Moisture-Associated Skin Damage
(MASD)

The moisture barrier of the skin plays a vital role in maintaining a relatively stable equilibrium between the interdependent fluids within the body. The moisture content in the skin regulates the inward and outward movement of the body fluids. Prolonged exposure to moisture can worsen the skin health making it vulnerable to injuries or to a situation where it cannot heal normally.

Moisture Associated Skin Diseases (MASD) includes injuries due to inflammation & erosion of the epidermis (denudation) which is caused by continued contact with moisture such as urine, stool, sweat, wound drainage, saliva, or mucus. There are four types of MASD:

1. Incontinence Associated Dermatitis
2. Intertriginous Dermatitis
3. Periwound Dermatitis
4. Peristomal Dermatitis

1. Incontinence-Associated Dermatitis (IAD)

When the skin is exposed to excessive amounts of urine or feces, the skin’s structure is disrupted, resulting in maceration. Water from the urine or feces is drawn in and trapped in the corneocytes, causing overhydration and skin denudation, making the skin prone to damage. Incontinence caused by combined urine and feces is more harmful because it contains a higher amount of digestive enzymes, which affect the skin’s acid levels (normally pH 4.6-5.5).

The areas of risk for IAD include Perineum, Perigenital areas, Buttocks, Gluteal folds, Thighs,
Lower back, Lower abdomen and in the skin folds of the groin, etc.

Control Methods:

  • Minimize skin exposure to urine and stool.
  • To develop a stringent skincare routine to maintain the integrity of the skin as a barrier, including cleaning methods, moisturization and use of a selective skin protectant.

Treatment Methods:

  • As part of the cleaning routine, the skin needs to be cleaned thoroughly, moisture maintenance to be ensured, and alongside a skin barrier cream or ointment to be applied to prevent further damage.
  • Any progression in terms of superficial or secondary infection to be treated by topical methods. In certain cases, a containment strategy to be devised.

2. Intertriginous Dermatitis (ITD)

Intertrigo is the conditions of itchy, painful, and uncomfortable red rashes appearing in the large skin wrinkles due to microbial contamination, heat, humidity, immersion, friction, and lack of air circulation. These are skin-skin or skin-to-device inflammations leading to skin crack, bleed, ooze, and crust over, causing the surrounding area to be scaly. People with compromised immunity or bedridden are more likely to have intertrigo. It is seen to be a common complication in moist
environmental conditions.

The areas of risk include arms, breasts, toes, groins, and buttocks, etc.

Control Methods:

  • Reduce heat and moisture within the skin fold.
  • A dry environment to be ensured always.
  • Proper cleansing or shower after exercise, then thoroughly pat dry the skin folds.
  • A PH balanced or neutral skin cleanser to be used.
  • Promote proper general skin hygiene.

Treatment:

  • For any kind of secondary infections (Bacterial or Fungal), topical, or oral treatments to be a choice of action.
  • Weight monitoring is advised, to promote further complications.
  • Surgical treatment of excess skin can also help reduce the risk of ITD, although this is not always recommended.

3. Peri-wound Dermatitis

It occurs when the wound exudate, which contains protein-based enzymes, comes in contact with the tissue surrounding the wound for prolonged periods.

Prolonged exposure of peri-wound skin to excessive moisture along with these enzymes lead not only to maceration but also an injury to the skin similar to the one caused by trauma, chemical, or thermal burn. This condition causes skin irritation and itching, making it more vulnerable to pressure, shear, and friction, all of which can impede wound healing.

Diabetic foot ulcers, venous leg ulcers, pressure ulcers, fungating tumors, and full-thickness burns
are more prone to developing peri-wound moisture-associated dermatitis.

Control Methods:

  • Absorptive dressings are to be selected.
  • Wound, peri-wound, and wound tissues are to be mapped and analysed.
  • Skin protectants and/or barrier films can be used on the peri-wound tissue if and as needed.
  • Consultation with a wound care specialist is to be ensured as needed.

Treatment:

  • The very initial step in the treatment and management of any peri-wound moistureassociated dermatitis is to manage the excessive exudate. This could be considered as anything ranging from absorptive dressings or windowed dressings to external collection devices or vacuum-assisted compression and similar in extreme cases.
  • Skin protectants of varied compositions offer a range of protection for the peri-wound skin from maceration. After exudate management, the skin will progress toward healing.

4. Peristomal Moisture-Associated Dermatitis:

This damage occurs when the surrounding skin encounters effluent from the stoma. It can cause inflammation of the skin and possible erosion. The damage can occur soon after the initial surgery and reduces as the individual becomes more competent at caring for the stoma.

Control Methods:

  • Manage peristomal moisture sources such as perspiration, wound exudate, and external sources to ensure proper pouch adhesion.
  • Ensure the pouch is not being left in one place for too long or too short of a period. Time management plays an important role here. Longer wear times may lead to compromised adhesion of the pouch and unwanted occlusion of the underlying skin. Also, shorter wear times can result in mechanical and rough striping of the skin.
  • When adjusting to get the right fit by moulding and cutting of the skin barrier to fit the
    stoma, it is recommended that frequent and correct measurements of the stoma are to be
    conducted over the first 6 weeks to adjust to the changing shape of the stoma.

Treatment:

  • Reevaluation of the pouching system shall ensure drainage, correct fit, and output type shall define the skin barrier fitment.
  • Topical treatments such as powders, pastes, or rings can be used for moisture absorption under the skin barrier. An additional physical barrier can reduce existing irritation and may allow for proper adhesion of the skin barrier.
  • The wound’s etiology should be addressed at all times, and exudate should be managed with an appropriate absorptive dressing.

Source:

IAD:https://www.nursingtimes.net/clinical-archive/tissue-viability/incontinence-associateddermatitis-1-risk-factors-for-skin-damage-02-03-2020/
ITD: https://www.healthline.com/health/intertrigo#pictures
https://www.nursingcenter.com/ce_articleprint?an=00129334-201708000-00008
Preventional Treatment: https://www.woundsource.com/patientcondition/moisture-associatedskin-damage-masd