Know how to correctly identify these four common types of Moisture Associated Skin Damage (MASD) for best wound care practices.
It might sound reasonable to assume that Moisture Associated Skin Damage (MASD) is the result of, well … moisture. The fact is that it takes more than just moisture to cause MASD, which is the inflammation and erosion of the skin that’s caused by prolonged exposure to various sources of moisture, including, urine, stool, perspiration, wound exudate, mucous, or saliva. Skin does not break down in water alone. However, when moisture on the skin is combined with friction, chemical irritants or bacterial/microbial factors, that’s when the real damage occurs.
For effective wound care, clinicians must be able to properly assess MASD from the onset – even if at first the diagnosis isn’t obvious. It all begins with good clue gathering, and knowing the characteristics of each of the four common types.
Because moisture on the skin increases skin permeability (which alters pH and cools the tissue), it compromises the barrier function of the skin’s protective acid mantle. This, in turn, makes the skin more susceptible to friction and shearing forces.
Correct MASD identification is critical for treatment, and should begin as soon as initial signs appear. The first step is to conduct a complete skin assessment. Don’t ever assume that you know what’s going on at first glance. Follow the general rule of thumb for any wound expert, and keep looking! Take your time, be methodical, and note the location, texture, moisture level, maceration, denuding and changes in skin color.
Know your type
Incontinence-Associated Dermatitis (IAD)
One of the most common forms of MASD is incontinence-associated dermatitis (IAD), which is the inflammation of the skin from extended exposure to urine or stool. You may also know it as perineal dermatitis, irritant dermatitis or diaper rash (in children). The highest-risk patients are those that have both fecal and urinary incontinence.
As mentioned earlier, moisture requires an additional irritant in order to produce MASD. Urine contains ammonia, which increases the skin’s pH and destroys the protective acid mantle. Adding to the problem, frequent skin cleansing in response to urinary or fecal incontinence can increase the risk of breakdown. Even incontinent briefs can contribute to IAD by causing perspiration in the affected area. Although the briefs pull the actual fluids away, the microclimate remains moist and warm.
So how do you know if it’s IAD? Here are typical characteristics:
- Found over fatty tissue of the buttocks, perineum, inner thigh and groin (though they can occur over bony prominences).
- Distributed in a consolidated or patchy formation.
- Covers diffuse areas, shaped like a mirror image in the skin fold or linear area in the anal cleft.
- Is superficial or partial thickness in depth. Note: if there’s tissue destruction into the subcutaneous tissue or deeper, it must be staged as a pressure ulcer (for more information, see the WCEI blog “Will the Real Pressure Ulcer Please Stand Up?”)
- Presents with non-uniform redness in the wound bed, maceration in the surrounding skin and peri-anal redness. No necrosis.
- Has diffuse and irregular wound margins.
Intertriginous Dermatitis (ITD)
Intertriginous dermatitis, also called intertrigo, is an inflammatory condition of opposing skin surfaces caused by moisture. You’ll find it in skin folds, such as under the breasts, in the axillary (armpit) area, or inguinal (groin) region. It’s particularly common in obese patients.
Moisture can become trapped in the skin fold, where there is a lack of air circulation. The excess moisture causes the dead cells in the uppermost layer of the skin (the stratum corneum) to become saturated and then puff up. The result is rough textures (which means they won’t glide very well), and the result is skin-on-skin friction.
Characteristics of ITD:
- Found in the skin folds.
- Distributed in a linear, mirror image on each side of the fold
- Always partial thickness.
- Presents as mild erythema (redness) that can quickly progress to erosion, oozing, maceration or crusting.
- Surrounding skin is often macerated and prone to bacterial and fungal infections such as candidiasis.
- Can be painful, itchy and may produce odor.
It’s important to realize that a patient can suffer from both IAD and ITD at the same time, coexisting side-by-side.
Periwound Moisture-Associated Dermatitis
Periwound moisture-associated dermatitis occurs when the skin adjacent to a chronic wound becomes exposed to exudate or toxins from bacteria in the wound bed, causing inflammation and erosion. This is a result of too much exudate that hasn’t been properly managed. Left untreated, the periwound will eventually break down and the wound will enlarge.
Infected wounds are especially prone to periwound moisture-associated dermatitis because they produce more exudate. The condition is more common in the elderly and immunocompromised, but our clinical practices can contribute as well. This can be due to a number of risk factors, including improper dressing selection, infrequent dressing changes, and aggressive tape removal.
Peristomal Moisture-Associated Dermatitis
The final common type of MASD is peristomal moisture-associated dermatitis. This form of inflammation and skin erosion occurs only in ostomy patients. It begins at the stoma/skin junction, and can extend outward as much as 4 inches in any direction. As many as 50% of patients with a stoma experience this condition, which can be extremely detrimental to their quality of life.
Peristomal moisture-assisted dermatitis can happen around any stoma, including tracheostomies, gastrostomies, urostomies, and colostomies. However, ileostomy patients – those with stomas at the small intestine – have the highest risk since the effluent (output from the stoma) is watery and caustic. When the pouching system leaks due to improper sizing, an uneven peristomal plane or incorrect wear time, the effluent causes skin irritation and potential breakdown.
Pay close attention to the area around the stoma, keeping a close eye out for potential problems, including well-defined erythema, edema, and loss of the epidermis. You may also see papules, vesicles, itching, crusting and oozing. As with other forms of MASD, it’s important to address the problem early.
Do you know your MASD types?
What types of MASD have you encountered the most in your facility, and have you ever had trouble identifying them? Do you have any tips for MASD identification, and has early identification made a difference in patient outcome? Please tell us about your experiences by leaving your comments below.
Wound Care Education Institute® provides online and onsite courses in the fields of Skin, Wound, Diabetic and Ostomy Management. Health care professionals who meet the eligibility requirements may sit for the prestigious WCC®, DWC® and OMS national board certification examinations through the National Alliance of Wound Care and Ostomy® (NAWCO®). For more information see wcei.net.