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© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
D. Z. Bliss (ed.), Management of Fecal Incontinence for the Advanced Practice
Nurse, https://doi.org/10.1007/978-3-031-94526-7_14
14
Management ofSkin Damage
Associated withFecal andDouble
Incontinence
MikelGray
, DonnaZ.Bliss
, andSheilaHowesTrammel
Abstract
Irritant contact dermatitis and pressure injury are common sequelae of fecal
incontinence. The advanced practice nurse prevents and treats these problems
while managing the underlying fecal incontinence. This chapter describes the
manifestations of irritant contact dermatitis due to incontinence and pressure
injury, explains how to assess these conditions and their severity, including on
darkly pigmented skin, and how to make a differential diagnosis. The chapter
explains the association of incontinence to the inammation of irritant contact
dermatitis and pressure injury along with other risk factors. It summarizes the
interventions used for prevention and treatment of both skin problems highlight-
ing the expected outcomes for the advanced practice nurse to evaluate.
M. Gray
Department of Urology, University of Virginia, Charlottesville, VA, USA
e-mail: mg5k@uvahealth.org
D. Z. Bliss (*)
University of Minnesota School of Nursing, Minneapolis, MN, USA
e-mail: bliss@umn.edu
S. H. Trammel
Nurse Practitioner, Henepin County Medical Center, Minneapolis, MN, USA
300
14.1 Incontinence andSkin Damage
A holistic approach to management of fecal incontinence by the advanced practice
nurse encompasses prevention and treatment of associated skin damage. Fecal
incontinence is a cause (etiologic factor) of irritant contact dermatitis and an inde-
pendent risk factor for pressure injury, including full thickness pressure injuries
[1–4]. This risk is thought to be highest in patients with incontinence of liquid stool
(diarrhea) and double (i.e., fecal and urinary) incontinence [5–8].
Inammation of the skin in the presence of fecal or urinary incontinence is now
referred to as irritant contact dermatitis [9, 10]; other terms for this condition in
adults have included incontinence-associated dermatitis, perineal dermatitis, and
moisture-associated skin damage. A diagnostic code for incontinence-associated
dermatitis due to fecal, urinary, and dual incontinence, along with several other
moisture-associated skin damage problems, were added to the International
Classication of Diseases, version 10, Clinical Modication, (ICD-10 CM), prompt-
ing the most recent change in terminology [9, 10]. The ICD-10 CM code for
Incontinence Associated Irritant Contact Dermatitis is L24A2.
Irritant contact dermatitis is inammation of the skin caused by prolonged expo-
sure to various sources of moisture, including feces, urine, perspiration, uid with
digestive secretions, wound exudate, mucus, or saliva [11, 12]. A pressure injury,
historically referred to as a pressure ulcer, pressure sore, or decubitus ulcer, is
dened as a localized area of damage to the skin or underlying tissue that occurs in
the presence of pressure or pressure in combination with shearing forces; multiple
ICD-10CM codes are used to identify pressure injury based on its location, wound
depth, and associated factors such as use of a medical device [13–15]. In this chap-
ter, the terms irritant contact dermatitis and pressure injury will be used.
14.2 Irritant Contact Dermatitis: Prevalence
andAssociated Factors
Irritant contact dermatitis has been reported in patients in a variety of clinical set-
tings, including 3–11% of residents in nursing homes and long-term acute care
facilities [16–18], 20–35% of hospitalized patients [2, 3, 19, 20] and 5–50% or more
of critically ill patients [8, 21–23]. In addition, approximately 40% of individuals
living in the community who have fecal incontinence experience episodes of irritant
contact dermatitis [1, 24].
A systematic review and meta-analysis of pooled ndings from 24 epidemio-
logic studies of irritant contact dermatitis identied independent risk factors in criti-
cally ill patients; they are advanced age, fever, altered level of consciousness, high
Acute Physiology and Chronic Health Evaluation (APACHE) II score, a lower
Braden Scale Score, lower oxygen saturation, having double incontinence, inconti-
nence of liquid stool, higher frequency of incontinence episodes, and a higher
Perineal Assessment Tool (PAT) score [21]. The PAT is an instrument developed to
evaluate the risk of irritant contact dermatitis; scoring is based on evaluation of
M. Gray et al.
301
duration of irritant exposure, intensity/type of irritant, perineal skin condition, and
contributing factors that may cause diarrhea [25].
14.3 Assessment andDifferential Diagnosis ofIrritant
Contact Dermatitis
Knowledge of assessing, diagnosing, and treating irritant contact dermatitis will
assist the advanced practice nurse in managing this problem in patients in their own
practice or consulting to nursing staff in other settings. Assessment includes inspec-
tion, palpation, and history/interview.
Inspection of the skin is an important part of the assessment of irritant contact
dermatitis and includes determination of the location, size, depth and character of
damaged and immediately adjacent skin. A consensus of wound ostomy and conti-
nence nurses identied common signs of irritant contact dermatitis identied by
skin inspection; they are erythema, and loss of supercial skin layers, i.e., the epi-
dermis and sometimes the subepidermis, and the presence of a rash [26]. Erythema
is redness of the skin primarily due to dilation of supercial capillaries in inamma-
tion, which can manifest as pink, purple, or red coloring (see Figs.14.1 and 14.2).
In darkly pigmented skin, redness may not be apparent and areas with erythema
may appear hyperpigmented (darker) or less commonly hypopigmented (lighter)
compared to non-affected areas [27, 28].
Loss of skin can result in serous drainage and a shiny, glistening appearance of
the area (see Fig.14.3). Areas with skin erosion or denudation are typically bright
red regardless of underlying skin tone. Damaged skin in patients with large areas of
erosion also may contain yellow debris; this nding should not be confused with
necrotic fat (slough) seen in full thickness wounds (stage 3, 4, and unstageable pres-
sure injuries) that extend well below the dermis. Rather, irritant contact dermatitis
creates partial thickness skin loss, and the yellow material in the wound bed is an
inammatory discharge rather than necrotic tissue.
Fig. 14.1 Pink color on
upper buttocks and in the
crease between buttocks.
(Images used with
permission of patient and
chapter authors)
14 Management ofSkin Damage Associated withFecal andDouble Incontinence
302
Fig. 14.2 Pink color on
buttocks and thighs.
(Images used with
permission of patient and
chapter authors)
Fig. 14.3 Redness and
skin loss in the perianal
area and in the crease.
(Images used with
permission of patient and
chapter authors)
A rash may develop from fungal or bacterial infection as the protective function
of the skin barrier is impaired. Rash has been reported in 14.2–32% of hospitalized
patients [2, 29] and 34% in community-living individuals [1, 24]. The rash is typi-
cally raised and papular, red in color, and on the periphery of the area with irritant
contact dermatitis; hence, the rash is often described as “satellite lesions” (see
Fig.14.4). Although their location varies, rashes are particularly common in skin
folds such as the inner thighs, beneath the abdominal pannus of obese individuals,
or beneath the scrotum in males.
The edges of skin loss and rash are irregular. Inspecting darkly pigmented skin
in natural light or using a ashlight can be helpful in identifying irritant contact
dermatitis.
Palpation is another skill to be utilized in assessing irritant contact dermatitis
because there may be local swelling from inammation. The skin may feel soft or
boggy or taut. Changes in texture can also occur with the skin feeling rough com-
pared to non-damaged areas [27, 28].
M. Gray et al.
303
Fig. 14.4 Rash on the left
lower buttocks. (Image
used with permission of
patient and chapter
authors)
History taking focuses on identication of contributing factors and symptoms of
irritant contact dermatitis. Patients may feel varying degrees of soreness, discom-
fort, or pain, itching, tingling, or a burning sensation [1, 18, 30, 31].
This chapter focuses on differential diagnosis of irritant contact dermatitis versus
pressure injury, two of the more prevalent forms of genital skin damage seen in
patients with fecal incontinence. Irritant contact dermatitis, as its name implies,
occurs only in patients experiencing fecal, urinary or double (fecal and urinary)
incontinence [6]. Inammation occurs in areas where the skin is exposed to fecal
matter, urine, or a combination of stool and urine. In patients with fecal inconti-
nence, irritant contact dermatitis has been most commonly reported in the perianal
area, buttocks, and crease between the buttocks [1, 3, 19, 24]. In critically ill patients,
nursing home residents, and community-living patients with fecal incontinence,
Bliss etal. [1, 32] reported that the initial presentation of irritant contact dermatitis
varied in severity and was often present in more than one body area; additional sur-
veillance is needed to fully describe its course and spread. Irritant contact dermatitis
also may extend to the crease between the genitalia and the thighs, and also the
inner folds of the thighs. Expert wound, ostomy, and continence nurses identied 14
body areas where irritant contact dermatitis develops [8, 26, 33] (Fig.14.5).
Several characteristics aid the advanced practice nurse to differentiate from a
pressure injury. While both pressure injuries and share a common risk factor (fecal
or urinary incontinence), pressure injuries typically are attributable to a combina-
tion of a set of reasonably well-dened risk factors including immobility, impaired
sensory perceptions, poor nutrition, and exposure to shearing forces [18]. Unlike
irritant contact dermatitis that occurs in skin exposed to fecal matter or moisture,
pressure injuries are found over bony prominences or underneath a medical device
that lies in contact with the skin [14, 15]. Stage 1 pressure injuries may cause red-
ness that does not turn to a lighter tone when gently pressed with the ngers (referred
to as unblanchable erythema) similar to that seen with irritant contact dermatitis, but
it will be located over a bony prominence or underneath a medical device. Similar
to irritant contact dermatitis, Stage 2 pressure injuries are partial thickness wounds
but their location will likely also be over a bony prominence or underneath a medi-
cal device. In addition, a stage 2 pressure injury will have distinct border unlike the
14 Management ofSkin Damage Associated withFecal andDouble Incontinence
304
Fig. 14.5 The 14 body areas where irritant contact dermatitis can occur. Part of the educational
materials accompanying the Assessment and Severity of Irritant Contact Dermatitis due to
Incontinence (ASICDI) instrument. (Copyright University of Minnesota. All rights reserved 2015.
Reprinted with permission from Donna Bliss, PhD, RN)
diffuse borders of irritant contact dermatitis and associated loss of skin. Stage 3 and
4 pressure injuries differ from irritant contact dermatitis because they are full thick-
ness, extending into the subcutaneous tissues or exposing underlying bone.
Unstageable pressure injuries are also full thickness wounds characterized by true
slough (necrotic fatty tissue) or black eschar not seen in irritant contact dermatitis.
A deep tissue pressure injury is characterized by deep red, maroon, or purple lesion
with a dark wound bed or blood-lled blister [15]. These injuries can be differenti-
ated from irritant contact dermatitis both by their color and location.
14.4 Assessment ofSeverity ofIrritant Contact Dermatitis
The severity of irritant contact dermatitis is most often assessed by inspection. An
instrument to guide nursing staff in assessing and in monitoring its worsening or
improvement is the Assessment and Severity of Irritant Contact Dermatitis due to
Incontinence (ASICDI) instrument. This instrument that was previously called the
Incontinence Associated Skin Damage tool v. D.2 [26, 33] updated its name to
reect the change in term for irritant contact dermatitis. It was developed using
evidence from research and consensus of clinical experts and current literature [26,
33]. The ASICDI instrument is one of the only instruments for assessing irritant
contact dermatitis that has been tested for use with skin ranging from light to dark
pigmentation [26, 33, 34]. There is good validity and reliability of the ASICDI
instrument reported from testing using photograph cases and different types of
nurses, for example, wound ostomy, and continence nurse specialists and general
staff nurses [26, 33, 34].
M. Gray et al.
305
ab
Fig. 14.6 (a) Stage 3 pressure injury on the right buttock with slough and granulation tissue.
(Permission for reprinting images obtained from patient). (b) Stage 4 pressure injury on the right
ischial area with eschar, slough, and granulation and periwound erythema present. (Images used
with permission from patients and chapter authors)
Assessing the severity of irritant contact dermatitis involves inspecting and scor-
ing skin condition of the 14 body areas where irritant contact dermatitis may occur
(Fig. 14.5). The ASICDI guides nursing staff as to which body areas to assess
(Fig.14.6). It provides a single score of irritant contact dermatitis severity ranging
from 0 to 56 and also a severity score for each body area (Fig.14.5). The scores
focus on the main observable signs of irritant contact dermatitis, redness, skin loss,
and rash and are weighted with higher scores showing greater severity. Monitoring
changes in these scores assists in evaluating improvement and worsening of irritant
contact dermatitis and effectiveness of the treatment plan. Various types of nurses
and nursing staff from those in a hospital, critical care unit, and a nursing home have
found the ASICDI instrument easy to use within minimal instruction [26, 34].
The ASICDI instrument offers several educational and guidance materials. The
14 body areas where irritant contact dermatitis occurs are numbered on gures with
different body shapes and skin color (see Fig.14.5). There is a chart showing a
range of colors of the signs of irritant contact dermatitis on skin with light, medium,
and dark pigmentation, which was created using pixels from digital photos of
patients’ skin. The advanced practice nurse can use the ASICDI instrument without
any fees to educate clinical staff about irritant contact dermatitis and in research and
quality improvement projects. The instrument can also be licensed for widespread
use in a practice setting.
14.5 Prevention andManagement ofIrritant
Contact Dermatitis
14.5.1 Structured Skin Care Regimen
Current evidence and best practice support use of a structured skin care protocol for
preventing and managing irritant contact dermatitis [17, 35–37]. Interventions
14 Management ofSkin Damage Associated withFecal andDouble Incontinence
306
designed for prevention irritant contact dermatitis are similar to those used for its
management [38, 39]. Two principle-based approaches to a structured skin care
program have been proposed to aid in designing such a program; they are “cleanse,
moisturize, and protect” [7] and “cleanse, protect, and restore” [40]. Each is based
on cleansing at least daily and following fecal incontinence episodes, followed by
application of a topical, leave-on product that protects the skin against further expo-
sure to irritants and enhance the skin’s moisture barrier.
Cleansing should gently remove fecal matter, urine, microorganisms, and addi-
tional soiling from the surface of the skin. In persons with fecal incontinence, the
skin should be cleansed daily and after episodes of fecal incontinence. The optimal
cleanser should closely reect the acidic nature (acid mantle) of the surface of
healthy skin, whose pH normally ranges from 5.4 to5.9 [7]. An acidic pH contrib-
utes to numerous protective functions of the skin; it promotes growth of certain
species of bacteria that while exerting antimicrobial activity against coliform and
other bacterial, fungal, and viral pathogens. The skin’s acid mantle activates enzyme
function and promotes cohesion and layering of lipid cells necessary to maintain
optimal moisture of levels within the stratum corneum of the skin and regulate tran-
sepidermal water loss levels [41]. Bar soaps consist of alkalis and fatty acids.
Although they effectively remove irritants and dirt from the skin by releasing free
alkali and insoluble acid salts when mixed with water, bar soaps are alkaline with a
pH varying from 8.0 to 11.0 [42]. Bathing with bar soap and water transiently raises
the pH of the skin, increasing its vulnerability to colonization with pathogenic bac-
terial or fungal species found in the gastrointestinal tract, reducing adhesion of the
lipid and protein barrier of the stratum corneum, and altering enzymatic activity in
the skin that negatively inuences cell adhesion [43]. This transient effect is not
harmful in persons who bathe daily, but it is more pronounced when skin is inamed
from irritant contact dermatitis and when fecal or urinary incontinence create the
need for more frequent bathing; therefore, use of soap and water alone should be
avoided in these situations.
A variety of personal and incontinence cleansers are available whose pH ranges
are similar to that of normal skin, and their use is recommended for cleansing the
perineal and perianal areas over bar or cake soap and water in persons with fecal
incontinence. Many of these products are designed as no rinse products that do not
require rinsing with water and drying with a towel as does cleansing with soap and
water. Research in healthy subjects suggests that these products are equally effec-
tive in removing pathogenic microorganisms when compared to soap and water
[44]. Research also suggests that cleansing persons with frequent incontinence or
irritant contact dermatitis should minimize the friction associated with use of bar
soap, a reusable wash cloth, and towel drying because they impair the skin’s protec-
tive barrier [45]. Soft disposable wipes that come in varying sizes are an alternative
to reusable cloths, and some contain a cleanser, moisturizer, and skin protectant.
Protection of the skin typically involves use of a topical leave on product con-
taining one or multiple ingredients formulated into a cream, ointment, or liquid
polymer acrylate [38]. Cream-based products are emulsions with a water base, and
ointment-based products are oil-based emulsions. Liquid polymer acrylates,
M. Gray et al.