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aintaining perineal skin integrity is one of the biggest challenges in long-term and extended-care settings, where 50 to 70 percent of patients suffer from urinary incontinence.¹ A breach in the perineal area’s vulnerable skin can be devastating, especially in the elderly. Elderly skin is more prone to assault and trauma and less able to withstand injury than younger skin because of its decreased barrier protection and epidermal turnover rate and reduced natural protection from sebum. Bodily waste, namely urine and feces, usually causes damage to skin in the institutionalized elderly.
Perineal skin injury has been found in as many as one-third of hospitalized adults.² How can we combat this ever-vexing problem? Read on for tips to combat incontinent dermatitis, denudation, Candida infections, and pressure ulcers.

Moisture

       Skin moisture and wetness from incontinence can be risk factors for skin breakdown.³ Moisture alters the resiliency of the epidermis and exposes it to external factors.
Bodily waste can also be particularly caustic to the skin. Fecal material contains more than 500 different organisms that can irritate perineal skin. Incontinent dermatitis occurs when urine contacts the skin—especially dry, cracked, elderly skin—for a prolonged period of time, providing a breeding ground for bacteria. The pediatric population is also affected by incontinent dermatitis.
       Compromised pediatric skin is prone to diaper dermatitis if incontinence and proper perineal practices are not followed. Additionally, ammonia increases the pH of the skin, reducing its protective acid mantle and causing chemical irritation. Fecal incontinence and urinary incontinence form a recipe for disaster. When feces pass along the gastrointestinal tract, the digestive enzymes that break down food are gradually inactivated. However, if feces come in contact with urine, the urine converts to ammonia—reactivating the enzymes, increasing the pH, further irritating the skin, and upsetting the bacterial balance. With
Clostridium difficile (C. difficile), the bowel mucosa is swollen and unable to absorb liquid or break down digestive enzymes, and the stool transit time is decreased and results in enzyme-rich and caustic diarrhea, causing a chemical burn to the unprotected skin.⁴

Perineal Assessment and Risk

       Though rarely used in clinical practice, the literature describes two different assessment tools, the Perineal Dermatitis Grading Scale and the Perirectal Skin Assessment Tool (PSAT). The PSAT measures the degree of skin breakdown, while the Perineal Dermatitis Grading Scale is more like a wound and skin assessment, specifically targeting location of dermatitis, skin color and integrity, amount of skin involvement, and symptoms, such as pain. The scale also includes an area for a brief description of the skin assessment or the patient’s symptoms.⁵
       A new validated tool developed by Nix can be used to assess risk for perineal skin damage.² The Perineal Assessment Tool (PAT) is an instrument that identifies four determinants of perineal skin breakdown: duration of irritant, intensity and type of irritant, perineal skin condition, and contributing factors causing diarrhea.
       Each sub-scale reflects degrees of risk factors. All sub-scales are rated from 1 (least risk) to 3 (most risk). Each rating has a descriptor and a description of each level of the scale. Total scores can range from 4 (least risk) to 12 (most risk). A score between 4 and 6 on the PAT scale is considered a low risk, and a score between 7 and 12 is considered a high risk (see Table 1).
       Consider adding this tool to your assessment sheet along with your Braden Risk Assessment Score and recording it on a weekly basis. A care plan can be developed using specific skin care products, based on the patient’s PAT score—evidence-based perineal care at its best!

Case Study

       Ms. Smythe is 89 years old and incontinent of soft stool. The staff is changing her linens about every three to four hours, she has redness and signs of dermatitis, and she also suffers from frequent urinary tract infections (UTIs) with antibiotic use and poor appetite.
       Her score would be 8, since she scores a 2 on each of the four parameters. She is considered high risk and should be evaluated for a specific perineal care plan, including a silicone or paste-type barrier cream.

Routine Care

       Prophylactic skin care should be the mantra in your facility. Gentle skin cleansers and moisturizers for every patient are mandatory. When incontinence rears its ugly head, we are obliged to charge forth with more than just the basics. The care plan entails three easy steps: clean, moisturize, and protect.

Clean
       Cleansing can be as simple as soap and water, but soap and hot water can be extremely damaging to the skin, especially the delicate perineal region. Easier to use and healthier are soap-free cleansers that contain gentle pH-balanced surfactants to maintain the skin’s acid mantle.
       Sprays and foams are simple and cost-effective options for quick cleanups. Some require rinsing, while others do not; some have a fragrance, and others are fragrance free. Some even contain protectant ingredients, such as dimethicone, to soothe and protect the skin. Foams (e.g., Soothe & Cool® Foaming No-Rinse Perineal Wash, Medline Industries, Inc., Mundelein, Illinois) are great because of their ability to “self-scrub” or lift and separate the debris by nature of the bubbling action. They stay in place without dripping or running and are cost effective.
       Another option is pre-moistened wipes, which save time and decrease the need for wash cloths and linen use. They are extremely convenient, and staff appreciate the ease of use with this method of cleansing. Some, such as ReadyCleanse™ with Dimethicone (Medline), also have a built-in protectant. Other examples are Comfort Shield® Perineal Care Washcloths by Sage Products, Inc. (Cary, Illinois) and Aloetouch® Premium Cleansing Cloths by Medline.
       Other all-in-one products clean, moisturize, and provide a light barrier in one step. One clinical trial showed promise in saving time and money by using unique products, such as Aloe Vesta® 3-n-1 Cleansing Foam by ConvaTec, a Bristol-Myers Squibb Co. (Princeton, New Jersey) and Peri Fresh 3-n-1 Cream by Medline.²

Moisturize

       Moisturizing is the second step and should take place whenever water comes in contact with the skin, i.e., after a bath, shower, or incontinence cleanup. Lotions, creams, and ointments provide immediate protection from superficial dehydration. A head-to-toe approach is a good insurance policy for all patients, regardless of whether risk is substantiated.
       Skin hydration is paramount to prevention of perineal skin problems. Lotions and creams help seal in the skin’s moisture by preventing water loss and lubricating dry, aging skin. A rule of thumb is the dryer the skin, the thicker the product you should be applying. Remember to always seal the moisture in immediately after cleaning or bathing.
       There are hundreds of products to choose from in this category. Choose wisely, looking at more than just price. Keeping the environment adequately humidified is also important, especially in the winter months.

Protect

       Perhaps the most important step in caring for the incontinent patient’s perineal skin is protection. Protectants or barriers offer the skin a barricade from caustic substances, such as urine and feces. Petrolatum-containing ointments or creams are basic protectants. Examples include Baza® Clear Skin Protectant Ointment with Natural Vitamins A & D (Coloplast Corporation, Marietta, Georgia), Aloe Vesta® 2-n-1 Protective Ointment (ConvaTec), and Soothe & Cool Moisture Barrier Ointment (Medline).
       These products are suitable for the occasional incontinent episode or uncomplicated urinary incontinence, but they do not stand up to multiple incontinent episodes. Products containing dimethicone and zinc oxide are more substantial, holding up under mixed incontinence and incontinence of liquid and diarrhea stool. Products with dimethicone, such as Secura Dimethicone Protectant (Smith & Nephew, Largo, Florida) and Remedy Nutrashield (Medline), are perfect illustrations.
       Paste products, considered to be “second-generation” barrier products, are especially durable, because they adhere to both intact and denuded or open skin. They are purposely difficult to remove, so they remain on the skin and are effective for longer periods of time. Examples include Remedy Calazime Protectant Paste (Medline) and Calmoseptine Ointment (Calmoseptine, Inc., Huntington Beach, California). Products containing karaya gum are particularly tenacious and useful.
       Liquid copolymer film barriers also help protect intact skin. These products come in multi-use spray containers, single-use sachet packets, and pre-moistened applicators. The purpose is to create a plastic-like film that protects the skin from moisture.
       After applying the barrier, intertriginous areas (where skin touches skin, such as under the arms) should be held apart and allowed to dry or fanned dry. Beware of using alcohol-containing products if the resident has broken skin. If the skin is denuded or broken, copolymer-type barrier products, such as 3M™ Cavilon™ No Sting Barrier Film (3M Health Care, St. Paul, Minnesota) are a good choice.

Synergy

       Skin care systems available from most of the major skin care companies offer pH-balanced products that work synergistically to help cleanse, moisturize, and protect vulnerable perineal skin. Products to fit your facility’s needs can be chosen to match a custom skin care program developed especially for your residents’ skin care and perineal challenges. Smith & Nephew’s Secura line, 3M’s Cavilon line, and Medline’s Remedy line are good examples.

What’s Going On?

       Incontinence is not a normal part of the aging process. Patients may be incontinent for a number of reasons. Tube feedings, fecal impaction, or an overuse of antibiotics resulting in decreased bowel flora and opportunistic Clostridium difficile, for example, can cause fecal incontinence.
       Medication, a urinary tract infection, or the patient’s inability to reach the bathroom (as a result of either physical or mental conditions) can cause urinary incontinence. Consultation with a wound, ostomy, and continence nurse can offer the patient and facility relief as well as results. Once the cause of the incontinence is determined, the care plan can be developed to manage the problem.
       If the cause is reversible, patients need to be given frequent and scheduled voiding opportunities with positive reinforcement for staying dry and requesting help to toilet. Research has shown that a prompted voiding regimen can decrease the frequency of incontinent episodes in the elderly.⁶ The Wound, Ostomy, and Continence Nurses Society Guideline for the Prevention and Management of Pressure Ulcers recommends the following for managing incontinence:⁷
• Establish a bowel and bladder program for patients with incontinence
• Cleanse skin gently at each time of soiling with pH-balanced cleansers
• Use incontinence skin barriers (e.g., creams, ointments, pastes, and film-forming skin protectants) as needed to protect and maintain intact skin
• Select underpads, diapers, or briefs that are absorbent to wick incontinence moisture away from skin versus trapping the moisture against the skin, which causes maceration
• Consider using a pouching system or collection device to contain urine or stool to protect the skin from the effluent
• Consider short-term use of an indwelling catheter in situations where the severity of urinary incontinence has contributed to or may contaminate the pressure ulcer.

Incontinent Collectors, Briefs, and Underpads

       Indwelling catheters are not ideal long-term choices for your incontinent patients and can cause more problems than they solve. Containment devices and absorptive products are better selections, because they help manage urinary or fecal incontinence in addition to protecting the skin without causing further harm. Consider the use of collection devices, such as fecal incontinent collectors, external catheters, underpads, and adult briefs and diapers, as a part of your adjunctive treatment plan for those patients with incontinent skin issues. For example, Coloplast’s Conveen® Ultra Secure Self-Sealing Male External Catheter is easy to use and can prevent serious skin problems before they happen.
       A fairly new product that is receiving rave reviews is the Zassi Bowel Management System (BMS) by Zassi Medical Evolutions in Fernandina Beach, California (see Figure 1). This is a catheter system designed to safely and reliably divert, collect, and contain potentially harmful and contaminated gastrointestinal waste from bedridden and immobilized patients. The BMS does not damage the anal sphincter.
       Another similar product, the brand-new Flexi-Seal® FMS (Fecal Management System), is ConvaTec’s answer to reducing the risk of skin breakdown and infection and improving patient care for fecal management.
       These novel products offer fecal incontinence management and can also decrease the spread of serious infections, making them wonderful additions to the intensive care unit (ICU), for instance.
       Underpads, both disposable and reusable, have come a long way. The old-time plastic and paper linen savers do nothing to protect the skin; rather, they hold moisture, which can irritate the skin. Today, products like Medline’s Maxima Reusable Underpad and the Sahara Super Absorbent Reusable Underpad actively pull dangerous moisture from the patient’s skin.
       Adult incontinent briefs and diapers have also improved greatly. Advanced products have absorptive gel-core polymers that wick moisture away and provide a quick-drying surface for the skin. Gone are the days of cellulose-core diapers or laundered cloth diapers, which tend to make the skin more wet, can alter the skin’s pH, and can produce contact dermatitis. Good ones to try: Prevail® IB Full-Mat Adult Briefs (First Quality Products, Inc., Great Neck, New York) and Medline’s Protection Plus Ultra. Both come in several sizes appropriate for all of your clients’ needs.
       Sizing is supremely important. If the brief doesn’t fit the patient properly, you are sacrificing protection and possibly causing unintentional skin injuries. Make sure your staff is trained to fit adult incontinent briefs. Many incontinence care industry representatives offer training as a value-added service.

Denudation

       Denudation occurs when moist skin is further injured by friction, producing a loss of epidermis and a “raw” look (see Figure 2). This damage can occur during turning and repositioning or as a result of the patient sliding down in the bed or chair. Rough handling during activities of daily living, such as dressing or routine perineal care with rough wash cloths, can also cause denudation. The epidermis is eroded and the dermis is exposed—creating, in essence, a partial-thickness wound.
       How can we effectively treat this common perineal skin problem? Products that contain karaya gum provide a true barrier from incontinence and allow denuded skin to heal beneath the protection. They are a great place to start. Soothe & Cool Skin Paste (Medline) is a good one.

Fungus Among Us

       Patients with incontinence are often at risk for fungal infections, caused especially by yeast or Candida albicans. These fungi prefer a dark, moist place to check in and hide—and what better an area than the perineum. The risk is increased in incontinent individuals who have diabetes or are also receiving antibiotics or immunosuppressants.
       Candida often manifests as a maculopapular, angry-looking rash with small satellite lesions (see Figure 3). Yeast colonization and subsequent tissue destruction are sometimes mistaken for denudation. Commercial powders or creams containing 2-percent miconozole nitrate, such as Remedy Antifungal Powder and Cream (Medline) or Baza® Antifungal Moisture Skin Care Barrier Cream (Coloplast), are decent over-the-counter applications. Keep in mind that they must be used for a minimum of two weeks, even if the rash seems to be completely cleared prior to that.

Important but Often Forgotten Matters

       Important issues to consider when choosing perineal care products include staff acceptance, scented and non-scented varieties, simplicity of removal (both from the tube and/or container and the patient), ease of use, patient comfort, pH, effectiveness, caregiver time involvement, and product elegance. When trying these products, be sure to have the company representatives available for educational in-services and questions. Special posters, “road maps,” and reminders can be very helpful in promoting staff understanding and staff compliance.
       Educational programs should offer more than just product application. Continuing education units (CEUs) are a welcome value-added service from your manufacturers and distributors. Be sure to ask for them!

A Dry, Protected Perineum is a Healthy Perineum

       Now that you know the latest and greatest on protecting your patients’ perineal skin, you’re on the right track. If soap and water and a jar of petroleum jelly are on your formulary, consider asking your skin and wound care manufacturers and distributors to try some of the newer perineal cleansers, foams, and wipes and some of the advanced protectants and second-generation skin barriers. Your residents will be dry, and the rewards will be healthy perineal skin and decreased risk of wound development.

Suggested Reading

       Fantl JA, Newman DK, Colling J, et al. Clinical Practice Guideline Number 2 (1996 update): Urinary Incontinence in Adults: Acute and Chronic Management. Rockville, MD: US Department of Health and Human Services. Agency for Health Care Policy and Research; 1996. AHCPR Publication 96-082.

Helpful Websites

• Wound, Ostomy and Continence Nurses Society: http://www.wocn.org
• National Association for Continence: http://www.nafc.org