Skin cleansers and leave-on product interventions for preventing incontinence-associated dermatitis in adults

TY - JOUR

T1 - Skin cleansers and leave-on product interventions for preventing incontinence-associated dermatitis in adults

AU - Graham, Tanya

AU - Beeckman, Dimitri

AU - Kottner, Jan

AU - Fader, Mandy

AU - Fiorentino, Francesca

AU - Fitzpatrick, Joanne M

AU - Gray, Mikel

AU - Harris, Ruth

AU - Sooriah, Sangeeta

AU - Wallace, Sheila A

AU - Worsley, Peter

AU - Woodward, Susan

PY - 2025/5/14

Y1 - 2025/5/14

N2 - AbstractBackgroundIncontinence-associated dermatitis (IAD) is a common skin problem in adults who are incontinent for urine, stool, or both. Prevention requires skin care interventions, such as skin cleansing and the application of skin protectants/barriers (leave-on products).ObjectivesTo assess the effects of skin care cleansers, leave-on products and procedures for preventing incontinence-associated dermatitis in adults.Search methodsOn 29 April 2024, we searched the Cochrane Incontinence Specialised Register which includes searches of the Cochrane Central Register of Controlled Trials (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 criteriaWe selected randomised controlled trials (RCTs) and quasi-RCTs, from any healthcare setting, which included participants over 18 years, without IAD at baseline. We included trials comparing the effectiveness of skin cleansing interventions and the application of leave-on products, with different combinations.Data collection and analysisThree review authors independently screened titles, abstracts and full-texts. Four different review authors, independently extracted data and assessed risk of bias of the included trials. Data from studies not published in English were translated and extracted by volunteers from Cochrane Engage and the author's networks who were fluent in the language. Primary outcomes were: number of participants without IAD; adverse effects (of the interventions) including number of patients with intervention-related pain, with skin rash due to skin care product or procedure, with itching due to skin care product or procedure and any other serious or unexpected adverse effect associated with the intervention or procedure. Secondary outcomes were: number of participants satisfied with skincare products or procedures for prevention of IAD; clinicians' observations of adherence to protocol specification throughout the period of the intervention and quality of life (condition-specific or generic). GRADE was used to assess the certainty of the evidence.Main resultsWe included 15 trials with 1,020 participants in a qualitative synthesis (n=41 from nursing homes; n=65 from both care homes and hospital and n=914 from hospital settings). Participants were incontinent of urine, stool, or both. Thirteen trials had small sample sizes and two trials had 180 and 174 participants respectively. Six trials assessed outcomes in the short term (up to 7 days) and four in the medium term (8 days to 1 month). One trial timed assessments between 1-3 months (long term assessment). For the remaining studies, the timing of assessment was unclear. The overall risk of bias in the included studies was high. The data were not suitable for meta-analysis due to heterogeneity in participant population, skin care products, skin care procedures, outcomes, and measurement tools.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 product(s). We found evidence in three trials, of very low quality, that soap and water performed poorly in the prevention of IAD. The first trial found that using a disposable washcloth containing 3% dimethicone might be more effective than using soap and water (RR 0.14, 95% CI 0.01 to 2.28; 12 participants; very low certainly of evidence). The second trial reported that using a foam cleanser might be more effective than soap and water (RR 0.35, 95% CI 0.14 to 0.85; 65participants; very low certainly of evidence). The third trial reported lower erythema scores for participants using a no rinse skin cleanser when compared with soap and water (no RR available; 10 participants; medium term).Findings from other trials, all being of low to very low quality, suggest that combining a skin cleanser with a leave-on product is more effective than skin cleansing alone (RR 0.71, 95% CI 0.14 to 3.68; 1 study; 31 participants; very low certainly of evidence); (RR 0.03, 95% CI 0.00 to 0.53; 1 study; 180 participants; very low certainly of evidence).Two studies found that using a combination of leave-on products might be more effective than using one product alone (RR 0.85, 95% CI 0.36 to 2.02; 1 study; 74 participants ;very low certainly of evidence); (RR 0.25, 95% CI0.03 to 1.86; 1 study; 20 participants; very low certainly of evidence). One trial found that fewer people using a combination of skin cleansing and a leave-on product experienced pain compared to those receiving cleansing with no leave-on product applied (RR 0.33, 95% CI 0.09 to 1.19; 180 participants; low certainly of evidence). One trial found that fewer people using a no rinse skin cleanser plus a skin cream developed pain compared to those using soap and water followed by a lotion. (RR 0.58, 95% CI 0.19 to 1.74; 31 participants; low certainly of evidence). One trial found that fewer participants using skin cleansing and a leave-on product experienced intervention-related itch compared to those receiving the conventional skin care regime in which no product was applied. (RR 0.04, 95% CI0.01 to 0.29; 180 participants; low certainly of evidence). This trial found that more participants using a structured protocol of cleansing and topical product application were very satisfied or satisfied with the intervention products and procedures compared to those receiving conventional skin care in which no product was applied. One trial reported that a treatment protocol was adhered to faithfully (100% of observed days in the intervention group) but the control protocol was less stringently followed (84% of observed days). No trials reported on the primary outcome 'adverse effects: skin rash or other adverse effects’ or on ’quality of life’.Authors' conclusionsLittle evidence, of very low to low quality, exists on the effects of interventions for preventing IAD in adults. Soap and water performed poorly in prevention of IAD. Using skin cleansers in combination with leave-on products (moisturisers, skin protectants) may be more effective than not using these products. High quality confirmatory trials using standardised, and comparable prevention regimens in different settings/regions are required.

AB - AbstractBackgroundIncontinence-associated dermatitis (IAD) is a common skin problem in adults who are incontinent for urine, stool, or both. Prevention requires skin care interventions, such as skin cleansing and the application of skin protectants/barriers (leave-on products).ObjectivesTo assess the effects of skin care cleansers, leave-on products and procedures for preventing incontinence-associated dermatitis in adults.Search methodsOn 29 April 2024, we searched the Cochrane Incontinence Specialised Register which includes searches of the Cochrane Central Register of Controlled Trials (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 criteriaWe selected randomised controlled trials (RCTs) and quasi-RCTs, from any healthcare setting, which included participants over 18 years, without IAD at baseline. We included trials comparing the effectiveness of skin cleansing interventions and the application of leave-on products, with different combinations.Data collection and analysisThree review authors independently screened titles, abstracts and full-texts. Four different review authors, independently extracted data and assessed risk of bias of the included trials. Data from studies not published in English were translated and extracted by volunteers from Cochrane Engage and the author's networks who were fluent in the language. Primary outcomes were: number of participants without IAD; adverse effects (of the interventions) including number of patients with intervention-related pain, with skin rash due to skin care product or procedure, with itching due to skin care product or procedure and any other serious or unexpected adverse effect associated with the intervention or procedure. Secondary outcomes were: number of participants satisfied with skincare products or procedures for prevention of IAD; clinicians' observations of adherence to protocol specification throughout the period of the intervention and quality of life (condition-specific or generic). GRADE was used to assess the certainty of the evidence.Main resultsWe included 15 trials with 1,020 participants in a qualitative synthesis (n=41 from nursing homes; n=65 from both care homes and hospital and n=914 from hospital settings). Participants were incontinent of urine, stool, or both. Thirteen trials had small sample sizes and two trials had 180 and 174 participants respectively. Six trials assessed outcomes in the short term (up to 7 days) and four in the medium term (8 days to 1 month). One trial timed assessments between 1-3 months (long term assessment). For the remaining studies, the timing of assessment was unclear. The overall risk of bias in the included studies was high. The data were not suitable for meta-analysis due to heterogeneity in participant population, skin care products, skin care procedures, outcomes, and measurement tools.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 product(s). We found evidence in three trials, of very low quality, that soap and water performed poorly in the prevention of IAD. The first trial found that using a disposable washcloth containing 3% dimethicone might be more effective than using soap and water (RR 0.14, 95% CI 0.01 to 2.28; 12 participants; very low certainly of evidence). The second trial reported that using a foam cleanser might be more effective than soap and water (RR 0.35, 95% CI 0.14 to 0.85; 65participants; very low certainly of evidence). The third trial reported lower erythema scores for participants using a no rinse skin cleanser when compared with soap and water (no RR available; 10 participants; medium term).Findings from other trials, all being of low to very low quality, suggest that combining a skin cleanser with a leave-on product is more effective than skin cleansing alone (RR 0.71, 95% CI 0.14 to 3.68; 1 study; 31 participants; very low certainly of evidence); (RR 0.03, 95% CI 0.00 to 0.53; 1 study; 180 participants; very low certainly of evidence).Two studies found that using a combination of leave-on products might be more effective than using one product alone (RR 0.85, 95% CI 0.36 to 2.02; 1 study; 74 participants ;very low certainly of evidence); (RR 0.25, 95% CI0.03 to 1.86; 1 study; 20 participants; very low certainly of evidence). One trial found that fewer people using a combination of skin cleansing and a leave-on product experienced pain compared to those receiving cleansing with no leave-on product applied (RR 0.33, 95% CI 0.09 to 1.19; 180 participants; low certainly of evidence). One trial found that fewer people using a no rinse skin cleanser plus a skin cream developed pain compared to those using soap and water followed by a lotion. (RR 0.58, 95% CI 0.19 to 1.74; 31 participants; low certainly of evidence). One trial found that fewer participants using skin cleansing and a leave-on product experienced intervention-related itch compared to those receiving the conventional skin care regime in which no product was applied. (RR 0.04, 95% CI0.01 to 0.29; 180 participants; low certainly of evidence). This trial found that more participants using a structured protocol of cleansing and topical product application were very satisfied or satisfied with the intervention products and procedures compared to those receiving conventional skin care in which no product was applied. One trial reported that a treatment protocol was adhered to faithfully (100% of observed days in the intervention group) but the control protocol was less stringently followed (84% of observed days). No trials reported on the primary outcome 'adverse effects: skin rash or other adverse effects’ or on ’quality of life’.Authors' conclusionsLittle evidence, of very low to low quality, exists on the effects of interventions for preventing IAD in adults. Soap and water performed poorly in prevention of IAD. Using skin cleansers in combination with leave-on products (moisturisers, skin protectants) may be more effective than not using these products. High quality confirmatory trials using standardised, and comparable prevention regimens in different settings/regions are required.

KW - Incontinence associated dermatitis, IAD, prevention, skin cleansers, skin protectants

M3 - Article

SN - 1469-493X

JO - Cochrane Database of Systematic Reviews

JF - Cochrane Database of Systematic Reviews

ER -