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The chemical composition of the wound exudate greatly affects the potential
damage that can be wrought. The presence of bacteria, specific proteins, or
proteolytic enzymes, as well as the volume of wound exudate greatly reduce
the barrier function of the skin and can lead to maceration. Specifically,
exudate from chronic wounds has been found to contain a higher
concentration of proteolytic enzymes as compared to exudate from acute
wounds. Another factor affecting the occurrence of periwound maceration is
damage to skin by aggressive removal of adhesive wound dressings, which
affect the integrity of the skin barrier by stripping away parts of the epidermis.
Symptoms
Risk Factors
The following wounds are more prone to developing periwound moisture-
associated dermatitis:
Wound infection will also greatly increase the risk of periwound maceration, as
it increases the exudate production.
The following precautions can help minimize the risk of developing periwound
moisture-associated dermatitis in at-risk patients and to minimize
complications in patients already exhibiting symptoms:
There are several types of moisture that can cause peristomal moisture-
associated dermatitis, including exposure to urine or stool, sweat, wound
drainage, or other sources of water such as while bathing or swimming. As
part of the pouching process, solid skin barriers are placed around the stoma
to protect the underlying skin from detrimental components of the stoma
output (urine or stool). These barriers work to keep the skin dry by absorbing
both effluent from the stoma and moisture from the underlying skin. If too
much moisture is absorbed from the stoma, the barrier will cease to be
effective, allowing the effluent to come in contact with the peristomal skin. Too
much moisture underneath the barrier (sweat or exudate from an existing
peristomal wound) can occlude the underlying skin and lead to maceration.
Additionally, extended exposure of the pouch adhesive to water, typically
while showering or swimming, can cause adhesive failure, requiring more
frequent pouch changes and increasing the potential for mechanical damage
from repeatedly removing the adhesive.
Symptoms
Leakage of stomal effluent onto the peristomal skin will cause inflammation
and even skin erosion depending on the placement of the stoma (liquid and
enzyme content varies along the length of the intestine). Maceration, which is
marked by whitened and softened peristomal skin, is also common in cases
where moisture is trapped under the skin barrier and the skin becomes
occluded. The affected area may itch or be sore to the touch.
Risk Factors
The following precautions can help minimize the risk of developing peristomal
moisture-associated dermatitis in at-risk patients and to minimize
complications in patients already exhibiting symptoms:
Incontinence-Associated Dermatitis
Etiology
The affected area will present with erythema, as well as maceration. The area
may progress to painful partial-thickness erosions with weepy serous exudate.
If left untreated, pressure and friction may increase stress on the affected
area, leading to skin breakdown. Depending on the areas exposed to urine
and stool, IAD is not necessarily limited to the perineal area, and can extend
up onto the lower back or down onto the inner thighs.
Risk Factors
Intertriginous Dermatitis
Etiology
In addition to having more skin folds, obese individuals also present with
several physiological factors that can increase the risk of developing ITD.
These include an increase in perspiration to regulate body temperature,
increased transepidermal water loss (TEWL), and higher skin surface pH
(which makes the acid mantle less effective as a natural barrier to infection).
Symptoms
ITD typically presents with mild erythema that may progress to more severe
inflammation, erosion, oozing, exudation, maceration, and crusting of the
intertriginous skin mirrored on both sides of the fold. The individual may report
pain, itching, or burning sensations around the affected area. With toe web
ITD, the webbing may present with maceration, erythema, desquamation and
even erosion of the affected skin, impairing ambulation in severe cases.
Risk Factors
Obesity
Diabetes mellitus
Urinary and fecal incontinence
Hyperhidrosis
Poor hygiene
Malnutrition
Drooling (in infants)
Individuals who are bedridden
References
Alvey B, Beck DE. Peristomal Dermatology. Clin Colon Rectal Surg.
2008;21(1):41-44. doi: 10.1055/s-2008-1055320
Black JM, Gray M, Bliss DZ, Kennedy-Evans KL, Logan S, Baharestani MM,
Colwell JC, Goldberg M, Ratliff CR. MASD Part 2: Incontinence-Associated
Dermatitis and Intertriginous Dermatitis. J Wound Ostomy Continence Nurs.
2011;38(4):359-370. doi: 10.1097/WON.0b013e31822272d9
Colwell JC, Ratliff CR, Goldberg M, Baharestani MM, Bliss DZ, Gray M,
Kennedy-Evans KL, Logan S, Black JM. MASD Part 3: Peristomal Moisture–
Associated Dermatitis and Periwound Moisture–Associated Dermatitis. J
Wound Ostomy Continence Nurs. 2011;38(5):541-553. doi:
10.1097/WON.0b013e31822acd95
Gray M, Black JM, Baharestani MM, Bliss DZ, Colwell JC, Goldberg M,
Kennedy-Evans KL, Logan S, Ratliff CR. Moisture-Associated Skin Damage:
Overview and Pathophysiology. J Wound Ostomy Continence Nurs.
2011;38(3):233-241. doi: 10.1097/WON.0b013e318215f798
Janniger CK, Schwartz RA, Szepietowksi JC, Reich A. Intertrigo and Common
Secondary Skin Infections. Am Fam Physician. 2005;72(5):833-
838. http://www.aafp.org/afp/2005/0901/p833.html. Published September 1,
2005. Accessed November 15, 2012.
Products list:
The following section identifies specific products that are appropriate for the
management or treatment of moisture-associated skin damage, according to
the companies who chose to list them here. This list is not all-inclusive; other
products listed on WoundSource.com may also be indicated for this condition.
Dressings
Specialty Absorptives / Super Absorbents
Drawtex® Tracheostomy
Foam Dressings
Skin Care
Moisture Barriers
ConvaTec
Sensi-Care® Clear Zinc helps protect skin from the irritation associated
with incontinence and...
Coloplast Corp.
ConvaTec
Hy-Tape International
Wound Cleansers
Wound Cleanser Products
Moisture Management
Textiles
Coloplast Corp.
Links
[1] http://www.incontinencesource.com/blog/mad-wet-hen-incontinence-moisture-
related-skin-damage
[2] http://www.incontinencesource.com/whitepaper/choosing-incontinence-skin-care-
products-minimize-transepidermal-water-loss
[3] http://www.woundsource.com/patientcondition/risk-patient-diabetic-foot-ulcers
[4] http://www.woundsource.com/product-category/skin-care/liquid-skin-protectors
[5] http://www.ostomysource.com/blog/differentiating-between-peristomal-contact-
dermatitis-and-candidiasis
[6] http://www.ostomysource.com/blog/defining-acceptable-ostomy-pouch-wear-time
[7] http://medetec.co.uk/
[8] http://www.aafp.org/afp/2005/0901/p833.html
[9] http://www.wounds-uk.com/pdf/content_10467.pdf
[10] http://www.worldwidewounds.com/2008/march/Thomas/Maceration-and-the-role-of-
dressings.html