Skin integrity: MASD, IAD & Incontinence
Best Practice and Evidence for Preventing and Managing IAD
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Hello, I'm Ruth Timmins and welcome to today's podcast on Moisture Associated Skin Damage. We are very pleased to be able to hear from our very special guest, who is a world-leading expert in this topic, Professor Dimitri Beeckman. He is a Professor of Skin Integrity and Clinical Nursing at Ghent University, and we're really honoured to have you with us today. So, welcome, Dimitri.
Thank you very much, Ruth, for having me today.
Yeah. So this is a really interesting topic. And I'm sure many of our audience are looking forward to hearing your thoughts on this. So, perhaps, first of all, could you give us an overview of the latest best practice recommendations on the prevention and management of moisture-associated skin damage and the document that was published last year, 2020?(1) And how can this help clinicians in their clinical practice?
Well, Ruth, that's a very good opening question, so thank you for that. So first of all, patients with risk factors for moisture-associated skin damage, they should be identified as early as possible. And then based on that systematic approach towards risk assessment, we have to initiate preventative measures as soon as possible. And what we also learned from the recent years in our research and clinical practice is that causal treatment is much more conducive to long-term success than just topical treatment. So, it's really focusing on the cause and then combining this with a good topical treatment. So, the topical treatment is based on the clinical presentation and it should be individualised. So, for MASD, the large amount of body fluids, they should be removed and kept away again from the skin by using appropriate adjuvants or products or devices. Absorbent products, they should consist of effective absorbents with a high retention capacity. We really recommend not using any occlusive products because they really promote MASD and they are contraindicated. The exposed skin as well as lesions, they should be gently cleansed first of all, gently cleansed with what we call a hypoallergenic, non-irritating product. The skin should also be cleansed only with products that do not require rinsing. We do not recommend any alkaline soaps and from our research, we recommend special moist and cleansing wipes or disposable cleansing system, especially the no-rinse products can be used without any water. So, those are recommended. And examples of those products are, for example, the foam. So, if you apply a foam on the skin, it will help to remove the dirt from stool, for example, from the skin, and it will not add any friction to the skin. So, that's the first step is really cleansing. So, after the cleansing, the skin should be dried but in a gentle way and we recommend never to rub or to blow dry. In cases of the presence of localised infection or a high-risk for infection, an anti-microbial or an antifungal treatment may be indicated, but this only after the appropriate diagnosis has been set. It's very difficult to make a distinction between skincare products and skin protection products as the ingredients there and the effects of those products, they are usually quite similar. Many skincare products, they also have protective effects. Skin protection products, they will serve to prevent or to minimise the direct contact of the skin with the body fluids because that is really fundamental. We have to protect the skin. We have to add and support the skin from actually body fluids and those products, they usually contain viscose lipophilic ingredients, such as, for example, petrolatum, paraffin or film formers such as, for example, the silicones, dimethicone and the acrylates. We also have to realise that most of the products that are available, they contain a combination of the ingredients that I just mentioned, and they can not only protect the skin, but they also have to support the regeneration of the skin after the irritation took place. We can use wipes, we can use sprays for applying those products to the skin, and in case of skin loss, we have to focus on reepithelialisation and that can be promoted by using skin protectants, for example, containing cyanoacrylates. In many cases, zinc or zinc oxide ointments are used and they are suitable as skin protection. But and that's an important consideration. It should be noted that many of these topical zinc oxide products, they are particularly viscose, skin-based, and they are difficult to remove and it will make the wound assessments more difficult. And my final point to answer your question, Ruth, is that if we apply such skin protectants, we always have to use the appropriate amounts and the appropriate frequency and we have to follow the manufacturer's instructions when applying. So that is really, in a nutshell, what we recommend in our Best Practice Document that we published last year.
OK, thank you, Dimitri. And I know MASD or moisture associated skin damages, sort of that umbrella term for several types of skin damage. But perhaps you could give a brief explanation of the different types and how they differ.
OK, well, that's a good question as well. This is about diagnosis. And as I mentioned in your first question is skin damage caused by bodily fluids is, as you said, known as moisture-associated skin damage, MASD. But this is mainly used in the English-speaking countries as a terminology and all these different skin damages, they have an important common feature. So, that feature is that the deterioration of skin integrity is due to the prolonged exposure to body fluids, such as, for example, urine, stool, sweats, wound exudates, associated physical irritative or chemical irritation. So, these are really common in the different skin conditions covered by the umbrella of MASD. There are many other comorbidities and co-factors that play an important role, for example, ageing, the general skin functioning and the structure, smoking, metabolic diseases, obesity, malnutrition. And in our 2020 Best Practice Document, the diseases, incontinence-associated dermatitis or IAD, intertriginous dermatitis or intertrigo, periwounds and peristomal dermatitis, they are presented in a differentiated manner. In each of these conditions, the diagnosis of the local wound infection is really crucial. And what our clinical signs of an infection that's erythema to the surrounding skin, an increase of temperature or heat, oedema, induration of swelling, pains, spontaneous pain, pressure pain and very important is a stalled wound healing and also the increase and/or the change of the colour and the smell of the exudate. So, in the document, we describe four different types of MASD. So, as I mentioned before, the peristomal dermatitis. And peristomal dermatitis is actually more, it's a toxic eczema around the site of, for example, a colostomy stoma. We have to realise that it occurs in between 30 and 67% of all stoma patients. So, this is not a little problem in our clinical practice. The second one is incontinence-associated dermatitis, and that is a skin inflammation after the contact with urine and/or faeces. And there are different anatomical predilection sites, for example, the perineal, the perianal, the buttocks and inside the thighs. And depending on the position of the body, the convex areas, they are most frequently affected. So, that's the second condition covered by the MASD umbrella. The third condition are diseases caused by sweats, occlusion, friction in body areas where the skin meets the skin. So, that means intertriginous and that's why we call them intertriginous dermatitis. So, the predilection sites, they include the armpits, the surmamaria area and also between the toes. And then the third condition that is associated with would exudate. And we know while the production of wound exudate is really vital to wound healing. If it is not managed effectively, the wound exudate can cause damage to the periwounds. Periwound skin damage or the periwound area at least, is particularly vulnerable to MASD. And we can observe this in quite a significant number of people. So, that's why we really have to consider periwound as an important aspect.
And how should we classify and document these different types of MASD please?
Oh, that's a very, very good question. It's about policymaking, it's about reimbursement. So, MASD currently is classified in the international classification of diseases. So, that's, let's say, a compendium by the WHO, the World Health Organisation. And it is classified as an irritant contact dermatitis. So, I would encourage the audience to visit the website of the WHO, search for ICD11 coding. And in that coding system, you will find MASD as a specific condition with the four different skin diseases that are covered by MASD with all the definitions, the criteria, et cetera. And just to go a little bit deeper in this question for incontinence-associated dermatitis, there is a specific classification system that we developed and published and disseminated as from 2018.(2). So, why did we develop a specific classification system for IAD? We know that IAD, it's highly prevalent among individuals suffering from incontinence. And what we've learned from research and clinical practice is that there is quite a huge heterogeneity in reported outcomes, there are many instruments and we really need a more standardised classification system. So, just to come back to the GLOBIAD. So, the GLOBIAD is a tool that consists of two main categories, persistent redness, irritation, inflammation. So, that is a category one. And the category two is the skin loss. Each category, both one and two, is subdivided into an A, and an A means without clinical signs of infection, and a B means with clinical signs of infection. You really have to remember that faeces, they contain large amounts of bacteria and fungi. And if the skin barrier is compromised, that skin contact may result yeah in frequent bacterial and/or fungal, what we call superinfections. So, that's why we decided to add a specific category for infection because the presence of infection will, well, require from clinicians that they use a different approach. An important rule is we have to rule out the infection first before applying, for example, skin protectant. So, that's why we added those A and B categories in this classification system.(2). What we've also learned is that the level of ever when asking clinicians to make a diagnosis of the presence of infection is quite high, so that's why we always recommend training, education before implementing such a tool in your clinical practice.
So, Dimitri, what are the key things clinicians should consider in MASD prevention and treatment, would you say?
Well, that's a good question again. It's about... so I will try just to summarise the key clinical prevention and treatment recommendations. And I will start with the diagnosis that our international best practice document is the one that we are discussing on today and we recommend to inspect the areas of the skin that may be affected by the moisture. In case of incontinence-associated dermatitis, the perineum, the peri-genital area, the buttocks, the gluteal folds, the thigh, the lower back, the lower abdomen, actually, every part of the body that is covered by, for example, an incontinence pad. We also advise clinicians to observe the skin very thoroughly and to document any signs of maceration, erythema, the presence of lesions, which can be vesicles, papules, pustules, the presence of erosion, dilidation, and again, key signs of fungal and bacterial infection. But all those clinical signs of infection, wide-scaling of the skin, the presence of satellite lesions, and then following the diagnosis, we recommend a holistic assessment and a holistic tailoring of the prevention and treatment measures. Please, and that that's really, really, really key is it should include a detailed assessment of pain as well. Pain means in this case for MASD, burning, tingling, and itching and that's specifically in the affected area. So, for me, this is really key for clinicians to implement in their day-to-day care for patients suffering from MASD.
And so, Dimitri, what advice would you give to clinicians who are looking to implement these recommendations, perhaps from the document in their local clinical setting or facility?
Yeah, that that's very important. It's not enough just to use and to have the best practice documents. We have to consider on how to implement this and how to change behaviour and to improve patient outcomes. Thinking of implementing a best practice is thinking in terms of a project. So, it's a project that you will manage just like any other project that you would do. And there are different options. I would say that searching for good examples in other organisations' already established implementation practices can be very, very inspiring. Planning such a project is really fundamental. And I just want to make and I want to give some very practical tips. So, first of all, it's doing your homework. Do a study or research best practices of other organisations, other teams, both inside the organisation and also external from the organisation on how they have been implementing best practice documents. It should not be on skin or it should not be on MASD, but I think that you can have some inspiration from other projects that were successful. You have to search for colleagues, collaborators within different fields, for example, the IT. If you consider using a classification tool. If you want to implement this in your electronic patient documentation, you have to work together with the IT department, you have to work together with the medical doctors, with the dermatologist, with the continence specialist. Maybe you have to search for more support at management level to make your project a success. Secondly, communication. You have to communicate and communicate and communicate. You have to communicate with collaborators about the best practice initiative, about who to involve, what you're going to do, when you're going to do it, why you're doing this project, and please this is really important is you never can overcommunicate. A third important point is measuring. You need to establish a metric. So, what are you going to measure against? You need a metric to place to measure against. So, for example, potentially and probably you want to decrease your MASD incidence, you have to set a target, for example, decreasing the MASD the incidence by 50% in the first three months of the implementation. And that's so if there is agreement between your team, that can be a metric that you will use in your project. You have to change the management. You have to have a change management component in place prior to the implementation. So, how are you going to handle concerns and fears of colleagues that will work with you on this project? Modification of the best practice document and tailoring. So, what we've developed is a document for international use. You have to take the best out of the document that you have to adjust where necessary, and you have to define and to decide what best practice will work for your organisation and which will not work for your organisation. But please, if you take out the potential and the most important aspects from that document, you really have to consider the evidence and don't change the evidence basis. Another important recommendation is getting everyone involved. You need to get your colleagues, your interdisciplinary colleagues involved in your projects. And a final point is this is really your project. So, you will probably involve other experts, both nationally and maybe internationally colleagues, but always remember that you are responsible for your project. So, you will bring experts to the table, clinical experts, implementation experts. But in the end, you are the person that will make the decisions together with your team. And then the final point is and that's I think so fundamental, keep evaluating, keep refining. So, once you've implemented your best practice, your work is absolutely not done. You have to evaluate. You have to refine your project, the best practice implementation process. And you need to keep on meeting the changing needs of your patients. So, it's about communication, planning, metrics, modification, involving people, considering this really as your project and that evaluating and refining.
Yeah, that's some really great advice there, Dimitri, so thank you for that. And I guess, what do you see for future developments and research in this area of MASD? What do you see that's going to be happening in the future?
Well, this is about research, and I know research is not always up to speed. We've made significant progress, both clinical but also from more fundamental and basic science. So, for me, really key for the future is we need more detailed and a wider range of studies about prevalence and incidence of MASD using more standardised definitions and study methodology. So, I am very pleased that the ICD coding is available now. So, that will increase the standardisation. So, I think that's the first important future development for research. Secondly is that's more from a basic science point of view. The natural history of IAD development is not fully clear yet. So, the aetiology the pathophysiology and specifically the progression, because that progression is important for clinicians to define and to identify key clinical decisions in their management and their prevention. I think thirdly is, I would say risk prediction. The risk prediction models, so we have a range of risk factors. We don't have risk assessment tools. And to be honest, we will never reach or we will never develop only risk assessment tools as we have them for pressure pain to your pressure ulcers. What we need for IAD is a risk prediction model, including, for example, transepidermal water loss, other skin parameters to help us in early detection and prediction of IAD in incontinence patients or MASD for patients that are suffering from moisture impact on skin. I think that's an important third area. There has been ample research on quality of life related to MASD. So, that's more from a qualitative point of view that I think we really, really need it. So, we need to identify what are key clinical issues or key issues that patients are suffering from. And then that's an open door. We need more comparative effectiveness studies on different products, on different skincare regimens, both for prevention and management of IAD. And these studies should be supported by health economics. So, for the time being, we made significant process in our understanding, in our clinical understanding and prevention and management. But that area should be further developed in the future. And not only the clinical part but also the health economic part should have a place in the future for research on MASD.
Yeah, there's still plenty to do, isn't there, I think, in this area, and to learn more about MASD. So, I guess we're nearly at the end of our time now. But what would be the key takeaway messages you'd like our audience to remember today, Dimitri?
Well, it's again a very good question and I will try to be very brief in my takeaway message. For clinicians, it's about focusing on key clinical diagnostic criteria. So, we have to confirm the diagnosis and we have to consider the multidisciplinary approach or interdisciplinary approach to this condition of MASD. We need the clinical expertise and experience of a variety of clinicians, nurses, physicians being general practitioners or GP's, dermatologists, geriatricians, urologists, neurologists, occupational therapists, physical therapists, clinical nurse specialists, et cetera, et cetera. So, this is not a unique disciplinary domain. And this is my final point. If we continue approach this condition in a more unique disciplinary manner, we will never achieve our goal of better patient care. So, this is really my take-home or takeaway message for today.
Well, thank you, Dimitri. I think that's all we've got time for today. We could spend a lot of time discussing this, I think. But thank you so much for joining us today. And thank you to our audience as well for joining this podcast. And don't forget to check out the resources that are available attached to the podcast and tune in next time. We look forward to seeing you then. Thanks again, Dimitri.
You're welcome, Ruth. Thank you very much.
And bye for now.
It is known that incontinence-associated dermatitis contributes to pressure injury risk. (3,4). Protect your patients with the PROSHIELD skincare range guarding intact and damaged skin from irritation caused by incontinence and other bodily fluids, easy to apply and to remove, and pH balance. For more information, contact your local Smith+Nephew representative or email us at email@example.com. The information presented in this podcast is for educational purposes only. It is not intended to serve as medical advice. Products listed outline of care are examples only. Product selection and management should always be based on comprehensive clinical assessment. The detailed product information including indications for use, contraindications, precautions and warnings, please consult the products applicable instructions for use prior to use. Helping you get closer to zero pressure injury incidence.
1. Fletcher J, Beeckman D,Boyles A et al (2020)International Best Practice Recommendations: Prevention and management
of moisture-associated skin damage (MASD). Wounds International. Available online at www.woundsinternational.com
2. Beeckman D., Van den Bussche K., Alves P., Beele H., Ciprandi G., Coyer F., de Groot T., De
Meyer D., Dunk A.M., Fourie A., García-Molina P., Gray M., Iblasi A., Jelnes R., Johansen E.,
Karadag A., LeBlanc K., Kis Dadara Z., Long M.A., Meaume S., Pokorna A., Romanelli M.,
Ruppert S., Schoonhoven L., Smet S., Smith C., Steininger A., Stockmayr M., Van Damme N.,
Voegeli D., Van Hecke A., Verhaeghe S., Woo K. and Kottner J. The Ghent Global IAD Categorisation
Tool (GLOBIAD). Skin Integrity Research Group - Ghent University 2017. Available to
download from www.UCVVGent.be
3. Beeckman D et al. Proceedings of the Global IAD Expert Panel. Incontinence associated dermatitis: moving prevention forward. Wounds International 2015. Available to download from www.woundsinternational.com
4.. European Pressure Injury Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance.Prevention and Treatment of Pressure ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/ PPPIA 2019
Prof. Dimitri Beeckman is Professor of Nursing Science at Ghent University (Belgium) and Örebro University (Sweden). He is Visiting Professor at the Royal College of Surgeons in Ireland, Monash University (Australia) and the University of Southern Denmark. He is the President of European Pressure Ulcer Advisory Panel (EPUAP), the International Skin Tear Advisory Panel (ISTAP) and a council member of the European Wound Management Association (EWMA). He is the Programme Director of the Masters in Nursing and Midwifery at Ghent University. He leads the Skin Integrity Research Group (SKINT) at Ghent University and the Swedish Centre for Skin and Wound Research (SCENTR) at Örebro University. He specialises in skin integrity research, clinical trials, education, implementation, instrument development and psychometrics. He is the author of over 150 scientific publications and has presented his research in more than 60 countries. He is on the Editorial Board of the Journal of Wound, Ostomy and Continence Nursing, the Journal of Tissue Viability, International Journal of Nursing Studies Advances, Systematic Reviews and BMC Geriatrics. He holds international fellowships such as at Sigma Theta Tau International Honour Society of Nursing and at European Academy of Nursing Science.