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Skin Deep
November/December 2014
An Advanced Tissue newsletter written by Carolyn Brown, BS, MEd, RN, ARM, CWS, FACCWS
Q: I am the MDS nurse in an Austin Texas facility. A recent chart review identified various terms used to
identify skin breakdown due to urinary or fecal incontinence such as perineal dermatitis, adult diaper
rash and incontinence-associated dermatitis (IAD). Would you clarify a consistent term and treatment.
A: According to the RAI Manual, MDS 3.0, Section M, the standardized term for skin breakdown caused
by moisture is Moisture-Associated Skin Damage (MASD).
MASD is a general term for inflammation or skin erosion caused by prolonged exposure to moisture
such as urine, stool, sweat, saliva or wound drainage. 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.
Examination of the skin
MASD caused by urinary or fecal incontinence appears as a diffuse area of erythema.
It can extend into the skin folds and between the buttocks and down the inner thigh.
There may be scaling of the skin with papule and vesicle formation. These may open
with “weeping” of the skin, which exacerbates skin damage. Skin damage is shallow
or superficial, and edges are irregular or diffuse. The patient may report burning,
itching and pain. Maceration or a whitening of the skin may also be observed.
MASD is more difficult to see in persons with darkly pigmented skin.
Protecting the skin from moisture caused by incontinence
Skin should be cleansed and moisturized per facility protocol and a barrier ointment applied to protect
the skin from further exposure. Keeping the skin clean and dry, changing under pads or briefs after
soiling, and using barrier creams or ointments is usually all that is required for MASD to resolve. It is
helpful to keep the resident off the affected area to promote dryness and reduce friction.
Treatment interventions for MASD
Complete a comprehensive bowel and bladder assessment including identification of the type of urinary
or fecal incontinence. Note the time of day the incontinence occurs and monitor for patterns. It may be
possible that a toileting program is appropriate. Minimize caffeine, carbonated beverages, spicy foods
or acidic foods such as citrus products and fruit juices to prevent bladder spasms that lead to
incontinence. The incidence of fecal incontinence is increased if stool is liquid. Fiber added to food may
help, or active yogurt cultures, such as lactobacillus, may be given. If diarrhea is related to tube
feeding, the dietician should be consulted to adjust the rate or type of formula.
Four specific types of MASD will be discussed on the Advanced Tissue website, including:
• Incontinence-Associated Dermatitis (IAD)
• Periwound Moisture-Associated Dermatitis
• Peristomal Moisture-Associated Dermatitis
• Intertriginous Dermatitis (ITD)
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Skin Deep
November/December 2014
An Advanced Tissue newsletter written by Carolyn Brown, BS, MEd, RN, ARM, CWS, FACCWS
Page 2
Clarifying Terminology: Moisture-Associated Skin Damage
Moisture-Associated Skin Damage (MASD) is a common problem caused by four main
conditions, each having a slightly different etiology. Accurate assessment is essential in
distinguishing between them and implementing appropriate prevention and treatment
interventions. Specific types of MASD that will be discussed here are:
Incontinence-Associated Dermatitis (IAD)
Periwound Moisture-Associated Dermatitis
Peristomal Moisture-Associated Dermatitis
Intertriginous Dermatitis (ITD)
Incontinence-Associated Dermatitis (IAD)
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 Moisture-Associated Skin Damage (MASD), maceration also plays a key role in the
formation of IAD, and 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. 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
• Ability to toilet
Treatment & Interventions:
The following precautions can help minimize the risk of developing IAD in at-risk patients and to
minimize complications in patients already exhibiting symptoms:
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.
Skin Deep
November/December 2014
An Advanced Tissue newsletter written by Carolyn Brown, BS, MEd, RN, ARM, CWS, FACCWS
Page 3
Clarifying Terminology: Moisture-Associated Skin Damage, cont.
Periwound Moisture-Associated Dermatitis
Etiology:
The production of exudate is a normal result of the inflammatory stage of wound healing.
Excessive amounts of wound exudate can cause the periwound skin to become macerated and
at risk for break down. 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. 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 areas 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
patient may report 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.
Wound infection will also greatly increase the risk of periwound maceration, as it increases the
production of exudate.
Treatment & Interventions:
The following precautions can help minimize the risk of developing periwound moistureassociated dermatitis:
• Monitor the wound area routinely for changes in skin condition
• Manage wound exudate with dressings appropriately chosen for proper absorbency
• Apply a barrier film or skin protectant to the periwound skin as indicated
The first step in treatment of periwound moisture-associated dermatitis is managing the
excessive exudate. The absorptive or windowed dressings, external collection devices or
negative pressure wound therapy may also be appropriate. Liquid or cream-based skin
protectants offer a range of protection for periwound skin.
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 or wound drainage. As part of the pouching process,
solid skin barriers are placed around the stoma to protect the underlying skin from damaging
components of the stoma output (urine or stool). These barriers work to keep the skin dry by
absorbing both drainage from the stoma and moisture from the underlying skin. If too much
Skin Deep
November/December 2014
An Advanced Tissue newsletter written by Carolyn Brown, BS, MEd, RN, ARM, CWS, FACCWS
Page 4
Clarifying Terminology: Moisture-Associated Skin Damage, cont.
moisture is absorbed from the stoma, the barrier will cease to be effective, allowing the drainage
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.
Symptoms:
Leakage of stomal drainage onto the peristomal skin will cause inflammation and 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.
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 moistureassociated dermatitis:
Manage moisture sources (perspiration, wound exudate) and external sources to ensure proper
pouch adhesion
Ensure the pouch is changed as needed. Longer wear times may lead to compromised pouch
adhesion and occlusion of the underlying skin, 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 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.
Skin Deep
November/December 2014
An Advanced Tissue newsletter written by Carolyn Brown, BS, MEd, RN, ARM, CWS, FACCWS
Page 5
Clarifying Terminology: Moisture-Associated Skin Damage, cont.
Intertriginous Dermatitis (ITD)
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.
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 epidermal water loss 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.
Risk Factors:
• Obesity
• Diabetes mellitus
• Urinary and fecal incontinence
• Poor hygiene
• Malnutrition
• Individuals who are bedridden
Treatment & Interventions:
The following precautions can help minimize the risk of developing ITD 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, promote proper general hygiene
• Thoroughly pat dry the skin inside the fold
• Use a pH-balanced skin cleanser
The goal of treatment for ITD is to minimize moisture and friction within the skin fold and to treat
any infections. Topical or oral treatments should be used for any secondary fungal or bacterial
infections. 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.
Skin Deep
November/December 2014
An Advanced Tissue newsletter written by Carolyn Brown, BS, MEd, RN, ARM, CWS, FACCWS
Page 6
Clarifying Terminology: Moisture-Associated Skin Damage, cont.
Resources:
Gray M, Black JM, Baharestani MM et al (2011) Moisture-associated skin damage; overview and pathophysiology. J
Wound Ostomy Continence Nurs 38(3):233-41
Gary M, Beckman D, Bliss DZ et al (2012) Incontinence-associated dermatitis: a comprehensive review and update.
J Wound Ostomy Continence Nurs 39(1): 61-74

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