Incontinence-associated

dermatitis and Candida infection;

Current evidence and practice

Dr Jill Campbell RN

Clinical Nurse, Skin Integrity Service,

Royal Brisbane & Women’s Hospital.

Visiting Fellow, Faculty of Health,

Queensland University of Technology

Royal Brisbane and Women’s Hospital Metro North Health Service District

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• Rapidly ageing population • Increasing complexity of resident health status • Increasing chronic disease burden • Ageing workforce • Staff recruitment & retention challenges • Increasing cost & shrinking financial resources • The requirement for safe and quality care • New aged standards

Dr Jill Campbell

The perfect storm of challenges for 21st century aged care

Perhaps we deliver skin integrity care in silos?

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Do the multiple skin integrity silos have different priorities depending on the most pressing need ?

Or, is there one predominant skin silo that resources are directed to in response to the imperatives of

safety, governance and reputation?

In the context of multiple & competing demands how can we deliver quality, evidence-based skin integrity

care for our residents?

Dr Jill Campbell

However, these approaches may result in…

• Omission

• Duplication

• Fragmentation

• Confusion; for residents and staff

• Conflict & competing interests

• A narrow focus on a single condition can result in a narrow and disconnected solution

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Campbell, Coyer & Osborne (2014)

Dr Jill Campbell

Campbell, Coyer & Osborne (2014)

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Skin Safety Model

Conceptual Framework

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Campbell, Coyer & Osborne (2014)

Dr Jill Campbell

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Skin Injury; Potential Contributing Factors in RAC

Vulnerable Frail Skin

Situational Stressors

Resident Factors

Systems and

Process Factors

Dr Jill Campbell

A closer look at skin injury contributing factors

Resident Factors

• Advanced age

• Multiple chronic conditions

• Medications

• Poor nutrition/hydration

• Impaired cognition

• Impaired mobility

• Altered sensation

• Altered circulation & oxygenation

• Pain

Systems/Processes

• Funding models

• Staff levels & skill mix

• Governance

• Culture

• Safety culture/ procedures

• Handover/clinical communication

• Clinical equipment & resources

• Skin care processes & products

• Continence management

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Contributing factors contd…

Situational stressors

• Acute illness (eg UTI, URTI)

• Acute delirium

• Pain

• Depression

• Psychosocial stressors

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Skin Injury; Exacerbating elements in RAC

Potential Skin Injury

Skin irritants

Perspiration

Urine/faeces

Wound/stoma effluent

Medical adhesives

Pressure

Shear

Friction

Microclimate

Dr Jill Campbell

Potential skin injuries may be…

• Pressure Injury

• Skin Tear

• Moisture-associated skin damage;

– IAD

– Intertriginous dermatitis

– Peri-wound/peri-stomal skin damage

– Saliva related injury

• Medical-adhesive related skin injury

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Lived experience of a skin injury

• Pain

• Infection

• Chronic wound

• Disability

• Disfigurement

• Potential adverse impact on functional status

• Depression/distress

• Isolation

• Impaired wellbeing

• Increased cost

• Burden of frequent dressing changes

• Death Augustin et al (2012)

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Reconceptualising how we deliver skin care

• Skin safety approach provides a holistic unifying framework that integrates multiple risk factors

• Different skin injuries can have multiple shared risk factors

• Risk factors interact & can be highly individual

• Risk factors can change over time

• Systems & processes can contribute to injury

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Moving on to look at IAD

Dr Jill Campbell

IAD – What it is • A reactive skin response to chronic exposure to urine

& faeces-+

• Could be observed as inflammation, erythema

• +/- erosion

• A threat to skin integrity in incontinent patients (Beeckman et al 2015, Doughty et al 2012, Gray et al, 2007, Gray et al, 2012)

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• Pressure injury

• Skin tear

• Medical-adhesive related skin injury

• Moisture-associated skin damage caused by moisture other than urine and /or faeces.

HOWEVER; all of these skin injuries may occur concurrently with IAD.

Thorough assessment and accurate skin-injury identification is essential for appropriate management

IAD- What it isn’t

Dr Jill Campbell

• Moisture lesions

• Perineal dermatitis

• Incontinence dermatitis

• Contact dermatitis

• Intertrigo

• Heat rash

• Excoriation

• Pressure ulcer

• Nappy rash (Gray et al 2007)

IAD – lots of names

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IAD prevalence in aged care

ranges from

5-30%

Arnold-Long & Reed (2012), Beeckman et al (2012),

Bliss et al (2007), Boronat-Garrido, Kottner, Schmitz

& Lahmann (2016). ,

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Causative factors for IAD

1. Type of incontinence

2. Frequency of incontinent episodes

Beeckman et al (2

Beeckman et al 2015

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IAD Complications • Pain; can be severe & is compared to pain of a

burn Decreased quality of life, loss of

independence, disruption to activities /sleep

• Increased burden and cost of care

• Increased length of hospital stay

IAD predisposes to;

• Pressure injury

• Infection, eg Candida albicans

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If an individual is incontinent they are at risk of IAD

If an individual is continent, any pelvic skin injury is not IAD

Beeckman et al (2015).

Dr Jill Campbell

Download from: www.woundsinternational.com Beeckman et al (2015).

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IAD Categorisation Tool

Beeckman et. al, 2015 Dr Jill Campbell 23

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Beeckman et al (2018)

IAD Prevention

2 key interventions cited in literature;

• Manage incontinence

• Implement a structured skin care regimen

– Cleanse

– Protect

– Restore

Beeckman et al 2015

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A severity-based approach to treatment

Beeckman et al 2015

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Candida albicans • Candida albicans is the most common fungal

commensal organism in humans

• Colonises gastrointestinal & genitourinary tract 30-60% healthy individuals

• Can transform from commensal to pathogen

• Candida infection is reported as a frequent complication of IAD (one study found fungal infection in patients with IAD 32%) Campbell et al 2016

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Recognising Candida infection • Mainstay of diagnosis is clinical assessment/ visual

inspection followed by empirical treatment

• Microbiological testing (swabs) often not collected

• Candida infection may present as a central maculopapular rash with characteristic satellite lesions at margins of erythema

• Confluent non-specific rash/erythema

• May be thick, yellowish/white discharge, often in skin folds

• Remember, these presentations are not unique to Candida infections Campbell et al (2016).

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Clinical presentations of Candida infection

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Treating Candida infection

• Thorough skin inspection and clinical assessment

• Topical antifungal medication if clinical presentation of Candida

• Ensure full course of topical medication applied.

• Consider Candida Rx if not responding to best-practice skin care

• Consider topical anti-inflammatory as a pain and symptom management strategy.

• Topical steroid does not treat the fungal infection

• Evaluate response to treatment

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IAD pain; similar to burn pain

Junkin Selekof (2007)

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References

• Arnold-Long, M., Reed, L., Dunning, K., & Ying, J. (2011). Incontinence-associated dermatitis in a long-term acute care facility: Findings from a 12 week prospective study. Journal of Wound Ostomy & Continence Nursing, 38(3S), S7-S7

• Augustin, M., Carville, K., Clark, M., Curran, J., Flour, M., Lindholm, C., … &Young, T. (2012). International

consensus: Optimising wellbeing in people living with a wound. An expert working group review. London: Wounds

International. Retrieved from http://www.woundsinternational.com/media/issues/554/files/content_10309.pdf

• Beeckman D, Campbell J, Campbell K, et al. (2015). Proceedings of the Global IAD expert Panel. Incontinence-associated dermatitis: Moving prevention forward. Wounds International. www.woundsinternational.com accessed 20.9.18

• Beeckman D, Van den Bussche K, et al. (2018). Towards an international language for incontinence-associated dermatitis (IAD): design and evaluation of psychometric properties of the Ghent Global IAD Categorization Tool (GLOBIAD) in 30 countries. British Journal Dermatology. Jun; 178(6):1331-1340

• Campbell, J., Coyer, F., & Osborne, S. (2015). The Skin Safety Model: Reconceptualising skin vulnerability in

older patients. Journal of Nursing Scholarship, 48(1), 14-22.

• Campbell J., Coyer F., Mudge A., Robertson I., & Osborne S. (2016). Candida albicans colonisation, continence

status and incontinence-associated dermatitis in the acute care setting: A pilot study. International Wound Journal,

doi: 10.1111/iwj.12630

• Doughty, D. (2012). Differential assessment of trunk wounds: Pressure ulceration versus incontinence-associated

dermatitis versus intertriginous dermatitis. Ostomy Wound Management, 58(4), 20.

• Gray M, Bliss D, Doughty D, Ermer-Seltun J, Kennedy-Evans K, Palmer M. (2007). Incontinence-associated

dermatitis: A consensus. Journal Wound Ostomy Continence Nursing. 34(1):45-56.

• Gray, M., Beeckman, D., Bliss, D. Z., Fader, M., Logan, S., Junkin, J., . . . & Kurz, P. (2012). Incontinence-

associated dermatitis: A comprehensive review and update. Journal of Wound Ostomy & Continence Nursing,

39(1), 61-74.

• Junkin J, Selekof J. (2007). Prevalence of incontinence and associated skin injury in the acute care inpatient. J

Journal Wound, Ostomy & Continence Nursing. 2007;34(3):260-269.

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