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Skin Care | Total Barrier Protection

Select an Irritant:

Urine | Faeces | Chronic Exudate | Skin Stripping 

Skin – particularly older or more vulnerable skin – can become damaged when exposed to excessive moisture, especially over prolonged periods of time. As the skin becomes more damp and soggy, its permeability to external irritants and microorganisms increases and it becomes much more susceptible to damage from forces, such as pressure, shear and friction (1). Part of the protective function of the skin is provided by its naturally acidic pH (2).

Urine

Urine can cause significant irritation to skin. In the case of exposure to urine, there are two main effects:

  • Skin becomes overhydrated as water from the urine is pulled into the skin cells, causing them to swell and disrupting their normal structure. This disruption affects the barrier function of the skin, rendering it more susceptible to penetration by irritants which can make the skin more inflamed(3). It is also well-documented that wet skin is more easily injured from friction from clothing, incontinence pads and bed linen, and this effect is worsened by components of urine (3,4). This in turn can also exacerbate the effects of pressure and shear forces and increase risk of pressure ulcers developing (5).
  • Urine contains urea, a substance which is a product of protein metabolism in the body. When urine comes into contact with skin, the bacteria naturally found on the skin surface convert the urea into ammonia. Ammonia is an alkaline substance which increases the acidic skin pH, thereby further affecting its barrier function and increasing the risk of microorganisms causing a skin infection (2).

The effect of urine on the skin can be reduced through ideally eliminating skin contact with urine by managing incontinence where possible, ensuring appropriate incontinence products are used and changed as frequently as required. Skin should be cleansed using a pH-balanced, skin friendly cleanser to prevent dryness and further disruption of skin pH, avoiding friction on the skin with aggressive washcloths and rubbing dry (2).

Skin contact with urine can also be minimised with application of a skin barrier protectant which places a transparent, waterproof layer onto the skin to repel moisture, maintain skin barrier function and pH and prevent the entry of irritants and microorganisms.

Faeces

Exposure to faeces can cause major skin irritation and breakdown. Alongside having the ability to cause overhydration of the skin in a similar way to urine, faeces also contains highly irritant digestive enzymes which disrupt the structure of the skin and erode the skin surface, destroying its natural barrier protection. These digestive enzymes are found in the highest number in liquid faeces (1), which leads to a potential for much higher levels of skin damage when the patient suffers from acute or chronic episodes of diarrhoea or faecal incontinence of liquid stool. This can also be a particular problem for some patients with stomas, particularly ileostomies, whereby the peristomal skin may be frequently exposed to liquid stool.

When urine and faeces are present together, the combination of the urea and digestive enzymes produce heightened effects which can lead to more severe irritation. The enzymes also act on urea to convert it to ammonia, further increasing the pH, which then encourages further activity of the digestive enzymes and also microorganisms, resulting in a vicious circle of increasing irritation which further injures vulnerable skin (6). Patients with mixed incontinence are at a much higher risk of developing incontinence-related skin damage for this reason (7).

The principles of preventing skin damage from faecal or mixed incontinence are fundamentally the same as for urinary incontinence – managing or treating the incontinence where possible, and provision of a structured skin care regime involving pH friendly, gentle cleansing and skin protection using barrier products.

Due to the potential for increased severity of skin damage with exposure to faeces or a combination of urine and faeces, a stronger, more durable type of skin barrier protectant may need to be applied in the form of a barrier film or skin protectant ointment.

Skin Care | Total Barrier Protection

Chronic Exudate

While it is normal for all wounds to produce wound fluid, known as exudate, as part of the normal healing process (8), when large or excessive amounts of exudate is produced and is in contact with surrounding skin for long periods, there is the potential for overhydration of the skin and resulting disruption of skin barrier function (9). Some wound types, particularly bigger wounds such as leg ulcers and pressure ulcers and burns, are known to produce larger amounts of exudate which can lead to damaging maceration of surrounding skin. Peri-wound skin maceration presents as pale, white, soggy, wrinkly skin and has the potential to lead to delayed healing, wound enlargement and increased risk of infection.

This is particularly the case for chronic wounds as chronic wound exudate has been shown to contain higher amounts of active protein-digesting enzymes (eg. Matrix Metalloproteinases (MMP’s)) and cell signalling molecules known to encourage inflammation (Pro-Inflammatory Cytokines) (10). These substances, alongside corrosive cellular debris, predispose to skin breakdown (11), especially when the skin is exposed to excessive amounts of exudate for prolonged periods. Chronic wounds are also more highly predisposed to wound infection, which can often encourage an increased production of exudate.

Peri-wound skin management is required to prevent damage from chronic wound exudate in the form of appropriate dressings and use of a skin barrier protectant (12). The right size dressing with an absorbency level appropriate to the amount of wound exudate being produced should be chosen and changed frequently enough to ensure fluid is wicked away from the wound surface (12). An appropriate skin protectant in the form of a barrier film should be applied to the surrounding skin to prevent skin contact with both the wound fluid and the damaging irritants it contains to further minimise the risk of peri-wound maceration and breakdown.

Skin Stripping

Wounds are often managed using occlusive or semi-occlusive dressings that absorb exudate and maintain a moist wound healing environment. Depending on the location of the wound and its local management, dressings with an adhesive border or tapes are used to fix the dressing to the surrounding skin. In the case of patients with stomas, adhesive pouches are applied to the skin to contain urinary or faecal output.

These dressings or pouches may need to be changed frequently, and in the case of chronic wounds and irreversible stomas, sometimes over very prolonged periods of time, thus providing the potential to cause skin stripping. Skin stripping is trauma or damage due to the repeated application and removal of adhesive tapes, dressings or devices to the same area of skin (13).

As the device is removed from the skin, the adhesive present can also remove skin cells (corneocytes) from the very top layer of the skin (the stratum corneum of the epidermis) to varying degrees, causing superficial skin damage. Removal of these skin cells can cause damage the skin barrier function as there is increased permeability of the skin to water and electrolytes and a change in pH (14). This also increases the susceptibility of the skin to chemicals and microorganisms, which can cause further irritation and even infection (15). If the skin is also already being exposed to wound exudate or waste products, the potential for skin damage increases further as already moist skin becomes further hydrated and vulnerable to trauma.

Removal of the skin cells and superficial stratum corneum can initiate a wound healing response with the potential for development of inflammation, including redness, swelling and blistering (15). This can also cause extreme discomfort and pain and can affect patients’ quality of life.

Medical adhesive removers incorporating silicone can assist with the gentle removal of adhesive dressings, tapes and pouches, by breaking the strong adhesive bonds and thus reducing the risk of skin trauma and pain/discomfort. These products do not contain alcohol therefore do not sting even when applied to damaged skin.

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REFERENCES

  1. Beeckman D, Schoonhoven L, Verhaeghe S, et al. (2009) Prevention and treatment of incontinence-associated dermatitis: literature review. J Adv Nurs; 65(6): 1141-54.
  2. Beeckman D et al. (2015) Proceedings of the Global IAD Expert Panel. Incontinence associated dermatitis: moving prevention forward. Wounds International; Available from woundsinternational.com.
  3. Gray M, Beeckman D, Bliss DZ, et al. (2012) Incontinence-associated dermatitis: a comprehensive review and update. J WOCN; 39(1): 61-74.
  4. Mayrovitz HN, Sims M. (2001) Biophysical effects of water and synthetic urine on skin. Adv Skin Wound Care; 14(6): 302-8.
  5. Clark M,Romanelli M, Reger SI et al. (2010) Microclimate in context. In: International Review. Pressure ulcer prevention: pressure, shear, friction and microclimate in context. A consensus document. London: Wounds International.
  6. Ersser SJ, Getliffe K, Voegeli D, Regan S (2005) A critical view of the interrelationship between skin vulnerability and urinary incontinence and related nursing intervention. Int J Nurs Stud; 42: 823-35.
  7. Campbell JL, Coyer FM, Osborne SR (2014) Incontinence-associated dermatitis: a cross-sectional prevalence study in the Australian acute care hospital setting. Int Wound J; doi:10.1111/iwj.12322
  8. Voegeli D (2013) Moisture-associated skin damage: an overview for community nurses. Br J Comm Nurs. 18(1):6-12.
  9. Weir D. Pressure ulcers: assessment, classification and management. In: Krasner D, Rodeheaver G, Sibbald RG, eds. (2001) Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, 3rd ed. Wayne, Pa: HMP Communications: 621
  10. World Union of Wound Healing Societies (WUWHS) (2007) Principles of best practice: Wound exudate and the role of dressings. A consensus document. London: MEP Ltd.
  11. Colwell JC,  Ratliff  CR,  Goldberg  M  et    (2011)  MASD  part  3:  peristomal moisture- associated dermatitis and periwound moisture-associated dermatitis: a consensus. J WOCN; 38(5): 541-53
  12. Woo KY, Ayello EA, Sibbald RG (2009) The skin and periwound skin disorders and management. Wound Healing Southern Africa; 2(2):1-6
  13. Lawton S, Langøen A (2009) Assessing and managing vulnerable periwound skin. World Wide Wounds. Available at: http://www.worldwidewounds.com/2009/October/Lawton-Langoen/vulnerable-skin-2.html.
  14. Wilhelm D, Elsne P, Maibach HI (1991) Standardised trauma (tape stripping) in human vulvar and forearm skin. Effects on transepidermal water loss, capacitance and pH. Acta Derm Venereol; 71: 123-126.
  15. Dykes PJ, Heggie R, Hill SA (2007) Effects of adhesive dressings on the stratum corneum of the skin. J Wound Care; 10: 7-10