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Home > Patient Conditions > Moisture-Associated Skin Damage (MASD)

Moisture-associated skin damage (MASD) is the general term for


inflammation or skin erosion caused by prolonged exposure to a source of
moisture such as urine, stool, sweat, wound drainage, saliva, or mucus. It is
proposed that for MASD to occur, another complicating factor is required in
addition to mere moisture exposure. Possibilities include mechanical factors
(friction), chemical factors (irritants contained in the moisture source), or
microbial factors (microorganisms). The moisture barrier of the skin plays a
critical role in maintaining homeostasis within the body, mainly by concurrently
slowing the movement of water out of the body (transepidermal water loss, or
TEWL) and regulating the absorption of water and solutes from outside the
body. When exposed to excessive amounts of moisture, the skin will soften,
swell, and become wrinkled, all of which make the skin more susceptible to
damage from one of the complicating factors mentioned above.

The four specific types of moisture-associated skin damage that will be


discussed here are periwound moisture-associated dermatitis, peristomal
moisture-associated dermatitis, incontinence-associated dermatitis, and
intertriginous dermatitis.

Periwound Moisture-Associated Dermatitis


Etiology

The production of exudate is a normal result of the inflammatory stage of


wound healing. However, the advent of moist wound healing has brought with
it an understanding that moisture balance is the key to optimal outcomes.
Excessive amounts of wound exudate can cause the periwound (within 4 cm
of wound edge) skin to become macerated and even break down. This type of
skin damage is call periwound moisture-associated dermatitis.

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

Periwound moisture-associated dermatitis is marked by erythema (which may


be harder to discern in persons with darkly pigmented skin), maceration
(white, pale, or gray skin that is softened and/or wrinkled), and irregular or
diffuse edges (as opposed to pressure ulcers which typically have distinct
edges). Wounds with more viscous exudate are more prone to periwound
maceration, as the moisture is less likely to be lost by evaporating through the
dressing. The individual may report experiencing pain, burning or itching as a
result of the skin damage. Damage may be focused on the dependent area of
the wound in extremities, due to pooling of wound exudate.

Figure 1: Example of periwound maceration

Risk Factors
The following wounds are more prone to developing periwound moisture-
associated dermatitis:

 Diabetic foot ulcers


 Venous leg ulcers
 Pressure ulcers
 Fungating tumors
 Full-thickness (third-degree) burns

Wound infection will also greatly increase the risk of periwound maceration, as
it increases the exudate production.

Treatment & Interventions

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:

 Monitor the wound area routinely for changes in skin condition.


 Manage wound exudate with dressings chosen for proper absorbency.
 Apply a barrier film or skin protectant to the periwound skin when
appropriate.

The first step in treatment of periwound moisture-associated dermatitis is


managing the excessive exudate. This can mean anything from absorptive or
windowed dressings to external collection devices or negative pressure
wound therapy in extreme cases. Liquid, ointment, or cream-based skin
protectants offer a range of protection for the periwound skin from maceration.
After exudate has been managed, the skin should be allowed to progress to
healing.

Peristomal Moisture-Associated Dermatitis


Etiology

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 factors increase the risk of developing peristomal moisture-


associated dermatitis:

 Creasing of the skin underneath the skin barrier when changing


positions (standing, sitting, supine)
 Degree of stomal protrusion
 Improper pouching technique and wear time
 Increased perspiration or exposure to external moisture (e.g. swimming,
showering)

Treatment & Interventions

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:

 Manage peristomal moisture sources such as perspiration, wound


exudate, and external sources to ensure proper pouch adhesion.
 Make sure the pouch is not left in place for too long or too short of a
period. Longer wear times may lead to compromised pouch adhesion
and occlusion of the underlying skin, and shorter wear times can result
in mechanical stripping of the skin
 When cutting or molding the skin barrier to fit the stoma, it is
recommended that frequent measurements of the stoma be conducted
over the first 6 weeks to adjust to the changing shape of the stoma.

Treatment of peristomal moisture-associated dermatitis will be geared towards


preventing further irritation and healing the irritated skin. The pouching system
should be reevaluated to ensure proper fitting and drainage, with the skin
barrier suited to the type of output. Topical therapies such as skin barrier
powders, pastes or rings can be used to absorb moisture under the skin
barrier, provide an additional physical barrier, reduce existing irritation, and
allow for proper adhesion of the solid skin barrier. If exudate from an
underlying wound is the source of moisture, the etiology of the wound should
be addressed and exudate managed with an appropriate absorptive dressing.

Incontinence-Associated Dermatitis
Etiology

Incontinence-associated dermatitis (IAD) is predominantly a chemical irritation


resulting from urine or stool coming in contact with the skin. Ammonia from
urine and enzymes from stool can disrupt the acid mantle of the skin and
eventually cause the skin to break down. As with the other forms of MASD
discussed above, maceration also plays a key role in the formation of IAD,
and can makes the skin more susceptible to friction damage. While urinary
incontinence may lead to IAD, it is much more common in individuals with
fecal incontinence or mixed urinary and fecal incontinence.

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

 Use of containment or absorbent products, which can lead to excessive


occlusion and maceration
 Fecal or mixed urinary/fecal incontinence
 Toileting ability

Treatment & Interventions


The following precautions can help minimize the risk of developing
incontinence-associated dermatitis in at-risk patients and to minimize
complications in patients already exhibiting symptoms:

 Minimize skin exposure to urine and stool.


 Develop a consistent regimen of skin care to protect the integrity of the
skin barrier, including cleansing, moisturizing and use of a skin
protectant.

If measures can be taken to address the corresponding incontinence, these


should be considered while steps are taken to implement a skin care regimen
to protect the skin from continued irritation. After the skin has been properly
cleansed and moisturized, a skin barrier should be applied to protect the
affected skin from further exposure. Any secondary infection of the affected
area should be treated topically. In some cases, a containment or diversion
device may be indicated.

Intertriginous Dermatitis
Etiology

Intertriginous dermatitis (ITD), also referred to as intertrigo, results from sweat


being trapped in skin folds with minimal air circulation. When the sweat is not
able to evaporate, the stratum corneum becomes overly hydrated and
macerated, facilitating friction damage that is often mirrored on both sides of
the fold. This in turn leads to inflammation and denudation of the skin, making
the area more prone to infection. ITD typically affects infants because of their
exaggerated skin folds and stooped posture, obese individuals, and, in the
case of ITD affecting the webbing between the toes, active individuals that
wear closed toe or tight-fitting shoes.

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

Treatment & Interventions

The following precautions can help minimize the risk of developing


intertriginous dermatitis in at-risk patients and to minimize complications in
patients already exhibiting symptoms:

 Reduce heat and moisture within the skin fold


 Keep at-risk areas clean and dry
 Shower after exercise, then thoroughly pat dry the skin inside the fold
 Use a pH-balanced skin cleanser
 Promote proper general skin hygiene

The goal of treatment for intertriginous dermatitis is to minimize moisture and


friction in the skin fold and to treat any infections. Topical or oral treatments
should be used for any secondary fungal or bacterial infections. If weight loss
is possible, this will reduce future complications. While not often
recommended specifically as treatment for ITD, surgical removal of redundant
skin will also serve to reduce the risk of developing ITD. Light, non-
constricting, absorbent clothing made of natural fibers is recommended to
promote air circulation and moisture vapor transmission. Silver wicking textiles
or absorptive dressings may be placed in the skin fold to inhibit microbial
growth and absorb moisture. For toe web ITD, open-toed shoes are
recommended to promote air circulation.

Image Credit: Medetec (http://medetec.co.uk/). Used with permission.

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. Incontinence-Related Skin Damage: Essential Knowledge. Ostomy


Wound Manage. 2007;53(12):28-32. Accessed November 8, 2012.

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.

Ousey K, Bianchi J, Beldon P, Young T. The Identification and Management


of Moisture Lesions. Wounds UK. 2012;8(2):S1-20. http://www.wounds-
uk.com/pdf/content_10467.pdf Accessed November 14, 2012.

Thomas S. The role of dressings in the treatment of moisture-related skin


damage. World Wide
Wounds. http://www.worldwidewounds.com/2008/march/Thomas/Maceration-
and-the-role.... Published March 2008. Accessed November 8, 2012.

Zulkowski K. Diagnosing and Treating Moisture-Associated Skin Damage. Adv


Skin Wound Care. 2012;25(5):231-236. doi:
10.1097/01.ASW.0000414707.33267.92.
For more information on moisture-associated skin damage, a list of additional
resources is offered below. Follow the links provided for specific resource
contact information.

 Academy of Physicians in Wound Healing (APWH)


 Canadian Association of Wound Care (CAWC)
 Dermatology Nurses' Association (DNA)
 European Tissue Repair Society (ETRS)
 European Wound Management Association (EWMA)
 International Foundation for Functional Gastrointestinal Disorders
(IFFGD)
 National Association for Continence (NAFC)
 Simon Foundation for Continence
 World Council of Enterostomal Therapists (WCET)
 World Union of Wound Healing Societies (WUWHS)
 Wound, Ostomy, and Continence Nurses Society™ (WOCN®)

The following section includes additional WoundSource.com articles relating


to moisture-associated skin damage. To read the article(s) in full, follow the
title link provided.

 Urinary Incontinence: Assessment and Treatment


 Moisture-Associated Skin Damage in the Long-Term Care Setting:
Categories of MASD
 Moisture-Associated Skin Damage in Long-Term Care: Basics for
Identification and Prevention
 MASD: What Are the Types of Moisture-Associated Skin Damage?
 Incontinence-Associated Dermatitis: Prevention and Treatment
 Complications Associated with Moisture-Associated Skin Damage
 Skin Assessment and Moisture-Associated Skin Damage
 Moisture-Associated Skin Damage: Important Terms to Know
 Moisture-Associated Skin Damage: Your Questions Answered
 ConvaTec Launches Sensi-Care® Skin Protectant Incontinence Wipes
 Chronic Fungal Skin Infection Treatment and Prevention
 Classifying Skin Care Moisturizing Agents: What Does My Patient
Need?
 Is it Moisture-Associated Skin Damage or a Pressure Ulcer?
 Moisture-Associated Skin Damage: Prevention Strategies for Periwound
Skin
 Top 5 Ways to Prevent Skin Breakdown in Bariatric Patients
 Product Technology Overview: Remedy® Skin Care Line
 The Controversial Use of Bag Balm® in Skin Care Management
 Why I Go the Extra Mile: The Travels of a Certified Wound and Ostomy
Care Nurse
 Measure for Measure: Continence and Wound Assessment Upon
Admission
 Bed Bathing and Beyond: The Dos and Don'ts of Bedside Bathing
 Do You Know These 10 Risk Factors for Pressure Ulcers?
 Choosing Age-Appropriate Skin Care Products
 How to Identify Nutritional Deficiencies Based on Changes in Skin Color
 Use of the SCALE Model in Palliative Wound Care
 Incontinence and Skin Care Management for Improved Long-Term Care
 Reducing Avoidable Hospitalizations Among Nursing Facility Residents
 Preventing Maceration Associated With Negative Pressure Wound
Therapy Dressings
 Skin & Wound Care: Protectants and Moisture Barrier Products

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

 Drawex® Edema Wrap

SteadMed Medical, LLC

Drawex® Edema Wrap is a thinner, conformable variation of the same


combination of fibers used to...

 Drawtex® Tracheostomy

SteadMed Medical, LLC

Drawtex® Tracheostomy is a hydroconductive, non-adherent wound


dressing with ability to draw...

Foam Dressings

 Shapes by PolyMem® Sacral Dressing

Ferris Mfg. Corp.

Shapes by PolyMem® Sacral Dressing is a multifunctional, sacral


wound-shaped semi-permeable...

Skin Care
Moisture Barriers

Dr. Smith's® Zinc Oxide Adult Barrier Spray

MainPointe Pharmaceuticals, LLC


Dr. Smith's® Zinc Oxide Adult Barrier Spray is a touch-free spray
application moisture barrier....

Sensi-Care® Clear Zinc Skin Protectant

ConvaTec

Sensi-Care® Clear Zinc helps protect skin from the irritation associated
with incontinence and...

 Critic-Aid® Clear Ointment

Coloplast Corp.

Critic-Aid® Clear Ointment is a clear moisture barrier containing minimal


ingredients. Adheres...

 Sensi-Care® Skin Protectant Incontinence Wipes

ConvaTec

Sensi-Care® Skin Protectant Incontinence Wipes are formulated with a


combination of skin care...

Tapes & Securement


Tapes

Hy-Tape®, The Original Pink Tape®

Hy-Tape International

Hy-Tape®, The Original Pink Tape® is a waterproof, latex-free, UPF


50+ zinc oxide-based adhesive...

Wound Cleansers
Wound Cleanser Products

Vashe® Wound Solution

SteadMed Medical, LLC

Vashe® Wound Solution is intended for use in cleansing, irrigating,


moistening and debriding...

Moisture Management
Textiles

 InterDry® Moisture Wicking Fabric with Antimicrobial Silver

Coloplast Corp.

InterDry® Moisture Wicking Fabric with Antimicrobial Silver effectively


manages the...

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Source URL (modified on 2017-04-10


15:35): https://www.woundsource.com/patientcondition/moisture-associated-skin-
damage-masd

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

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