Prevention and Care for Incontinence-Associated Dermatitis Among Older Adults: A Systematic Review

Figures & data

Figure 1 Diagram for group assignment and independent review.

Figure 2 Flow chart of the review process and results.

Notes: Adapted from: Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi:10.1136/bmj.n71.³⁷ Creative Commons Attribution (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/legalcode).

Table 1 Critical Appraisal of the Selected Randomized Controlled Trials (RCTs)

JBI Critical Appraisal Checklist for Randomized Controlled Trials*
Studies/Total Score	Was true Randomization Used for Assignment of Participants to Treatment Groups?	Was Allocation to Treatment Groups Concealed?	Were Treatment Groups Similar at the Baseline?	Were Participants Blind to Treatment Assignment?	Were those Delivering Treatment Blind to Treatment Assignment?	Were Outcomes Assessors Blind to Treatment Assignment?	Were Treatment Groups Treated Identically Other Than the Intervention of Interest?	Was follow up Complete and if Not, were Differences Between Groups in Terms of their Follow up Adequately Described and Analyzed?	Were Participants Analyzed in the Groups to Which They were Randomized?	Were Outcomes Measured in the Same Way for Treatment Groups?	Were Outcomes Measured in a Reliable Way?	Was Appropriate Statistical Analysis Used?	Was the Trial Design Appropriate, and Any Deviations From the Standard Rct Design (Individual Randomization, Parallel Groups) Accounted for in the Conduct and Analysis of the Trial?
Sugama et al (2012)/(10/13)^Citation24	Y	Y	Y	Y	U	U	U	Y	Y	Y	Y	Y	Y
Kon et al (2017)/(9/13)^Citation25	Y	Y	N	N	N	Y	Y	Y	Y	Y	Y	Y	U

Notes: *Checklist reproduced from: Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Chapter 3: Systematic reviews of effectiveness. In: Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis. JBI; 2020. Available from: https://synthesismanual.jbi.global²⁰.

Abbreviations: Y, yes; N, no; U, unclear.

Table 2 Critical Appraisal of the Selected Systematic Reviews

JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses*
Studies/Total Score	Is the Review Question Clearly and Explicitly Stated?	Were the Inclusion Criteria Appropriate for the Review Question?	Was the Search Strategy Appropriate?	Were the Sources and Resources Used to Search For Studies Adequate?	Were the Criteria for Appraising Studies Appropriate?	Was Critical Appraisal Conducted by Two or More Reviewers Independently?	Were There Methods to Minimize Errors in Data Extraction?	Were the Methods Used to Combine Studies Appropriate?	Was the Likelihood of Publication Bias Assessed?	Were Recommendations For Policy and/or Practice Supported by the Reported Data?	Were the Specific Directives for New Research Appropriate?
Corcoran & Woodward. (2013)/(7/11)^Citation26	Y	Y	Y	Y	Y	U	U	U	N	Y	Y

Notes: *Checklist reproduced from: Aromataris E, Fernandez R, Godfrey C, Holly C, Kahlil H, Tungpunkom P. Summarizing systematic reviews: Methodological development, conduct and reporting of an Umbrella review approach. International Journal of Evidence Based Healthcare. 2015;13(3):132–140. https://doi.org/10.1097/XEB.0000000000000055.¹⁹ Copyright © 2015, International Journal of Evidence-Based Healthcare © 2015 The Joanna Briggs Institute.

Abbreviations: Y, yes; N, no; U, unclear.

Table 3 Critical Appraisal of the Selected Reviews (Text and Opinion Papers)

JBI Critical Appraisal Checklist for Text and Opinion Papers*
Studies/Total Score	Is the Source of the Opinion Clearly Identified?	Does the Source of Opinion Have Standing in the Field of Expertise?	Are the Interests of the Relevant Population the Central Focus of the Opinion?	Is the Stated Position the Result of an Analytical Process, and is There Logic in the Opinion Expressed?	Is There Reference to the Extant Literature?	Is Any Incongruence with the Literature/Sources Logically Defended?
Kliangprom & Putivanit (2017)/(5/6)^Citation28	Y	Y	Y	Y	Y	N
Iamma, W. (2017)/(4/6)^Citation27	Y	Y	Y	Y	N	N
Yates A. (2018a)/(5/6)^Citation29	Y	Y	Y	Y	Y	N
Yates A. (2018b)/(5/6)^Citation30	Y	Y	Y	Y	Y	N
Lumbers M. (2019)/(5/6)^Citation2	Y	Y	Y	Y	Y	N
Holloway, S. (2019)/(5/6)^Citation8	Y	Y	Y	Y	Y	N

Notes: *Checklist reproduced from: McArthur A, Klugarova J, Yan H, Florescu S. Innovations in the systematic review of text and opinion. International Journal of Evidence Based Healthcare. 2015;13(3):188–195. https://doi.org/10.1097/XEB.0000000000000060.²¹ Copyright © 2015, International Journal of Evidence-Based Healthcare © 2015 The Joanna Briggs Institute.

Abbreviations: Y, yes; N, no; U, unclear.

Table 4 Critical Appraisal of the Selected Case Reports

JBI Critical Appraisal Checklist for Case Reports*
Studies/Total Score	Were Patient’s Demographic Characteristics Clearly Described?	Was the Patient’s History Clearly Described and Presented as a Timeline?	Was the Current Clinical Condition of the Patient on Presentation Clearly Described?	Were Diagnostic Tests or Assessment Methods and the Results Clearly Described?	Was the Intervention(s) or Treatment Procedure(s) Clearly Described?	Was the Post-Intervention Clinical Condition Clearly Described?	Were Adverse Events (Harms) or Unanticipated Events Identified and Described?	Does the Case Report Provide Takeaway Lessons?
Beldon, P. (2012)/(5/8)^Citation1	Y	N	Y	Y	Y	Y	N	N
Parnham, Copson, and Loban (2020)/(6/8)^Citation10	Y	Y	Y	Y	Y	Y	N	N

Notes: *Checklist reproduced from: Moola S., Munn Z, Tufanaru C et al. Chapter 7: Systematic reviews of etiology and risk. In: Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis. JBI; 2020. Available from: https://synthesismanual.jbi.global.²²

Abbreviations: Y, yes; N, no; U, unclear.

Table 5 Quality Assessment Results of the Selected Studies

Quality Assessment of the Evidence by GRADE Guideline*
No.	^a Risk of Bias (Limitation of Study Design, Confounding Factors, Missing Data, Adherence Measurement)			^b Precision (Methodology, Statistical Certainty, Amount of Information on A Certain Factor How Precisely an Object of Study is Measured)		^c Directness (Extent to Which the People, Interventions, and Outcome Measures are Similar to Those of Interest, Confident Results Come From the Direct Evidence)		^d Consistency (Relevant Measurement Application Where Several Items that Propose to Measure the Same General Construct Produce Similar Scores, no Overlapping and Missing, Statistical Significance)		Certainty of Evidence
	Low	Unclear	High	Precise	Imprecise	Direct	Indirect	Consistent	Inconsistent
Beldon, P. (2012)^Citation1	√				√	√			√	Low
Sugama et al. (2012)^Citation24		√		√		√		√		Moderate
Kon et al. (2017)^Citation25	√				√	√		√		Moderate
Parnham, Copson, and Loban (2020)^Citation10	√				√	√			√	Low

Notes: ^aRisk of bias; ^bPrecision; ^cDirectness; ^dConsistency. *GRADE guideline reproduced from: Schünemann H, Brożek J, Guyatt G, Oxman A, editors. GRADE Handbook. 2013. Available from: https://gdt.gradepro.org/app/handbook/handbook.html?fbclid=IwAR04O97yy. Retrieved June 4, 2021.²³ © 2013 - The GRADE Working Group.

Table 6 A Summary of the Reviewed Studies About Prevention and Care Among Older Adults with Incontinence-Associated Dermatitis (IAD)

Authors	Type of Article and Design	Settings	Level, Certainty of Evidence and Methodological Quality	Sample Size	Prevention, Care, and Outcomes	Research Notes
Beldon, P. (2012)^Citation1	Mixed: Literature review and cases report	United Kingdom (In-patient department)	Level 4.d Low^bd (5/8)	3 mixed sex	1. Assessment and management of the causes of incontinence. 2. Use skin cleansing pH between 4 to 6.8 to maintain an acid mantle, natural oils, and a moist surface. Cleansing after each episode of incontinence should be performed promptly. Soap and water are not advised. 3. Apply skin moisturizing to replace natural lubricants lost during skin cleansing. 4. Apply skin barrier such as petroleum, dimethicone (LBF Barrier Cream), lanolin or zinc oxide-based cream. Individual care is recommended. 5. Use an incontinence pad or containment devices. 6. Three patients who were washed by water including a small amount of emollient, water alone and patted dry, warm water and patted dry, and applying LBF barrier cream, reported restored skin integrity, improved skin texture, reduced pain, and provided comfort and assurance of efficacy to the individual.	1. An intervention with products used for prevention and care of IAD, a flow chart or step by step guideline is not provided. 2. The methodology of implementing the intervention (LBF Barrier Cream) did not control for confounding factors (age, chronic diseases, conditions, and severity levels of IAD) when studying the outcomes (skin recovery, pain, and comfortable).
Sugama et al. (2012)^Citation24	Research Article: RCT	Japan (Geriatric medical hospital)	Level 1.c Moderate^a (10/13)	60 female	1. To prevent IAD, the researchers developed an improved apertured film plus feminine pad to decrease inflammation caused by incontinence. This special design was the dry-feel Attends Incontinence Care Pad with frontal absorbent material on a pad 23 cm. wide. The pad was designed to absorb urine in the frontal area by using a combination of absorbent polymer and pulp only to minimized exposure of the buttocks to urine, while a second sheet is embedded between the top sheet and the absorbent material to prevent the absorbed urine from flowing back to the pad surface and buttocks area. In addition, the slit in the urinary excretion point and the flexed convex surface of the pad fit in the perineal region, also preventing leakage to the buttock area. This pad improved frontal absorption and backflow as compared with conventional products. The number of patients recovered completely from IAD in the experimental group (13 patients) than in the control group (4 patients). The time of recovery in experimental group was significantly faster than control group. However, moisture content and skin pH were similar in both groups.	1. The experimental group wore the hospital standard pad and a diaper during the night (20:00–9:00) because the volume of the test pad was not adequate for changing the incontinence pad during the night in the test hospital. The control group wore the standard pad and diaper at all times. This may affect research findings because experimental group wore mixed styles of pad. If health care professionals expect the same results in practice, they should apply the same procedure used in the study. Wearing the test pad for 24 hours needs to be explored in future study. 2. This study included only females, bedridden, older adults; therefore, its findings cannot be applied to males and older adults living sedentary or ambulatory lifestyles. 3. The RCT study did not calculate sample size based on a power analysis, so level of evidence from this study was quiet low.
Corcoran & Woodward. (2013)^Citation26	Research Article: Integrative review	Multiple settings (Long term care and in-patient department)	Level 3.b-(7/11)	6 studies (1618 mixed sex)	1. The products to prevent and treat IAD were the following: barrier film for 14 days, zinc oxide oil for 14 days, skin cleanser, barrier cream, Cavilon barrier film 3 times a week, 12% zinc oxide after each incontinent episode, 1% dimethicone after each incontinent episode, 43% petrolatum after each incontinent episode, 98% petrolatum after each incontinent episode, a non-aqueous product, a petrolatum containing water in oil, a petrolatum containing oil-in-water, two zinc-oxide-based products, glycerin, a moisturizer containing lanolin, a fine-grain emulsion of 50% lanolin, beeswax and petrolatum, Cavilon barrier film 3 times a day, and a petrolatum ointments as needed. 2. The zinc oxide product was the most effective in preventing irritation to skin but offered the least hydration. In contrast, the glycerin offered the most hydration, with the oil-in-water and dimethicone product offering hydration up to 6 hours.	1. Studies showed that using the barrier as part of a skin care protocol can help to prevent and/or treat IAD; however, there is insufficient evidence to recommend any one barrier product for use in a standard skin care protocol for IAD. 2. Some of the studies had small sample sizes and short evaluation times. Using larger sample sizes and a long-term study may return stronger and more effective recommendations to guide practice. 3. The studies used a variety of methods to assess skin integrity. Some did not report what instrument was being used to measure the severity of IAD. This may affect validity of the selected studies. 4. Some studies reported only the product used, however, authors did not report how to apply or how often the products were being used to prevent or treat IAD. 5. Females were the majority group in the studies, so this may have affected the results. A subgroup analysis to compare between male and female should be conducted. 6. Results could be biased because the products were received from the companies. 7. One study included in this review reported that participants had poor compliance with the protocol and was lost to follow-up. The results may not represent the true effect of the products. 8. Some studies applied the products under a protocol. However, it is difficult to conclude that the results were from the product or protocol. 9. The authors systematically searched the literature but did not use all standard processes for their review. This could limit their quality of the review.
Kliangprom & Putivanit (2017)^Citation28	Academic Article: Literature review	Thailand	Level 5.c-(5/6)	-	1. Assessment and reassessment (no identification when and how often to assess) 2. Avoid and reduce causes and risks of skin breakdown: Avoid rubbing, wiping and rinsing. Leave adhesive bandage/gauze on the skin for over 24 hours. When removing adhesive bandage, peel it back carefully rather than pulling it up and off; olive oil helps loosen the adhesive during removal. Manage incontinence: If using a diaper, change it every four hours instead of eight hours. 3. Apply skin protectant: Skin barrier film (Aloe Vesta 2-in-1 Protective Ointment, Secura TM Protective Ointment, and Baza Protect); skin barrier cream. 4. Select skin cleansing creme with natural pH and surfactant as well as skin nourishing products. Cleansing products should have a pH 5.2–5.5. Apply skin care lotion and moisturizer at least two times a day, and eat food with high protein.	This is a literature review that did not provide systematic search methods. Articles may not represent all studies with older adults. Details for caring for IAD were not given, such as what were the recommend products, how to apply the products, the quantity to apply, the frequency to apply, and when to apply? An outcome evaluation to identify the effectiveness of IAD care was not provided.
Iamma, W. (2017)^Citation27	Academic article (miscellaneous): Literature review	Thailand	Level 5.c-(4/6)	-	1. Observe and manage cause of incontinence, such as evacuation and urinary catheterization. 2. Clean immediately after each episode of urine and bowel incontinence by using products without alcohol, chemical color, lotion, and perfume/fragrance. Do not use warm water to wash. If using soap, use 2–3 small drops of liquid soap for children. Gently clean the wet skin with a soft towel. 3. Nurture skin by applying lotion without alcohol, chemical color, and perfume/fragrance. 4. Apply skin barrier cream, such as petroleum gel, zinc oxide, and dimethicone. 5. Use a pad instead of a diaper to promote air flow and decrease area of skin contact with urine and feces. 6. Position the person on one side instead of laying on the back to decrease the area of skin contact with urine and feces.	1. Missing was how the product was to be applied, the quantity to apply, and the frequency to apply. 2. All preventions and treatments were based on the author’s experience, which was the lowest level of evidence. An outcome evaluation to identify the effectiveness of IAD care was not provided.
Kon et al. (2017)^Citation25	Research article: RCT	Japan (Long term care)	Level 1.c Moderate^b (9/13)	33 female	1. Intervention group received skin cleansing with wet towels at each pad change, moisturizing and protective skin cleanser (including polyquaternium-51, an emollient and copolymer; and dimethicone were applied once a day); moisturizing (skin cream under investigation was applied three times daily and after product changes); and skin protectant (3M Cavilon Skin Barrier Cream was applied three times daily) for 14 days. The control group received only cleansing with wet towels at each pad change, moisturizing, and protective skin cleanser, including polyquaternium-51, an emollient and copolymer, and dimethicone once a day for 14 days. 2. In the experimental group, erythema was lower than in the control group after 14 days (p = 0.004). Moreover, the application of skin barrier cream was significantly associated with increased stratum corneum hydration (B = 0.443, p = 0.031), decreased skin pH (B = −0.439, p = 0.020), and decreased magnitude of erythema (B = −0.451, p = 0.018).	The study had a small sample size (33 instead of 133 from sample calculation), included females only, and had a short time evaluation period. This study included patients with mild IAD (inflammation only without skin loss or cutaneous rash). Thus, the findings may not be generalizable to older women with higher severity of IAD. However, the study controlled for confounding factors, such as temperature (controlled at 20–26 degree Celsius) and relative humidity (35–52%) at studied settings.
Yates, A. (2018a)^Citation29	Academic article: Literature review	United Kingdom	Level 5.c-(5/6)	-	1. Screening: Incontinence assessment, IAD risk assessment, and skin damaging assessment (if skin is already damaged) should be performed. 2. Cleaning: Remove irritants from skin such as urine/feces by using skin cleanser with pH near to that of the skin, use a gentle technique to minimize friction, avoid alkaline soaps, use a no-rinse liquid cleanser or pre-moistened wipe, and be gentle with dry skin. 3. Protection: Place a barrier on skin to prevent direct contact with urine/feces using petroleum jelly, zinc oxide, dimethicone, and acrylate terpolymer. 4. Restoring: Replenish the skin barrier using a tropical skin care product such as moisturizers or emollients. 5. Other: Identify, assess, and treat patients with incontinence, use skin risk assessment tools, provide good skin care regime, use appropriate barrier products, use the correct continence products (fecal management system, pads), use the correct absorbency pad product (ie, too high absorbency can be as damaging as not high enough), smooth pads to prevent creases, inspect skin at regular intervals, and keep individuals hydrated. Don’ts: Use traditional soap and water, avoid use of certain creams/talcum powder, do not double pad, do not rub skin dry, do not assume it is a pressure sore, do not assume incontinence is inevitable, and leave soiled pad products in contact with skin for any length of time.	This review provided specific care for older adults. However, the author did not state the process used to comprehensively search to confirm that all relevant articles were included before making a conclusion. Moreover, the recommendation missed some specific details, such as the quantity of the product to apply, the frequency of application, and when to apply the product. Finally, the author provided only interventions or products to deal with IAD but did not indicate when results would be noticed after applying the interventions and products and how to evaluate the outcomes.
Yates, A. (2018b)^Citation30	Academic article: Literature review	United Kingdom	Level 5.c-(5/6)	-	1. Prevention of skin problems: Incontinence assessment, IAD risk assessment, and grade of damage should be conducted if IAD has already occurred. Avoidance of IAD should be the first priority. This should include routine continence and skin assessment, appropriate containment, and implementation of an IAD management system. 2. Use of barrier products: Barrier products can act as a waterproof physical barrier between the skin and other substances. Following an episode of incontinence, the skin should be cleaned immediately using a cleanser with a similar pH to the skin, avoiding soap and water. The skin barriers can be creams, ointments, pastes, and spray. Applying greasy creams and ointments is a concern. They might clog pores on a continence pad product, leading to pad product failure and leakage. Advances in product development and improvement in pads might be used to fix the problem of clogging.	This academic article provided few concepts of taking care of IAD in older adults. More information is needed, such as names of the recommended products and how to apply and when we can use the product. The health care professional will find it is difficult to apply knowledge from this article.
Lumbers, M. (2019)^Citation2	Academic article: Literature review	United Kingdom	Level 5.c-(5/6)	-	1. Clean: Skin following an episode of incontinence should be cleaned and dried carefully as soon after the event as possible. Maintaining a pH of 5.5 and ensuring a slightly acidic mantle to discourage bacteria colonization while removing any debris are important. 2. Protect and Restore: Barrier products, in the form of creams, films, and sprays, should be applied to prevent moisture from urine and feces causing overhydration and damage to the skin. A product for promoting moisturizing intact skin should be applied. Some barrier products adversely affect the absorption ability of fluid into incontinence. This is a concern because it may block the pores of the incontinence pads, preventing the fluid from being absorbed into the pad. Thus, fluid may leak and create a wet environment that contributes to further skin damage. 3. Address causative factors: First line management should involve a review of the patient’s toilet practices. A non-invasive method should be the first choice in preventing incontinence. 4. Educate staff, patients, and care givers, who should take part in caring for IAD. If they are educated, they not only address issues but are well placed to help prevent recurrence.	This academic article provided the concepts of taking care of a patient with IAD. However, few details are provided. The article presents concepts, but the practitioner needs more concrete guidelines in caring for patients with IAD.
Holloway, S. (2019)^Citation8	Academic article: Literature review	United Kingdom	Level 5.c-(5/6)	-	1. Structured skin care regimen included: Remove irritant from the skin and protect from further exposure. Use devices or products that wick moisture away from the affected area or the skin that is at risk. Cleanse perineal skin after each episode of incontinence with a cleanser/wipe that has a pH close to 5.5 Use disposable wash basins for cleansing the skin to reduce cross infection risk. Check closely in skin folds for residual feces and urine. Remove these irritants after each episode of incontinence. Moisturize and protect using skin barrier products. Educate all care providers on the preferred methods of skin care.	The author provided only concepts of taking care of IAD, with few details. The concepts would be difficult to implement in practice because skin care, cleaning procedures, and barrier products to take care of IAD were not given. More information is need about the quantity of the products to be applied, when to apply the product, how long to clean up after each episode of incontinence, and the frequency of application.
Parnham, Copson, and Loban (2020)^Citation10	Research Article: Cases report	United Kingdom (In-patient department)	Level 4.d Low^bd (6/8)	3 female	1. Assessment: Three assessment tools were provided, including IAD severity instrument which gives a severity score, anatomical location, and range of photographs: Ghent Global IAD Categorization tool and this similar to The classification system issued by the European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance that cause confusion when documenting the extent of skin damage; and Skin Moisture Alert Reporting Tool which is highly recommended for use. 2. Address the underlying causes: Management system of incontinence. 3. Implement a structured skin care regimen: Skin cleansing should be applied after each episode of incontinence. Soap, water, cloths, and towels should be avoided since they can cause high pH, dry skin, and skin damage from shear forces. No-rinse cleansers such as pH-balance soap and spray foam should be applied. Barrier protection: The protection forms can be creams, films, and ointments. They are water repellent and commonly contain petrolatum, zinc oxide, or dimethicone. However, films were strongly recommended since its advantages are drying quickly on the skin surface and reducing the risk of skin tripping on dressing removal. The three IAD cases were treated by using the Medi Derma-Pro Foam and Spray Incontinence Cleanser with the soft, disposable wipe. The areas were allowed to air dry. A thin coating of Medi Derma-Pro Skin Protectant Ointment was applied over the affected area and repeated after every episode of incontinence. Healing was noticeable in the 2^nd, 4^th, and 7^th week.	1. Only concepts were presented but a product’s name was reported in three case studies. 2. Few case studies may limit the conclusion of this studies. 3. One of the three cases was classified as severe IAD, other two were not classified. The authors present the effectiveness of products only for patients who had IAD but did not address IAD prevention.
Joanna Briggs Institute levels of evidence Level 1.c - Experimental study: Randomized controlled trial Level 3.b - Observational analytical study: Systematic review of quasi-experimental and other lower study designs Level 4.d - Observational descriptive study: Case study Level 5.c – Expert opinion: Bench research/single expert opinion
GRADE Working Group Grades of Evidence for certainty of evidence High: The research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different is low. Moderate: The research provides a good indication of the likely effect. The likelihood that the effect will be substantially different is moderate. Low: The research provides some indication of the likely effect. The likelihood that it will be substantially different (a large enough difference that it might have an effect on a decision) is high. Very low: The research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different (a large enough difference that it might influence a decision) is very high.
Explanations a. Risk of bias (low, unclear, high) b. Consistency (consistency, inconsistency, unknown/non applicable) d. Precision (precise, imprecise)

Notes: The scores of Methodological Quality of the Studies are shown in fractions based on Joanna Briggs Institute and the Mixed Methods Appraisal Tools.

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