nursing Group (2012) Best practice in emollient therapy: a statement for healthcare professionals. Dermatological Nursing; 11: 4, S1-S19.Draelos ZD (2010) Active agents in common skin care products. Plastic and Reconstructive Surgery; 125: 2, 719-724.Flanagan M (2013) Maintaining Skin Integrity (Ch 2). In: Wound Healing and Skin Integrity – Principles and Practice. Wiley.Gray M et al (2002) Perineal skin care for the incontinent patient. Advances in Skin and Wound Care; 15: 4, 170-178. Guest JF et al (2011) Clinical and economic evidence supporting a transparent barrier film dressing in incontinence-associated dermatitis and peri-wound skin protection. Journal of Wound Care; 20: 2, 76-84. Langøen A, Bianchi J (2013) Maintaining skin integrity. In: Flanagan M (ed) Wound Healing and Skin Integrity. Principles and Practice. Wiley.Mahoney M et al (2011) Issues related to accurate classification of buttocks wounds. Journal of Wound Ostomy and Continence Nursing; 38: 6, 635-642.Morris L (2011) Flexi-Seal® faecal management system for preventing and managing moisture lesions. Wounds UK; 7: 2, 88-93.NHS England and NHS Improvement (2020) Commissioning for Quality and Innovation (CQUIN). Guidance for 2020/21. NHS England and NHS Improvement.Palese A, Carniel G (2011) The effects of a multi-intervention incontinence care program on clinical, economic, and environmental outcomes. Journal of Wound Ostomy and Continence Nursing; 38: 2, 177-183.Park KH, Kim KS (2014) Effect of a structured skin care regimen on patients with fecal incontinence: a comparison cohort study. Journal of Wound Ostomy and Continence Nursing; 41: 2, 161-167.Voegeli D (2012) Moisture-associated skin damage: aetiology, prevention and treatment. British Journal of Nursing; 21: 9, 517-521.Voegeli D (2008) The effect of washing and drying practices on skin barrier function. Journal of Wound Ostomy and Continence Nursing; 35: 1, 84-90. Woo KY et al (2017a) Management of moisture-associated skin damage: a scoping review. Advances in Skin and Wound Care; 30: 11, 494-501.Woo KY et al (2017b) Exploration of pressure ulcer and related skin problems across the spectrum of health care settings in Ontario using administrative data. International Wound Journal; 14: 1, 24-30.Zulkowski K (2012) Diagnosing and treating moisture-associated skin damage. Advances in Skin and Wound Care; 25: 5, 231-236.

Incontinence-associated dermatitis series

Part 1: Risk factors MarPart 2: Prevention and treatment AprPart 3: Reporting skin damage May

CLINICAL SERIES


Fig 4. Skin candidiasis

ALAM

Y

Box 1. The principles of emollient and moisturiser use

lEmollients and moisturisers should be applied regularly before soiling and immediately after cleansing if the patient has been incontinent, to ensure maximum effect

lTo be effective emollients and moisturisers should be liberally appliedlEmollients and moisturisers should be applied to the skin using a stroking action in

the direction of hair growth, avoiding circular or rubbing motions to avoid folliculitis. They should be dotted over the skin and spread to leave a thin film on the skin

lA detailed explanation of how to use emollients should be provided to carers to encourage concordance and improve effectiveness

lComplete emollient therapy should be continued once the incontinence has been resolved as this will continue to support skin barrier function and protect the patient’s skin in the event of further incontinence

Sources: Beeckman et al (2015); British Dermatological Nursing Group (2012)

For more articles on continence, go to nursingtimes.net/continence


Citation for this article: Schofield A (2020) Incontinence-associated dermatitis 3: systems for reporting skin damage. Nursing Times; 116: 5, 23-26.

Pressure ulcers have an adverse effect on patients’ health and quality of life so their preven-tion, or accurate diagnosis and

management when they do occur, are vital to ensure safe and effective care; however, this is challenging for health professionals (Rutherford et al, 2018). Moisture-associ-ated skin damage (MASD) – and in par-ticular incontinence-associated derma-titis (IAD) – are often misdiagnosed as pressure damage and inappropriately reported at a local and national level. This misdiagnosis has implications for patients who may receive the wrong treatment, which can not only delay healing, but also lead to further skin breakdown.

Pressure ulcer reportingIn recent years there has been a focus on the incidence and prevalence of pressure ulcers and several initiatives have been introduced to reduce this avoidable harm.

The NHS Safety ThermometerThe NHS Safety Thermometer (safetyther-mometer.nhs.uk) provided a ‘temperature check’ on harm from pressure ulcers,

which could be used alongside other indi-cators – such as falls, venous thromboem-bolism and catheter-associated urinary tract infections – to measure progress in providing a harm-free care environment for patients. It allowed wards, teams and organisations to measure risk of harm during their working day – for example, at shift handover, during wards rounds or in other settings such as patients’ own homes.

In the author’s opinion, the thermom-eter system had its limitations and worked better in acute ward settings than in com-munity services. It required organisations to count – on a given day each month – the number of new and existing pressure ulcers. However, some trusts opted out of using the system, which meant there was no clear picture of the extent of the problem as not every organisation was reporting in the same way.

Following a consultation in 2019/20, national collection of NHS Safety Ther-mometer data ceased in April 2020. This was a response to concerns about the burden of data collection on clinical staff and to focus attention on new improve-ment initiatives.

Keywords Incontinence-associated dermatitis/Pressure ulcers/Assessment This article has been double-blind peer reviewed

Key points Pressure ulcer data collection is reported at local and national level

Moisture-associated skin damage is a risk factor for pressure ulcers

Local reporting of this damage enables the extent of the problem to be identified and steps to be taken to ensure appropriate management

Improved identification and management will contribute to pressure ulcer reduction

Incontinence-associated dermatitis 3: systems for reporting skin damage

Author Alison Schofield is tissue viability clinical nurse specialist, Northern Lincolnshire and Goole NHS Foundation Trust.

Abstract Moisture-associated skin damage – in particular, incontinence-associated dermatitis – is a risk factor for pressure ulceration. The two problems can occur independently in the same patient but require different treatment regimens. This final article in this three-part series describes current reporting systems for pressure ulceration and explains why moisture-associated skin damage has been included. Risk factors for incontinence-associated dermatitis are discussed in part 1, while part 2 focuses on strategies to maintain and support skin function.

Citation Schofield A (2020) Incontinence-associated dermatitis 3: systems for reporting skin damage. Nursing Times; 116: 5, 23-26.

In this article...● Patient safety initiatives to improve the assessment and reporting of pressure ulcers● How to distinguish between a pressure ulcer and moisture-associated skin damage● Why reporting of moisture-associated skin damage is important




highlights the importance of identifying MASD.

NHS Commissioning for Quality and Innovation framework 2020/21A new Commissioning for Quality and Innovation (CQUIN) 2020/21 framework, including assessment and documentation of pressure risk assessment, was intro-duced this year. It is expected to: ● Contribute to a reduction in the

number of pressure ulcers nationally;● Improve standards of care for residents

in nursing homes (NHS England, 2020). Patients to be included are community

hospital inpatients and NHS-funded resi-dents in care homes. The requirement is that 60% of adult inpatients or residents will: ● Receive a validated pressure ulcer risk

assessment;● Have an individualised plan of care

based on this assessment. This requires staff to have adequate

knowledge about pressure-related skin damage and MASD to ensure pressure damage is accurately diagnosed.

Due to the coronavirus pandemic, the CQUIN 2020/21 framework has been tem-porarily suspended but management of patient’s skin during this time must con-tinue to be a priority for all health profes-sionals providing patient care.

Categories of MASD and reportingMASD is the umbrella term for four clin-ical manifestations of the condition, which are outlined in Box 2.

Pressure ulcer frameworkA revised pressure ulcer definitions and measurement framework has been designed by NHS Improvement (2018a) (Box 1). It was developed to: ● Standardise the reporting of pressure

ulcers locally and nationally;● Ensure quality-improvement methods

are used to inform changes in practice and improve patient outcomes. The recommendations were designed to

be applied locally, with an expectation that full roll-out would occur in April 2019; trusts in England adopted the guidance, although some were delayed but the delay was supported by NHSI.

In the past, not all trusts reported on suspected deep-tissue injury or unstage-able pressure ulcers, but these are now included in reporting (NHSI, 2018a). NHSI also recommends that all moisture damage is reported locally, but agreement is required on what level or types of moisture damage – the different types of which are outlined in Box 2 – should be included. This is decided collaboratively and usually involves heads of nursing and tissue via-bility teams. Improved identification and management of MASD will contribute to pressure ulcer reduction as it is a high-risk factor for pressure, shear and friction forces on vulnerable skin (see Part 2).

Many education tools – such as React to Red (NHS England, 2015), which is aimed at care home providers – incorporate incontinence as a risk factor, and the aSSKINg framework (NHSI, 2018b) also


Box 1. Pressure ulcer definition and measurement framework

●A pressure ulcer is defined as “localised damage to the skin and/or underlying tissue, usually over a bony prominence (or related to a medical or other device), resulting from sustained pressure (including pressure associated with shear). The damage can be present as intact skin or an open ulcer and may be painful”

●A pressure ulcer that has developed due to the presence of a medical device should be referred to as a medical device-related pressure ulcer

●A pressure ulcer that has developed at the end of life due to skin failure should not be referred to as a Kennedy ulcer

●Organisations should follow the current system of categorising that is recommended in international guidelines – National Pressure Ulcer Advisory Panel et al (2014) – incorporating categories 1, 2, 3 and 4, including deep-tissue injury and unstageable pressure damage

●A pressure ulcer on admission is defined as a pressure ulcer that is observed during the skin assessment undertaken on admission to that service

●A new pressure ulcer within a setting is a pressure ulcer that it is first observed during the current episode of care

●MASD should be counted and reported in addition to pressure ulcers●Where skin damage is caused by a combination of MASD and pressure, it should

be reported based on the category of pressure damage

MASD = moisture-associated skin damage. Source: Adapted from NHS Improvement (2018a)

Box 2. Types of MASD

Intertriginous dermatitis ●Occurs wherever two skin surfaces

come into close contact with each other (Black et al, 2011)

●Common sites include under the breasts and, in children, it can be found in the folds of the neck (Voegeli, 2016)

●Related to perspiration, friction and bacterial/fungal bioburden

●In obese individuals, the skin folds are more pronounced and intertriginous dermatitis is often found in the abdominal or pubic panniculus (Voegeli, 2016)

Periwound MASD●Wound exudate contains proteolytic

enzymes that damage the stratum corneum

●Chronic wounds produce fluid with higher levels of proteolytic enzymes (Voegeli, 2016)

●The volume of exudate increases when infection is present (Vowden et al, 2015)

●Wound assessment and management includes correct product selection for exudate containment and barrier products for the periwound skin

Peristomal MASD●Commonly associated with colostomies

and ileostomies (Voegeli, 2016; Gray et al, 2013)

●Occurs when the surrounding skin comes into contact with liquid discharge from the stoma, leading to inflammation and excoriation

●Management includes: ● Selecting appropriate containment

devices ● Patient education in self-care ● A good skin care regimen

Incontinence-associated skin damage●The most commonly recognised form

of MASD●Caused by urine and/or faeces

(Beeckman, 2017)●Faeces contain enzymes that damage

the stratum corneum (Mugita et al, 2015)●Liquid faeces cause more damage than

solid faeces as the enzymes are more destructive (Campbell et al, 2016)

●Skin damage is usually found in the perianal area, although it can extend farther depending on the degree of the incontinence, speed and frequency with which the contaminants are removed from the skin (Beeckman, 2015)

MASD = moisture-associated skin damage.




● Erythema;● Presence of lesions (vesicles, papules,

pustules);● Erosion or denudation;● Signs of fungal or bacterial skin

infection. The assessment and management of

MASD is explored in detail in part 2.

Case study Mary Ellis (not the patient’s real name) is 57 years old and has spina bifida. She is a wheelchair user and lives with her hus-band, who is the main carer at home. She has loss of sensation below the waist and an ileal conduit. Mrs Ellis is reviewed annually at the spinal injuries hospital but otherwise attends her GP practice with any health problems. She has support from her husband, but is independent and leads a full life, including going on holiday, to the theatre and on shopping trips.

Presenting symptomsIn November 2018, Mr Ellis told the spe-cialist nurse practitioner at the GP surgery that he had noted a “crater” on his wife’s left buttock area that had “discharge and hardness on the surrounding skin”. Mrs Ellis was unaware of this as she had no sensation in the area. She preferred to care for her own hygiene needs but had been unaware that she was not removing faecal matter correctly from the skin after bowel care, and now has IAD.

Assessment and diagnosisOn assessment by the GP, two pressure ulcers were identified with necrotic tissue and purulent exudate, which was mal-odourous. The pressure ulcer categories were unstageable but highly likely to be category 4 once the non-viable tissue in the wound bed was debrided. Antibiotics were prescribed as the wound had clinical signs of spreading infection such as induration

as well as the underlying cause. Types of incontinence fall into three categories: ● Faecal incontinence (diarrhoea/formed

stool);● Double incontinence (faecal and

urinary);● Urinary incontinence.

When trying to distinguish between pressure damage and IAD, it is important to assess: ● Frequent episodes of incontinence

(especially faecal);● Use of occlusive containment products;● Poor skin condition;● Compromised mobility;● Diminished cognitive awareness;● Poor personal hygiene;● Pain;● Pyrexia;● Medication (immunosuppressants,

antibiotics);● Poor nutrition;● Critical illness.

The location of skin damage should also be considered; areas at risk of IAD include:● Perineum;● Perigenital areas;● Buttocks;● Gluteal fold;● Thighs;● Lower back;● Lower abdomen and skin folds (groin,

under large abdominal panniculus). These areas should be checked for the

following signs of IAD:● Maceration;

The revised reporting system estab-lished by NHSI – as outlined in NHSI (2018a) – encourages organisations to include all four types of MASD in local reporting systems as analysing incidents and clusters can lead to targeted education and better management in both acute and community settings. Some trusts have adopted separate categories for each type of MASD in their reporting, while others only report on incontinence-associated damage (IAD), which is the most common type (see Part 1). Specialist clinicians, such as tissue viability nurses, can help identify errors in categorisation of pressure ulcers and IAD, leading to more accurate pres-sure ulcer data.

The exact prevalence of IAD is not known and misdiagnosis, especially as a result of incorrectly distinguishing between IAD and category 2 pressure ulceration, is common. Clinicians are often faced with confusion and uncer-tainty when trying to diagnose superficial damage on the sacrum, which could be due to pressure damage, IAD or a combi-nation of both (National Pressure Ulcer Advisory Panel et al, 2014).

IAD is a recognised risk factor for pres-sure ulceration and the two conditions can coexist in an individual (Lachenbruch et al, 2016). Other risk factors, such as reduced mobility, which often coincide with incon-tinence, increase the incidence of pressure ulceration as the skin is fragile and vulner-able to forces such as shear and friction. The differences between pressure ulcers and moisture lesions are outlined in Table 1.

Accurate diagnosis of IADMisdiagnosis of IAD as pressure ulceration results in incorrect reporting both locally and nationally. Assessment tools that can help to identify moisture lesions include: ● The Perineal Assessment Tool (Nix,

2002); ● The Perirectal Skin Assessment Tool

(Storer-Brown, 1993); ● IAD Skin Condition Assessment Tool

(Kennedy et al, 1996);● Incontinence-associated Dermatitis

and its Severity (IADS) instrument (Borchert et al, 2010);

● The National Association of Tissue Viability Nurses Scotland’s skin excoriation tool (Healthcare Improvement Scotland, 2018).However, these should be used with

caution as they do not accurately assess patient risk (Beeckman, 2015) (see Part 2).

A baseline continence assessment is essential to identify the incontinence type,

Table 1. Differences between pressure ulcers and moisture lesions

Pressure ulcer Moisture lesion

Causation Usually pressure and/or shear are present

Moisture is usually present

Location More than likely over bony prominences

Less likely over bony prominences

Shape and edge Usually distinct edging and shape

Usually diffuse, rarely more than superficial

Depth Superficial or deep Superficial

Necrosis May be present Never present

Source: Defloor et al (2005)

“The exact prevalence of IAD is not known and misdiagnosis, especially as a result of incorrectly distinguishing between IAD and category 2 pressure ulceration, is common”




ReferencesBeeckman D (2017) A decade of research on Incontinence-Associated Dermatitis (IAD): Evidence, knowledge gaps and next steps. Journal of Tissue Viability; 26: 1, 47-56.Beeckman D (2015) Incontinence-associated dermatitis: moving prevention forward. Wounds International.Black JM et al (2011) MASD part 2: incontinence associated dermatitis and intertriginous dermatitis: a consensus. Journal of Wound Ostomy Continence Nursing; 38: 4, 359-7070. Borchert K et al (2010) The incontinence-associated dermatitis and its severity instrument: development and validation. Journal of Wound Ostomy Continence Nursing; 37: 5, 527-535.Campbell JL et al (2016) Incontinence-associated dermatitis: a cross-sectional prevalence study in the Australian acute care hospital setting. International Wound Journal; 13: 3, 403-411.Defloor T et al ( 2005) Pressure ulcer classification differentiation between pressure ulcers and moisture lesions. EPUAP Review; 6: 3, 81-85.Gray M et al (2013) Peristomal moisture-associated skin damage in adults with faecal ostomies: a comprehensive review and consensus. Journal of Wound Ostomy Continence Nursing; 40: 4, 389-399.Haesler E, Ousey K (2018) Evolution of the wound infection continuum. Wounds International; 9: 4, 6-10.Healthcare Improvement Scotland (2016) Scottish Excoriation & Moisture Related Skin Damage Tool. HIS.Kennedy K et al (1996) Cost-effectiveness Evaluation of a New Alcohol-free, Film-Forming Incontinence Skin Protectant . White Paper. 3M Healthcare.Lachenbruch C et al (2016) Pressure ulcer risk in the incontinent patient: analysis of incontinence and hospital acquired pressure ulcers from the International Pressure Ulcer Prevalence Survey. Journal of Wound Ostomy Continence Nursing; 43: 3, 235-241.Mugita Y et al (2015) Histopathology of incontinence-associated skin lesions: inner tissue damage due to invasion of proteolytic enzymes and bacteria in macerated rat skin. PLoS One; 10: 9, e0138117.National Pressure Ulcer Advisory Panel et al (2014) Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Cambridge Media.NHS England (2020) Commissioning for Quality and Innovation: CCG Indicator Specifications for 2020-2021. NHSE. NHS England (2015) React to Red: Reducing Pressure Ulcers in Care Home Settings. Atlas of Shared Learning. NHS England.NHS Improvement (2018a) Pressure Ulcers: Revised Definitions and Measurement. NHSI.NHS Improvement (2018b) Pressure Ulcer Core Curriculum. NHSI. Nix DH (2002) Validity and reliability of the Perineal Assessment Tool. Ostomy/Wound Management; 48: 2, 43-51.Rutherford C et al (2018) A patient-reported pressure ulcer health-related quality of life instrument for use in prevention trials (PU-QOL-P): psychometric evaluation. Health and Quality of Life Outcomes; 16: 1, 227. Storer-Brown D (1993) Perineal dermatitis: can we measure it? Ostomy Wound Management; 39: 7, 28-31. Voegeli D (2016) Incontinence-associated dermatitis: new insights into an old problem. British Journal of Nursing; 25: 5, 256-262.Vowden P et al (2015) Managing high viscosity exudate. Wounds UK; 11: 1, 56-60.

chair to bed, with evidence of skin damage caused by shearing across her thighs and buttocks. She slept in a double divan bed with her husband without a pressure-relieving mattress.

TreatmentThe local pathway for IAD was imple-mented; as the skin was broken a wash cleanser and barrier cream were pre-scribed, which addressed the problem caused by faecal enzymes on the skin. The aim of pressure ulcer treatment was debridement of purulent slough, and a top-ical negative pressure wound system was applied to the cavity to remove exudate and help reduced periwound excoriation.

Additional carer support was dis-cussed, and it was agreed that help would be provided for hygiene needs and preven-tion of further IAD. Following discussion with Mrs Ellis, a profiling bed with dynamic air mattress was put in place and regular bed rest was commenced with a repositioning plan. Once the IAD had resolved, a daily skin care plan was in place for carers to follow and a barrier product was prescribed.

OutcomeThe IAD resolved once the treatment plan was commenced and the pressure ulcer continued to heal after 10 months of man-agement by district nurses and Mrs Ellis performing pressure relief. Her skin con-dition is being maintained through appro-priate skin care, incontinence manage-ment and appropriate pressure relief.

ConclusionWith the introduction of the new defini-tions and measurement framework for pressure ulcers, it is now possible for health professionals to collect evidence and data for all types of MASD including IAD. Management strategies for both pres-sure ulcers and MASD need to be addressed and they should not be considered in isola-tion. It is important to detect skin damage in the early stages, whatever the cause – pressure or moisture – as this allows for preventative treatment plans to be put in place to stop further skin deterioration. There is a need for ongoing education and training in this area, alongside pressure ulcer prevention. NT

and increasing erythema; Mrs Ellis was showing signs of systemic infection – she experienced a loss of appetite and was feeling unwell.

According to the International Wound infection Continuum, systemic and top-ical antimicrobials are recommended at the point of spreading infection (Haesler and Ousey, 2018). IAD was also identified on the surrounding skin on the buttocks and thighs, with severe excoriation. Dress-ings were prescribed for the pressure ulcer, including an antimicrobial primary dressing, autolytic debridement of the slough and necrosis, and absorbency to protect the periwound edges. A barrier cream was also prescribed for the IAD, which was applied every 72 hours according to manufacturer’s instructions, after cleansing the skin with water and a pH-balanced cleanser.

A referral was made to the district nurses to provide a plan of care for Mrs Ellis at home, along with a referral to the surgical acute service to assess whether debridement and repair was required. The district nurses visited Mrs Ellis at home and completed a full holistic assessment including a thorough skin inspection. A referral to the tissue viability nurse was also made.

An aSSKINg risk assessment tool, which was developed locally by the tissue viability nurses and derived from NHSI’s (2018b) aSSKINg education curriculum, identified that Mrs Ellis spent long periods in her wheelchair. There was a pressure-relieving cushion provided by wheelchair services but this was inadequate. The pres-ence of IAD also made her skin very vulner-able to breakdown when moving from



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“Management strategies for pressure ulcers and MASD should not be considered in isolation”


Citation for this article: Lawton S (2020) Selecting and applying emollients to manage dry skin conditions. Nursing Times; 116: 11, 38-40.

Keywords Dry skin/Emollients/Moisturisers This article has been double-blind peer reviewed

Emollients, also known as moistur-isers, are the mainstay of treatments for dry skin conditions. The terms ‘moisturiser’ and ‘emollient’ are

often used interchangeably and describe their two main actions on the skin: to soften and increase hydration (Chiodo, 2008; Voegeli, 2007). This article outlines the prin-ciples and procedure for using emollients.

Properties and type of productEmollients are available in a variety of for-mulations: most are ‘leave-on’ products such as creams, ointments, gels, lotions and sprays that are applied directly to the skin and left to soak in; others are soap substitutes that avoid the drying effect of soap and have been designed to be used when washing, bathing and showering.

Recent literature does not advocate the prescription of bath or shower emollient preparations, as there is insufficient evi-dence of their clinical effectiveness to sup-port their use (Dowell, 2019). Patients should, instead, be advised to use their

normal leave-on emollients as soap substi-tutes when they wash, bathe and shower. Emollients are used to: l Cleanse the skin;l Remove old treatments;l Scale, hydrate and prepare the skin for

the application of topical treatments. Aqueous cream is no longer recom-

mended as a soap substitute or emollient as it contains sodium lauryl sulphate, which has a detrimental effect on skin bar-rier function (Danby et al, 2011).

Emollients can be further classified as:l Simple (no additional ingredients)

– these create a fine, moisture-retaining layer of non-physiologic lipid or oil, such as petrolatum or mineral oil, over the skin surface and, thereby, reduce water loss;

l Advanced – these hold water in the skin by using additional ingredients such as humectants (propylene glycol, lactic acid, urea and glycerol);

l Antipruritic (anti-itch) – these contain lauromacrogols, which have local anaesthetic properties to soothe itchy skin;

l Antibacterial – these contain antiseptics, such as benzalkonium chloride and chlorhexidine hydrochloride.The choice of emollient should not be

based on cost alone and several other fac-tors should be considered first (Van Zuuren et al, 2017; Moncrieff el al, 2013); the main points are listed in Box 1. Emollients should be prescribed in sufficient quanti-ties for patients to use them appropriately and experience the benefits of improved skin condition and reduced need for visits to health professionals (Roemmele, 2019).

Emollients should be used at least once daily. Some patients may need to apply them throughout the day, depending on the product type and severity of the under-lying skin condition; it is useful to give these patients smaller quantities, prefer-ably in containers supplied by the manu-facturer. If smaller quantities cannot be prescribed, emollients can be decanted from a large container into a smaller, clean cylindrical container (which should be washed or dried regularly) (British Derma-tological Nursing Group, 2012).

Clinical PracticePractical procedures Dermatology

Author Sandra Lawton is nurse consultant and clinical lead for dermatology, The Rotherham NHS Foundation Trust.

Abstract Regularly applying emollients is a fundamental aspect of care for patients with dry skin conditions, and choosing the most appropriate emollient is crucial to ensure their adherence to the prescribed regimen. This article outlines the principles for using emollients and the correct procedure to follow when applying them.

Citation Lawton S (2020) Selecting and applying emollients to manage dry skin conditions. Nursing Times; 116: 11, 38-40.

Selecting and applying emollients to manage dry skin conditions

Box 1. Factors to consider when prescribing an emollient lDryness of the skin, along with severity and stage of flare-upslPatients’ individual preference/tolerance and previous experiences of unwanted

effects such as stinging, burning and tingling, which are usually caused by a reaction to a certain ingredients (excipients) in the emollient. Sensitivities to excipients are not uncommon and should be checked before a prescription is issued; the British National Formulary lists all excipients in emollient preparations. Patients may also complain of overheating with thicker emollients

lProduct effectiveness and cosmetic acceptability – some patients may need to try or use several products before making their choice

lLifestyle factors and time of year – these may influence choice and use; it may be necessary to try a range of emollients before the best combination is settled upon

lSkin condition – creams and lotions are generally better for red, inflamed areas of skin because it is believed the evaporation of water-based products cools the skin; they are also less greasy and are often more cosmetically acceptable to patients than ointments. Ointments are preferable for dry skin (that is not inflamed) because they are more effective than creams; however, they are usually poorly tolerated by patients compared with creams, which may affect their acceptability and hence adherence. Ointments do not contain preservatives and may be more suitable for patients with sensitivities to these, but should not be used if infection is present

lPrescription quantity – adequate quantities (Table 1) should be prescribed; to treat the whole body, 600g per week should be prescribed for adults and 250-500g per week for children

lPatients should be given advice on the correct and safe use of emollients (Box 2)

Sources: Oakley and Lawton (2016); Moncrieff et al (2013)



to minimise the length of time the patient is exposed. Ensure the bed is at the correct working height.

6. Protect the floor with a sheet or towel to prevent a build-up of emollient and mini-mise the risk of slips and falls.

7. Decontaminate your hands and put on disposable gloves and an apron (Royal Col-lege of Nursing, 2020).

8. Ask the patient to describe their usual routine for washing, bathing and applying their emollients, and how much they are able to do independently.

9. If necessary, help the patient remove clothing covering the affected areas and use a sheet or gown to cover exposed areas.

10. If the emollient is in a tub, use a clean spoon or spatula to scoop it out – hands must not be used for this purpose (Fig 1). Pump dispensers for creams or lotions may be preferable, as they are cleaner and minimise the risk of antimicrobial contamination (British Dermatological Nursing Group, 2012).

1. Review the patient’s skin care needs in their care plan. Ensure someone is avail-able to provide assistance and chaperone you during the procedure if required.

2. Discuss the procedure with the patient, ask about their usual skin care routine and gain informed consent to apply emollients.

3. Ensure the patient’s privacy and check the environment is warm and draught free.

4. Check whether the patient wishes to use the toilet before starting the procedure.

5. Assemble your equipment close to hand

Applying emollients Equipment l Emollient product;l Topical medications (if required); l Single-use disposable apron and gloves;l Towels;l Patient gown;l Laundry skip;l Clean clothes and bed linen.

ProcedureThe following description outlines the pro-cedure when a nurse or carer is applying the emollient; however, patients should be given the opportunity to perform as much of the procedure as they can independently.

Box 2. Safety advice for patients and carers using emollients lDecanting – patients and carers should avoid putting their hands in emollient pots

and, instead, use a spoon or spatula to decant the product; this will reduce the risk of contamination causing infections

lFalls risk – patients should take care when entering and leaving the bath or shower if emollients have been used, due to the risk of slipping. Regular use of emollients at home or in care environments increases this risk because there will be a build-up of grease on the floor or bathroom facilities unless preventive measures are taken. The floor should be protected with a towel or bathmat; after using the emollient, the bath or shower should be washed with hot water and washing-up liquid (detergent) then rinsed well and dried with paper towels

lFire – patients should keep away from fire, flames and cigarettes when using any type of emollient (whether paraffin-based or not), as dressings, clothing and bedding that have been in contact with an emollient can easily catch fire. Even emollients with low or no paraffin content can act as accelerants in flammable and combustible fabrics, and these fires burn at higher temperatures. Washing fabrics at high temperatures may reduce the build-up of emollients, but does not remove them entirely. When fabric with dried-on cream comes into contact with a naked flame, the resulting fire burns quickly and intensely, and can cause serious injury or death. This risk increases with every application of the cream, as it transfers, dries and builds up on the fabric. Some cream remains even when items are washed, so it’s important to minimise the risk in additional ways, such as removing long-sleeved/loose clothing before cooking or using a safety lighter (Medical and Healthcare products Regulatory Agency, 2020)

lOxygen therapy – patients receiving oxygen therapy should be prescribed non-paraffin-based emollients and advised to take particular care about fire risk

Sources: Bit.ly/NHSEmollients; Hussain (2019); MHRA (2020)

Table 1. Quantity of emollient required per one-week prescriptiona Body site Cream or ointment Lotion

Face 15-30g 100ml

Hands 25-50g 200ml

Scalp 50-100g 200ml

Arms or legs 100-200g 200ml

Trunk 100-200g 500ml

Groin and genitalia 15-25g 100ml

aQuantities required will vary with the patient’s size and the severity and extent of skin dryness. For children, approximately half the amount stated is suitable. These recommendations do not apply to topical corticosteroids.

Source: Bit.ly/BNFDermPrep

Fig 1. Using emollient contained in a tub

JENN

IFER

N.R.

SMITH

1a. Use a spoon or spatula if emollient is contained in a tub

1b. Fingers must not be inserted into the tub even when gloves are worn

Clinical PracticePractical procedures



11. If the emollient is to be used for washing, showering or bathing, mix a small amount (around a teaspoonful) of emollient in the palm of your hand with a little warm water (Fig 2), gently spread it over damp or dry skin and then rinse it off. Pat the skin dry, taking care not to rub it.

12. After drying the skin, apply the leave-on emollient (this may be the one used for washing or may be a different product or formulation). Smoothe it gently onto the skin, in the direction of hair growth (Fig 3); this helps prevent hair follicles becoming blocked (folliculitis) (Bit.ly/NHSEmol-lients; Oakley and Morrison, 2014).

13. If other prescribed topical medications, such as topical steroids, are to be applied, allow the emollient to absorb into the skin for approximately 30 minutes before applying (Bit.ly/NHSEmollients).

14. If necessary, help the patient to dress.

15. Once the patient is warm and comfort-able, ensure the surrounding area is clean and dry to reduce the risk of slippage.

16. If used, clean the bath or shower with hot water and liquid detergent. Rinse well and dry with paper towels to prevent grease build-up and blocked drains.

17. Remove your apron and gloves, and

history of atopic dermatitis. British Journal of Dermatology; 165: 2, 329-334.Dowell G (2019) Prescribing of bath and shower preparations for dry and pruritic skin conditions. PrescQIPP Bulletin 244.Hussain F (2019) MHRA stakeholders meeting on fire hazards of emollients. The British Association of Dermatologists Newsletter; 22: 2, 20. Loveday HP et al (2014) epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection; 86: S1-S70.Medical and Healthcare products regulatory Authority (2020) Safe Use of Emollient Skin Creams to Treat Dry Skin Conditions. London: MHRA.Moncrieff G et al (2013) Use of emollients in dry-skin conditions: consensus statement. Clinical and Experimental Dermatology; 38: 3, 231-238.Oakley A, Morrison C (2014) Folliculitis. dermnetnz.org, April.Oakley R, Lawton S (2016) Views on unwanted effects of leave-on emollients and experiences surrounding their incidence. Dermatological Nursing; 15: 4, 38-43. Royal College of Nursing (2020) Tools of the Trade: Guidance for Health Care Staff on Glove Use and the Prevention of Work-related Contact Dermatitis. London: RCN.Ridd MJ et al (2019) Which emollients are effective and acceptable for eczema in children? British Medical Journal; 367: L5882.Roemmele S (2019) Emollient therapy in atopic dermatitis. Dermatology in Practice; 25: 3, 74-78.Van Zuuren EJ et al (2017). Emollients and moisturizers for eczema: abridged Cochrane systematic review including GRADE assessments. British Journal of Dermatology; 177: 5, 1256-1271.Voegeli D (2007) The role of emollients in the care of patients with dry skin. Nursing Standard; 22: 7, 62-68.

dispose of in line with local policy (Loveday et al, 2014). Decontaminate your hands.

18. Record the care undertaken, along with any abnormal findings and the skin condi-tion. Update the patient’s care plan.

ConclusionAlthough cost is an important considera-tion in all areas of healthcare, the pre-scribing of emollients should not only focus on this. The best and most cost-effec-tive emollient is the one the patient likes and will use as prescribed. There may be a trade-off between effectiveness and accept-ability, and the best emollient for patients may change over time and vary by body site and season (Ridd et al 2019). Their chosen emollients should be prescribed in suffi-cient quantities so they can use it appropri-ately and experience its benefits. NT

ReferencesBritish Dermatological Nursing Group (2012) Best practice in emollient therapy: a statement for healthcare professionals. Dermatological Nursing; 11: 4, S1-S19. Chiodo B (2008) The use of emollients in dry skin therapy. Journal of Community Nursing; 22: 10, 22-26. Danby SG et al (2011) The effect of aqueous cream BP on the skin barrier in volunteers with a previous

For more articles on dermatology, go to nursingtimes.net/dermatology

Clinical PracticePractical procedures

Professional responsibilitiesThis procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols.

Fig 2. Using emollient to wash, shower or bathe

Fig 3. Application of emollients

JENN

IFER

N.R.

SMITH

Mix a teaspoon of cream with a little warm water

Smooth the emollient onto the skin in the direction of hair growth

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