Moisture Associated Skin Damage Guideline

Publication: 27/07/2007  
Next review: 09/03/2024  
Clinical Guideline
CURRENT 
ID: 1153 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Prevention and Management of Moisture Associated Skin Damage Guideline

  1. Summary of guideline
  2. Aims
  3. Background
  4. Prevention
  5. Diagnosis
  6. Treatment and Management
  7. Provenance
  8. Evidence Base

Summary of Guideline

These guidelines summarise the management of skin that is exposed to prolonged or excessive moisture. There are many different terms used to describe this condition, but moisture associated skin damage (MASD) has emerged as the most appropriate (Gray et al 2007). It can range in severity from erythematous skin (reddening and inflammation) through to skin erosion and maceration (excoriation) with or without bleeding/exudate. MASD is caused by exposure of the skin to moisture such as urine, faeces, perspiration or exudate which triggers a cycle of events disrupting the natural protective qualities of the skin and seriously compromising skin integrity. The peri-anal area (this includes the areas between the vulva/scrotum and anus, the buttocks, anal cleft and inner upper thigh) is a particularly high risk area for MASD, but it can also occur to skin folds and peri-wound skin.
Prevention of MASD is of utmost importance when managing patient comfort and cost-effectiveness (Beeckman et al, 2009). The main aspects of prevention are effective assessment and the management of the source of the moisture. This includes continence promotion, regular assessment of skin integrity, cleansing the skin with an appropriate product, moisturising, and the application of a barrier product to the skin (Beeckman et al 2009).

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Aims

To improve the skincare of patients exposed to excessive or prolonged moisture, including prevention, diagnosis, and management of MASD.

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Background

MASD describes skin damage caused by prolonged exposure to fluid which, if left untreated, results in loss of the skin barrier function and susceptibility to development of a moisture lesion (Gray et al, 2011). Prolonged contact with faeces and/or urine can lead to a particular form of MASD called incontinence-associated dermatitis (IAD) (Voegeli, 2012), which is often referred to as nappy rash in paediatrics.
Due to the lack of an internationally validated and accepted method for collecting data on IAD and MASD, there is a wide variation in reported figures. Beeckman et al. (2015) reviewed the literature and reported prevalence (i.e. proportion of incontinent patients with IAD at a defined point in time) of 5.6%–50%.

MASD causes pain, discomfort, and reduced quality of life (Gray et al 2007) and increases the risk of pressure ulceration, as the epidermis (top layer of skin) erodes, affecting the tolerance of the skin to pressure, friction, and shear. The coefficient of friction is also shown to be greater over moist skin (EPUAP, 2019). The presence of MASD also increases the risk of secondary skin infections, with the most common being candidiasis.
Risk factors for MASD include:

  • Type of incontinence (faecal/urinary/double)
  • Frequent episodes of incontinence (especially faecal)
  • Use of occlusive containment products (e.g. incontinence pads)
  • Poor skin condition (e.g. due to aging/steroid use/diabetes)
  • Compromised mobility
  • Diminished cognitive awareness
  • Inability to perform personal hygiene
  • Pain
  • Pyrexia
  • Medications (antibiotics, immunosuppressants)
  • Poor nutritional status
  • Critical illness.

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Prevention

There are two key interventions that are critical for the prevention of MASD:

  • Identify and treat reversible causes to reduce, or ideally eliminate skin contact with source of moisture
    • Infection (urinary tract infection could cause incontinence, pyrexia could cause perspiration, wound infection could cause increase in exudate)
    • Constipation
    • Diuretics
    • Oedema
  • Implement a structured skin care regimen to protect the skin and help restore an effective skin barrier function (Beekman et al. 2015) (Appendix 1 for Adults, Appendix 2 for paediatrics).

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5. Diagnosis

Skin needs to be checked at every shift to monitor at risk patients in order to reduce the risk of skin breakdown, as per pressure ulcer prevention guidelines (http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=1984).
Lesions caused by MASD are often incorrectly classified as Category 2 pressure ulcers (DeFloor et al 2005). Whilst it is common to have both MASD and pressure related damage due to the likely clinical condition of this patient group, it is important that the skin is assessed with consideration to these problems having different aetiologies.

In individuals with light skin, MASD appears initially as erythema which can range from pink to red and can be confused with Category 1 pressure ulcers (PU). In patients with darker skin tones, skin may be paler, yellow, or darker purples or reds. Due to underlying inflammation the skin might feel warmer and firmer than unaffected skin. Lesions including vesicles or bullae, papules or pustules may be observed. Patients might report pain, discomfort, burning, itching, or tingling to the affected areas.
MASD and Category 2 pressure ulcers present very similarly, e.g. erythema with superficial skin loss. See Appendix 2 for differentiation between PU and MASD/IAD.

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6. Treatment / Management

Action

Rationale

Assess at risk areas such as buttocks, groin, and upper leg region for any signs of erythema or skin breaks at every hygiene change and document findings on the SSKIN bundle (as Vulnerable).

Regular skin assessment is vital to ensure any early signs of MASD are detected and appropriate nursing action taken. Accurate documentation ensures this is communicated to the entire nursing team.

Initiate appropriate strategies for the management of moisture/incontinence and ensure medical and nursing assessment, to identify cause of moisture/incontinence, has been completed.

Proper assessment and management of the source of moisture is fundamental to preventing MASD from developing. Appropriate strategies will reduce levels of incontinence and lessen the duration of faeces/urine being in contact with skin. Comprehensive assessment of the causes of moisture can lead to reduction in incidence or resolution of the problem.

Traditionally standard soap, water and a regular washcloth should be avoided when cleansing the skin

Standard soap is alkaline and has been shown to change skin pH, attacking the corneocytes and potentially damaging skin barrier function. Rough washcloths can cause friction damage. The application of water alone (unless instructed due to use of a barrier product) can impair the skin barrier function due to an increase in trans-epidermal water loss.

For normal intact skin cleanse after each episode of incontinence (or at least 2-hourly in patients with continuous incontinence or perspiration) with emollient wash with pH range similar to normal skin (e.g. Vernacare Senset foam). Ensure depths of all skin folds are reached. Use soft cloths and leave product on skin for 30 seconds prior to removing to avoid friction damage. Gently pat skin dry. Apply a simple moisturiser (see Box 1 on Appendix 1 for adults and Appendix 2 for paediatrics) to the entire area.

Prompt cleaning reduces the duration that irritants are in contact with skin. Emollient wash foams are pH balanced, do not strip the skin of its protective sebum, and donate some moisture to the skin. Leaving the foam for 30 seconds allows the surfactants to loosen any soiling and reduces the necessity for rubbing when removing thus preventing any friction damage. It is essential that all skin folds are thoroughly cleaned of soiling as failure to do so will leave irritants on the skin and lead to MASD. Patting skin dry reduces friction damage caused by rubbing skin dry. Ensure skin is dried thoroughly as residual moisture can allow the skin barrier to be compromised, leading to inflammation as well as macerating the skin which increases friction between the patient’s skin and the bed/chair, which in turn increases the risk of pressure ulcer development.
Application of simple moisturisers contributes to the suppleness of the skin and retains the acid mantle - the skins natural protective layer. Overall, this maintains the skins natural barrier function.

If patient is incontinent of faeces or has erythema
Application of barrier cream (see Box 2 on Appendix 1 and Appendix 2 for paediatrics)

Patients are at higher risk of MASD if the skin is erythematous as its barrier function is already compromised. Faeces is an irritant to the skin particularly, when in the presence of urine due to the activation of faecal enzymes by the raised pH.
Barrier creams will provide a more occlusive protective layer than simple moisturisers thereby preventing deterioration of skin integrity; however they also contain moisturisers/emollients and therefore help to maintain the skin’s natural barrier function as described above  

If there are skin breaks
Apply barrier product (see Box 3 on Appendix 1 and Appendix 2 for paediatrics)) to cover skin breaks (frequency will depend on product, according to manufacturer’s directions)

Breaks in the epidermis need covering to protect them and allow healing to occur beneath the protective cover. This can be difficult on large areas of superficial damage and areas of damage that are surrounded by fragile skin. Adhesive dressings are not suitable for this reason as the surrounding skin can be damaged by their presence, and if frequent replacing is required due to contamination, there is potential for further damage to the skin. Topical applications are therefore indicated. No sting barrier films provide an occlusive film through which the integrity of the skin can still be observed. They do not have to be reapplied at each wash; manufacturers’ instructions should be followed. 

For patients with highly exudating wounds Ensure a suitable dressing is used to manage exudate levels and dressing is changed at appropriate frequencies.  If there are signs of MASD, choose a more absorbent dressing and/or increase frequency of dressing changes and apply a barrier film to peri-wound

Irritation and damage to the peri-wound skin caused by super saturation or a dressing leads to maceration.  If exposure to exudate from the wound continues it can lead to erosion and denudation of the skin, which can lead to an increase in wound related pain and infection risk. Please refer to the wound management guidelines (http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=1423)

Refer to Tissue Viability if no improvement in skin condition after 7 days despite appropriate nursing interventions or concerns about management.

The Tissue Viability Specialist will have additional experience and knowledge of strategies to manage this problem. It is important that their advice is sought if no improvement is seen in the skin condition to prevent tissue breakdown and its associated complications and discomfort for the patient.

Links to Incontinence management strategies:
https://www.nice.org.uk/guidance/CG 49
https://www.nice.org.uk/guidance/ng123

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Appendix 1:

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Appendix 2

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Appendix 3

Provenance

Record: 1153
Objective: Please find the updated guidelines. The title has been changed to ‘Prevention and Management of Moisture Associated Skin Damage Guideline’ to cover all types of moisture related skin damage, not just incontinence.
Clinical condition: Moisture associated skin damage
Target patient group: Patients with incontinence or excessive moisture exposure
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Evidence base

References and Evidence levels:
Beeckman D, Schoonhoven L, Verhaeghe S, Heyneman A, Defloor T, (2009) Prevention and treatment of incontinence associated dermatitis-a literature review. Journal of Advanced Nursing 65(6):1141-54 
Evidence Base A

Beekman D, et al. (2015) Proceedings of the global IAD expert panel. Incontinence associated dermatitis: moving prevention forward. Wounds International (online)
Evidence Base C

DeFloor T, Schoonhoven L, Fletcher J et al (2005) Differentiation between pressure ulcers and moisture lesions Journal of Wound Ostomy and Continence Nursing 32(5):302-6)
Evidence Base A

Gray, M., Bliss, DZ., Doughty, DB., ErmerSeltun, J. ,Kennedy-Evans, KL .and Palmer, MH. (2007) Incontinence- associated dermatitis; a consensusJournal of Wound Ostomy& Continence Nursing. 34(1), pp.45-54. 
Evidence Base C

Woo, KY., Beeckman, D., Chakravarthy, D. (2017) Management of moisture associated skin damage: A scoping review. Advances of Skin and Wound Care. 30, pp494-501.
Evidence Base C

A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

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