Key Messages
• There is little evidence on the effects of different methods for preventing skin irritation caused by prolonged contact with urine (pee) or stool (poo) in adults. Some skin cleansers might be better than soap and water, and using skin cleansers together with leave-on products (moisturisers, skin protectants) might work better than using skin cleansers alone, but we are very uncertain about the results.
• To find out how best to prevent this skin irritation, we need more studies of standard methods tested in different care settings.
What is incontinence-associated dermatitis?
Incontinence-associated dermatitis is one of the most common skin problems in adults who leak urine, stool, or both. The skin becomes red and often sore or itchy, sometimes leading to open sores. The main approaches to preventing this problem include skin cleansing and applying products to protect the skin, such as moisturisers, skin protectants, or barriers (leave-on products).
What did we want to find out?
We wanted to know which skin cleansers and leave-on products work best to prevent incontinence-associated dermatitis in adults. We also wanted to know if the skin cleansers and leave-on products had any unwanted effects, such as pain, skin rash, or itching.
What did we do?
We methodically searched for studies that compared different methods of preventing incontinence-associated dermatitis (skin cleansing, leave-on products, or both) in healthcare settings. The people included in the studies had to be aged 18 years or older and could not have incontinence-associated dermatitis at the beginning of the study. We presented the results and rated our confidence in the evidence based on factors such as study methods and size.
What did we find?
We found 15 studies involving 1020 adults who were incontinent (who leaked urine, stool, or both) and who lived in a nursing home or were in hospital. Thirteen of these studies had a small sample size, while two trials involved over 170 adults. Six studies looked at results in the short term (up to 7 days), four in the medium term (8 days to 1 month), and one in the long term (1 month to 3 months). No other studies explained when they measured the results.
It was hard to combine and compare the results because the studies included many different products and measured the results in different ways.
Three studies compared different skin cleansers, five compared different leave-on products, and seven studies evaluated combinations of skin cleansers and leave-on products.
Main results
One study suggested that using a cleansing product may be more effective at preventing incontinence-associated dermatitis compared with soap and water, but another study found little to no difference between these two types of treatment. Similarly, one study showed that combining a skin cleanser with a leave-on product may be more effective than cleansing alone, while another study suggested there was little to no difference in effectiveness between the two approaches. We are very uncertain about the results of all comparisons, so we are unsure if any treatment works better than any other for preventing incontinence-associated dermatitis.
There may be little or no difference in the number of people experiencing treatment-related pain among those treated with a combination of skin cleansing and leave-on product and those treated with cleansing alone. Similarly, there may be little or no difference in the number of people experiencing treatment-related pain among those treated with a no-rinse skin cleanser plus a skin cream compared with those treated with soap and water followed by a lotion.
Using skin cleansing plus a leave-on product may lead to itching in fewer people compared with a skin care routine without a leave-on product.
What are the limitations of the evidence?
We are not confident in the evidence because most studies included few people and did not report the results consistently. In addition, there was considerable variation in the products and procedures used.
How up to date is this review?
The evidence is current to 29 April 2024.
Read the full abstract
Incontinence-associated dermatitis (IAD) is a common skin problem in adults with urinary incontinence, faecal incontinence, or both. Prevention involves skin care interventions such as skin cleansing and the application of skin protectants/barriers (leave-on products).
Objectives
To assess the effects of skin care cleansers, leave-on products, and procedures for preventing incontinence-associated dermatitis in adults.
Search strategy
On 29 April 2024, we searched the Cochrane Incontinence Specialised Register – which includes searches of CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, and WHO ICTRP – and hand-searched journals and conference proceedings. We searched reference lists of included studies to identify additional studies.
Selection criteria
We selected randomised controlled trials (RCTs) and quasi-RCTs conducted in any healthcare setting and involving participants aged over 18 years without IAD at baseline. We included trials comparing the effectiveness of skin cleansing interventions and leave-on products or combinations of interventions/leave-on products.
Data collection and analysis
Three review authors independently screened the titles, abstracts, and full-text articles. Four review authors independently extracted data and assessed risk of bias. Data from studies not published in English were translated and extracted by volunteers from Cochrane Engage and the review authors' networks. Primary outcomes were: number of participants with IAD and adverse effects related to the intervention (pain, skin rash, itching, and other serious adverse effects). Secondary outcomes were: number of participants satisfied with skin care products or procedures, adherence to the protocol throughout the intervention, and quality of life (condition-specific or generic). We used GRADE to assess the certainty of the evidence.
Main results
We included 15 trials with 1020 participants in a qualitative synthesis (41 participants from nursing homes; 65 from both care homes and hospital, and 914 from hospital settings). Participants had urinary incontinence, faecal incontinence, or both. Thirteen trials had small sample sizes and two trials had 180 and 174 participants. Six trials assessed outcomes in the short term (≤ 7 days), four in the medium term (8 days–1 month), and one in the long term (> 1 month–3 months). In the remaining studies, the timing of assessment was unclear. The overall risk of bias in the included studies was high. Substantial heterogeneity (in study populations, skin care products, skin care procedures, outcomes, and measurement tools) precluded meta-analysis.
Three trials compared skin cleansing interventions, and five trials compared leave-on products or a combination of leave-on products. Seven trials compared a combination of skin cleansers and leave-on products.
Number of participants with incontinence-associated dermatitis
Three trials compared a skin cleanser with soap and water. One provided evidence that using a foam cleanser might be more effective than soap and water for preventing IAD (RR 0.35, 95% CI 0.14 to 0.85; 65 participants; very low-certainty evidence), while another found little or no difference in effectiveness between a disposable washcloth containing 3% dimethicone and soap and water (RR 0.14, 95% CI 0.01 to 2.28; 12 participants; very low-certainty evidence). The third trial reported lower erythema scores with a no-rinse skin cleanser compared with soap and water, but we were unable to analyse these data.
In trials evaluating combinations of skin cleansers and leave-on products versus skin cleansing alone, one suggested the combined treatment may be more effective for preventing IAD (RR 0.03, 95% CI 0.00 to 0.53; 180 participants; very low certainty of evidence), and the other showed little to no difference between interventions (RR 0.71, 95% CI 0.14 to 3.68; 31 participants; very low-certainty evidence). Two studies showed little to no difference between a combination of leave-on products versus a single product (RR 0.85, 95% CI 0.36 to 2.02; 74 participants; very low-certainty evidence); (RR 0.25, 95% CI 0.03 to 1.86; 20 participants; very low-certainty evidence).
In general, we cannot draw meaningful conclusions about the effectiveness of the tested interventions in preventing IAD because of the very low certainty of the evidence for all comparisons.
Adverse effects: pain
One trial found that fewer people using a combination of skin cleansing and a leave-on product experienced pain compared with those receiving cleansing without a leave-on product (RR 0.33, 95% CI 0.09 to 1.19; 180 participants; low-certainty evidence), and one trial found that fewer people using a no-rinse skin cleanser plus a skin cream developed pain compared with those using soap and water followed by a lotion (RR 0.58, 95% CI 0.19 to 1.74; 31 participants; low-certainty evidence). However, our analyses of these two comparisons suggest there may be little to no difference between the tested interventions in terms of associated pain.
Adverse effects: itching
One trial found that skin cleansing and a leave-on product may be less frequently associated with itching compared with a conventional skin care regimen with no leave-on product (RR 0.04, 95% CI 0.01 to 0.29; 180 participants; low-certainty evidence).
Authors' conclusions
We found limited evidence, of low and very low certainty, on the effectiveness of interventions for preventing IAD in adults. Consequently, it is unclear whether any skin cleanser or leave-on product, used alone or in combination, performs better than any other. There is some very uncertain evidence that using a skin cleanser may be better at preventing IAD than soap and water, and that using a combination of a skin cleanser with a leave-on product may be better at preventing IAD than using a skin cleanser alone. There is a need for high-quality confirmatory trials using standardised, comparable prevention regimens in different settings/regions.
