Incontinence Care--Easy Isn't Better...or Cheaper

By: Howard L. Enfiejian, Ph.D.
Director of Research and Medical Communication
Derma Sciences, Inc., Old Forge, PA

Incontinence is common among elderly patients who often have concomitant illnesses with perineal manifestations. From this it follows that the dermatitis arising from ineffective incontinence care may mask perineal symptoms and obscure the ongoing diagnostic activity that is a part of chronic care. Urinary incontinence in particular is emotionally distressing and socially disruptive. Despite this, it was not until 1980 that the costs of urinary incontinence care were studied systematically. The size of the problem soon became apparent. In 1987 dollars, the direct costs of urinary incontinence care were over $10 billion. This vastly exceeded the 1987 costs for the care of patients with AIDS ($1.8 billion) and was comparable to costs for the care of patients with senile dementia ($15.8 billion). In effect, the prevention or management of incontinence dermatitis could free up vast amounts of money for use elsewhere in the health care system.

For reasons that include acquisition costs and convenience, soap and water remain common modes for incontinence care. Despite these advantages, soap and water can set up a vicious circle that actually aggravates incontinence dermatitis. Healthy skin maintains itself at an average pH of 5.5. This acid mantle discourages bacterial growth and provides a moisture barrier. Aging skin becomes increasingly dry and intolerant of alkaline substances. Here is where the problem begins. Many soaps commonly in use have pHs approaching 11. This alone can disrupt the perineal skin sufficiently to cause dermatitis. Ammonia from the urine and fecal digestive enzymes that are activated by an alkaline pH can also induce dermatitis. The persistence of all these elements on the perineal skin can cause catastrophic dermatitis. The resulting erosion of epidermis can be comparable to a deep chemical peel. It is logical, therefore, that the current ACHPR guidelines for managing acute and chronic urinary incontinence recommend the prevention and early treatment of skin breakdown.

These and other intrinsic and extrinsic factors can so irritate the skin that other diseases may be obscured. The range of these disorders almost reads like the index from a dermatology text: mechanical injury, bullous impetigo, folliculitis, candidiasis, psoriasis, erythrashma, intertrigo, scabies, pediculosis, syphilis, and malignancy, as well as infection from herpes simplex, herpes zoster, and tinea cruris--these affect not only perineal integrity but reflect the patient's general health. Obscuring the signs of these diseases through ineffective incontinence care will thus compromise the caregiver's ability to assess accurately the patient's overall condition.

These considerations have one overwhelming consequence. Institutions with strained budgets must not consider acquisition cost alone when choosing incontinence products. Although reimbursement issues may not now give caregivers much flexibility in choosing incontinence products, the time will soon come when outcome-oriented research will force the issue. The resources saved by taking the time to use pH-balanced cleansers, moisturizers, and barrier products will ultimately be too obvious to permit anything else.

Return to Main Page, Wound Care Institute Newsletter, Fall 1996