Perineal dermatitis is a potentially serious sequela facing any incontinent elder. If left untreated, both bacterial Staphylococcus) and yeast Candida albicans) infections may develop. The dermatosed area can cause much physical discomfort and add treatment cost. The majority of data on the pathogenesis and subsequent treatment of perineal dermatitis is derived from pediatric literature. Unfortunately, gerontological nurses caring for incontinent elders who develop this problem have had to depend on pediatric interventions. The generalizability and outcome of this practice is questionable, because there are structural differences between pediatric and geriatric skin. The purpose oí this article is to critically review the literature on perineal dermatitis in the elderly.
The United States Agency for Health Care Policy and Research guidelines on urinary incontinence do not address perineal dermatitis. These guidelines primarily focus on treating the etiology of the incontinence rather than the effects of incontinence (Panel for Urinary Incontinence in Adults, 1992). While this effort is laudable, for many incontinent elders treatment is not possible, and there are no clinical guidelines to assist the clinician in maintaining the skin integrity.
The actual health care costs associated with the prevention and treatment of perineal dermatitis in the elderly is unknown. However, we can extrapolate that a sizable portion of the health care cost associated with incontinence care is used to prevent and treat perineal dermatitis. The Health Care Financing Administration conservatively estimated that the federal government spends approximately $10 billion annually on incontinence care (Health Care Financing Administration Data for Urinary Incontinence Panel [HCFA], 1989). It is estimated that 10 million Americans suffer with urinary incontinence, with the majority being 65 years of age and older (Panel for Urinary Incontinence in Adults, 1992). More specifically, urinary incontinence has been conservatively estimated at 15% to 30% of noninstitutionalized elders (Panel for Urinary Incontinence in Adults, 1992). This agency also noted approximately 1.5 million nursing home residents suffer with urinary incontinence (Panel for Urinary Incontinence in Adults, 1992). Hu, Kaltrieder, and Igou (1990), in a controlled experimental study examining the cost effectiveness of disposable versus reusable diapers in a nursing home, further substantiated the current belief that approximately 50% of all elderly in nursing homes are incontinent of either urine or stool.
The incidence and prevalence of incontinence for elderly people in acute care settings has not been thoroughly documented. Sier, Ousiander, and Orzeck (1987), in a study exploring urinary incontinence among geriatric patients in an acute care setting, found that 35% N - 127) of their subjects N = 363) were incontinent of urine at least one time during hospitalization. The prevalence of urofecal incontinence has been noted to be approximately 20% in nursing home elderly (Isaacs & Walkly, 1964).
Pediatric Studies in Perineal Dermatitis
After a thorough review of the literature, only one study could be found that documented the prevalence of perineal dermatitis in the elderly. Lyder, Clemes-Lowrance, Davis, Sullivan, and Zucker (1992), investigating a structured skin care regimen to prevent perineal dermatitis, found a prevalence rate of 23% to 25% (during two independent surveys), respectively, on a geriatric psychiatry unit. Keller, Sinkovic, and Miles (1990) investigating the effectiveness of an adult disposable brief in two nursing homes, found a perineal dermatitis prevalence rate of 41% n = 121). This study however, did not report data regarding the types of incontinence found in the two nursing homes.
A number of psychological and physical risks associated with incontinence have been documented. Incontinence is often perceived by society as the most unacceptable and intolerable condition (Ebersole & Hess, 1990). A study by Lara, Troop, and Beadleson (1990) found a positive correlation between the incidence of urinary incontinence and nursing home placement by families. Urinary incontinence was the primary reason given by the elderly for increased social isolation (Rubin, 1990). A study by Wyman, Harkins, Choi, Taylor, and Fanti (1987) reported that women with urinary incontinence were often reported as depressed and embarrassed about their appearance and odor. Although there is a plethora of research in urinary incontinence, much research is still needed to answer questions such as decreasing wetness, improving quality of life, and reducing caregiver burden (Chiverton, 1996).
Animal Studies in Perineal Dermatitis
Transepidermal Water Loss
Transepidermal water loss (TEWL) is a passive event that occurs when a small amount of water crosses through the stratum corneum (outermost layer of the epidermis). It is a continuous event, unlike sweating which is transitory. The TEWL measurements are important to note because it provides a reliable indicator of how well the stratum corneum barrier is functioning. This can have direct implication for when nurses are assessing and evaluating the effectiveness of topical products. Most dermatological studies measure TEWL (Van Sam, Maillols, Guillot, & Gilhou, 1994).
Diaper Dermatitis in Pediatric Skin
Most studies examining perineal dermatitis are found in the pediatric literature (Table 1). It is questionable whether these findings can be generalized to the elderly population. What is known about geriatric skin is that the epidermal layer, which is composed primarily of keratinocyte (> 90%) and forms the stratum corneum (most superficial layer to external environment) decreases by 50% by age 80 (Kaminer & Gilchrest, 1994). This is important to note because the stratum corneum protects the skin from chemical and microbial insults. Additionally, the stratum corneum surface as observed through microphotography is not flat (as seen in children) but is endowed with ridges and wrinkles which become prominent with cutaneous aging (Agache, Mignot, & Makki, 1988). This morphological change increases the risk of abrasions in the elderly (Agache et al., 1988). This is clearly a significant difference between elder and pediatric skin. This phenomenon coupled with the reduced proliferation of keratinocytes increases the susceptibility of the aged skin to blisters and abrasions after mild insults (Lavker, 1989). Thus, it can be hypothesized that changes in pH levels of incontinent elderly patients coupled with increased moisture might make elders more susceptible to perineal dermatitis than is characteristic of the pediatric population.
In an attempt to model the etiology of perineal dermatitis, researchers have studied the effects of infant urine and stool on the skin of mice (Table 2). The findings from the mice models appear to be well accepted as important variables in the pathogenesis of perineal dermatitis (Brown & Sears, 1993; Dikstein & Zlotogorski, 1994; Kemp, 1994; Lyder et al., 1992). The mice models, however, were developed to mirror pediatric skin. All mice used in both studies were less than 3 months old (Berg, Buckingham, & Stewart, 1986; Buckingham & Berg, 1986). Thus, the relationship of the these findings to the elderly must be questioned.
With the exception of one preliminary study by this investigator, no other studies could be found that directly examined perineal dermatitis in the elderly. Kemp (1994), in a review of the clinical literature, noted that immobility in the elderly may play a role in the development of the dermatosed area. This investigator noted during anecdotal observations that many patients, who were incontinent of urine and were unable to lift their bodies, experienced their buttocks dragging across bed linens which increased the potential for sacral skin abrasions. Additionally, perineal dermatitis is believed to occur independently of wearing an adult disposable brief (Kemp, 1994). If older adults are left incontinent for a prolonged time on underpads or other surfaces, a dermatosis may occur on the sacral/coccyx area (Kemp, 1994).
No studies were found that examined the role of transepidermal water loss and skin surface pH levels in the development of perineal dermatitis in the elderly. What is known, however, is that TEWL is a passive phenomenon that corresponds to a small amount of water crossing through the stratum corneum and is dependent on the subcutaneous water vapor pressure grathent (Van Sam et al., 1994). The TEWL measurements are important in estimating the stratum corneum barrier capacity (Van Sam et al., 1994). A study by Wilhelm, Cua, and Maibach (1991) comparing TEWL and skin surface pH at 11 anatomical sites on 14 young adults and 15 elders found that TEWL was significantly lower in the elderly than in the young adults (p < .001). Conversely, the researchers found that there was no significant difference in skin surface pH between the elderly and young adults (Wilhelm et al., 1991). The researchers concluded that the skin barrier function to water loss is not impaired in aged skin. This was concluded by the researchers inability to determine any significant differences between the two skin measures (TEWL and pH) for the two groups. This study contradicts an earlier study by Roskos and Guy (1989) who found no differences in baseline TEWL when they compared elders to young adults. Only one study was found that compared TEWL and skin surface pH in intertriginous areas (inguinal and inframammary) between adult diabetics and nondiabetics. The researchers concluded that skin TEWL and skin surface pH were significantly higher in diabetics compared to healthy adults (p < .0001) (Yosipovitch, Tur, Morduchowicz, & Boner, 1993). It should be noted that none of the studies cited above included measurements of the perineum nor did any document whether or not the subjects were incontinent. This is important to note because TEWL and pH measurements may differ depending on anatomical location (Berardesca, Farinelli, Rabbliosis, & Maibach, 1991).
The review of the literature revealed no research in the prevention of perineal dermatitis in the elderly. Most adult disposable brief studies are completed by the manufacturers, tend not to be published, and focus on comfort and cost rather than on prevention of perineal dermatitis. Additionally, these studies tend to focus on skin wetness (visual observation) and absorbency of urine on the adult disposable brief (Keller et al., 1990).
Several prevention studies have been undertaken to decrease perineal dermatitis in the pediatric population (Farrington, 1992). Most have focused either on the efficacy of various diapers to keep the skin dry or topical products to prevent perineal dermatitis. One study by Kramer and Honig (1988) randomly assigned 28 infants to two groups. Caregivers in the control group changed the disposable briefs regularly and cleansed the perineum with soap and water. Caregivers in the experimental group added a moisturizer and moisture repellent to the regimen. The researchers found that only 1 (?/ = 16) infant in the experimental group and 7 N = 12) in the control group developed perineal dermatitis. Although Kramer and Honig (1988) had some success in using a moisturizer and moisture repellent to decrease perineal dermatitis in infants, this structured skin care regimen does not appear to be as effective in the elderly, based on Lyder et al.'s (1992) study.
Lyder et al. (1992) replicated Kramer's study in the elderly and found that an equal number of subjects developed perineal dermatitis whether or not a cleanser, moisturizer, and moisture repellent were used. Of the five (N= 15) patients who developed perineal dermatitis, all were urofecal incontinent. Lyder's group further found that all subjects that developed perineal dermatitis were urofecal incontinent with at least four incontinent episodes per 24 hours. The majority of subjects developed perineal dermatitis within 48 hours of urofecal incontinence (Lyder et al., 1992). All subjects wore adult disposable briefs for approximately 16 hours per day. The subjects that developed perineal dermatitis wore adult disposable briefs that were saturated with urofecal waste. Additionally, all subjects were diagnosed with dementia and were unable to notify the nurse of incontinent episodes. Although this was a preliminary study, several key nursing variables were identified. These key variables may contribute to the development of perineal dermatitis:
* Altered cognition (unable to communicate wetness to nurse).
* More than four incontinent episodes per 24 hours.
* Prolonged use of adult disposable briefs (at least 16 of 24 hours).
The results of this preliminary study suggested that this complex- interaction between urine and stool might contribute to perineal dermatitis in elderly incontinent patients.
Preventing Perineal Dermatitis: Nursing Guidelines
The main goal of the gerontological nurse in preventing perineal dermatitis should be to prevent excessive moisture in the perineal area. If the moisture is caused by incontinence, the nurse may refer to the United States Agency for Health Care Policy Guidelines on Urinary Incontinence (1992). These guidelines are free of charge and provide valuable information on the diagnosis and treatment of urinary incontinence. Moreover, the Wound, Ostomy and Continence Nurses Society (1994) provide standards of care in managing incontinence as well as other wound care issues.
Although little is known about this pervasive problem in the elderly, there are several guidelines that can be used to keep the perineal area dry. The use of a superabsorbent adult disposable briefs designed to absorb moisture and offer a quickdrying surface to the skin should be used (Kemp, 1994). Additionally, the use of underpads applied directly to the skin may be helpful in decreasing wetness to the skin. The gerontological nurse must be vigilant to perform frequent checks (at least every 2 hours) to ensure that the adult disposable briefs or underpads are dry. The use of moisture repellents may also be very helpful in keeping the skin free from direct contact of irritants.
The review of literature revealed a significant lack of research on the pathogenesis of perineal dermatitis in the elderly. The majority of what is known about this condition stems from the pediatric population. The differences between TEWL and skin surface pH levels in pediatric and geriatric «kin raises questions about the further generalizability of the pediatric studies. There appears to be some controversy in the literature regarding whether baseline TEWL is increased or decreased in cutaneous aging. The literature did reveal some data indicating that skin surface pH increases with age; however, no data on the perineum was found. No studies examining the role of TEWL and skin surface pH and its association in the development of perineal dermatitis in she elderly were found. Additionally, no studies were found that examine the nursing variables identified in the literature search. The paucity oí scientific data on this serious and costly condition warrants additional research in this area.
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Pediatric Studies in Perineal Dermatitis
Animal Studies in Perineal Dermatitis