Rare Operative Intervention for Urinary and Fecal Incontinence-Associated Dermatitis

Samantha Delapena, MD; Philomene Spadafore, RN, MHA; Stephanie E. Bollenbach, MD; Areta Kowal-Vern, MD; Kevin N. Foster, MD, MBA, FACS; Marc R. Matthews, MD, FASC

Disclosures

Wounds. 2021;33(4):E31-E33. 

In This Article

Abstract and Introduction

Abstract

Incontinence-associated dermatitis (IAD) is considered a cause of moisture-associated skin damage after prolonged exposure to urinary and fecal incontinence. While partial-thickness burns are often managed with topical therapies, daily dressing changes, patient positioning, hydration, nutrition, and pain management, deep partial-thickness and full-thickness burn injuries require surgical excision and, ultimately, skin grafting. The elderly and very young as well as those with medical comorbidities can develop urinary and fecal incontinence. Urinary ammonia and gastrointestinal lipolytic enzymes and proteases can produce caustic damage to weakened elderly or immature skin. In this report, 2 cases of IAD are presented as chemical burns. After a prolonged interval of urinary and fecal incontinence, an incapacitated 65-year-old male with 14% total body surface area (TBSA) partial-thickness wounds, and an 85-year-old female with 4% TBSA full-thickness wounds were admitted to the burn center and underwent operative management.

Introduction

Moisture-associated skin damage (MASD) can involve partial-thickness (PT) skin erosion and loss after extended exposure to urine, feces, perspiration, mucus, or saliva.[1] Urinary and fecal incontinence produces incontinence-associated dermatitis (IAD) due to an inflammatory response that injures the stratum corneum layer of the integument, favoring fungal and bacterial colonization as well as infection.[2–4] Urinary ammonia (produced by urease from urea) induces an alkalization of the skin layers, which are usually more acidic, thereby weakening the stratum corneum.[5] Gastrointestinal lipolytic enzymes and proteases further damage the skin, including the deep layers of stratum lucidum and stratum granulosum.[6] Pressure ulcers and injuries are usually the main differential diagnosis. If there is a persistence of skin redness without infection, other possible diagnoses include psoriasis inversa, seborrheic dermatitis, allergic contact dermatitis, acrodermatitis enteropathica, and autoimmune bullous skin diseases.[7] In addition to age and comorbidities, risk factors for urinary and fecal or dual incontinence include the perineal environment, toileting ability, tissue tolerance, skin pH, absorbent products, lack of structured skin care, friction/shear, bacterial colonization, low albumin, poor nutrition, impaired cognition, and compromised mobility.[3,8] The present 2 cases illustrate the rare association of IAD presenting as a chemical burn, which may require debridement and skin grafting. This approach, albeit rare, does not differ significantly from typical partial-thickness and full-thickness burn treatment.

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