What is Moisture-Associated Skin Damage (MASD)?

Moisture-associated skin damage (MASD) is caused by prolonged exposure of skin to various sources of moisture, including urine or faeces, perspiration, wound discharge, mucus, saliva, and their contents (Gray et al, 2011; Woo et al, 2017). When skin is exposed to prolonged moisture, the natural Ph level of the skin changes and can become sore and break eventually (Gray et al, 2011; Woo et al, 2017). Other factors contributing to MASD include germs on the skin surface, and mechanical factors such as friction (Gray et al, 2011). When the skin breaks down due to the presence of moisture it is more at risk of becoming damaged due to pressure (Fletcher, 2020).

Prevention of MASD

MASD can be prevented by making sure:

Skin is regularly washed with a pH balanced cleanser, kept as dry as possible and checked regularly.
A skin barrier film or cream is used, if at risk of MASD. This forms a protective layer between the skin and external irritants and moisture (Gray et al, 2011; McNichol et al, 2018).
Any pads used for incontinence meet the correct level of absorbency (Beeckman et al, 2018).
Any wound dressings meet the correct level of absorbency required.
Any stoma/urostomy products are well fitted and emptied regularly.
Regular change of position if the ability to walk is reduced/limited (Beeckman et al, 2020).

Types of MASD

Incontinence-Associated Dermatitis (IAD):

IAD is caused due to a chemical irritation when urine or faeces meets the skin. Ammonia from the urine and enzymes from the faeces disrupt the acid balance of the skin and eventually causes the skin to break down (Woo et al, 2017). The affected area will present with swelling, skin changes and then it may progress to painful partial-thickness sores with a weepy sometimes green or clear fluid leakage. Faeces contains enzymes which increase the risk of infection when the skin is broken. With incontinence of urine and or faeces, the risk of developing MASD increases (Beeckman et al, 2018). Other related risk factors include reduced ability to walk resulting in difficulty getting to the toilet; diuretics (water tablets) and regular urine infections. Some medical conditions can result in incontinence which increases the risk of MASD. These are Multiple Sclerosis (MS); Parkinsons; Dementia; Spinal cord injury; Learning disabilities; Alzheimer’s disease; Crohn’s disease and Ulcerative colitis (Fletcher, 2020).

Intertriginous Dermatitis (ITD):

This occurs when sweat is trapped in skin folds with minimal air circulation and is subjected to friction (Metin et al, 2018). This leads to inflammation and stripping of the skin, making the area more prone to infection (Kottner et al, 2020). Obese people are more at risk of ITD due to excessive skin folds, increased perspiration to regulate body temperature, and higher skin surface pH (Gabriel et al, 2019; Kottner et al, 2020).

Periwound Moisture-Associated Dermatitis:

The production of leakage is a normal response during the inflammatory stage of wound healing. Excessive amounts of wound exudate can cause the area around the wound (within 4cm of wound edge) to become damaged and break down (Fletcher, 2020). The presence of bacteria, specific proteins, or enzymes, and the volume of wound leakage greatly reduce the skin barrier function. Another factor affecting the occurrence of periwound damage is heavy handed removal of adhesive wound dressings, which affects the ability of the skin barrier by stripping away parts of the inner layer of the skin (Fletcher, 2020).

Body Areas Prone to MASD

Areas of the body prone to high risk of MASD include buttocks, groins, anal cleft and inner thighs, skin folds (e.g. under the abdomen and breasts), skin surrounding a stoma, urostomy sites and wet wounds.

Signs & Symptoms of MASD

MASD can be difficult to spot for people with darker skin. It's therefore useful to look out for the following (Fletcher et.al, 2020):

Persistent red, sore and unbroken skin (this is not as obvious in darker pigmented skin).
Skin is shiny and moist in appearance (again, not as obvious in darker pigmented skin).
Multiple smaller areas of broken skin, where the skin has been stripped away. This can be superficial skin damage but can quickly extend in size and affect deeper tissues.
Skin that is warm when touched.
Skin that itches or stings.
Wet skin.

Implementing an Appropriate Care Pathway

The approach to care will be similar in the first instance for all four types of moisture-associated skin damage and should focus on the following:

Adopt a structured skin care regimen
Use products that absorb and/or keep moisture away from the skin.
Control the cause of excessive moisture.
Treat infection (Voegeli, 2020).
Avoid soap and water as traditional soap is made up of alkalis and fatty acids that raise the pH of the skin (Voegeli, 2020).
The use of soft cloths and liquid barrier films and moisture barrier creams are recommended (Lichterfeld-Kottner et al, 2020).

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References

Beeckman, D., Campbell, K., Le Blanc, K. et.al (2020) Best practice recommendations for holistic strategies to promote and maintain skin integrity. Wounds International. Available online at: https://www.woundsinternational.com/resources/details/best-practice-recommendations-holistic-strategies-promote-and-maintain-skin-integrity.
Beeckman, D., Smet, S., Van den Bussche, K. (2018) Incontinence-associated dermatitis: why do we need a core outcome set for clinical research? Wounds International 9(2): 21-25
Fletcher, J. (2020) Pressure ulcer education 6: incontinence assessment and Care. Nursing Times [online]; 116: 3, 42-44.
Fletcher, J., Beeckman, D., Boyles, A. et al (2020) International Best Practice Recommendations: Prevention and management of moisture-associated skin damage (MASD). Wounds International. Available online at woundsinternational.com
Gabriel, S., Hahnel, E., Blume-Peytavi, U., Kottner, J. (2019) Prevalence and associated factors of intertrigo in aged nursing home residents: a multi-center cross-sectional prevalence study. BMC Geriatrics 19(1): 105
Gray, M., Black, J.M., Baharestani, M.M., Bliss, D.Z., Colwell, J.C., Goldberg, M., Kennedy-Evans, K.L., Logan, S., Ratliff, C.R. (2011) Moisture-associated skin damage: overview and pathophysiology. J Wound Ostomy Continence Nursing. May-Jun;38(3):233-241.
Kottner, J., Everink, I., Van Haastregt, J. (2020) Prevalence of intertrigo and associated factors: A secondary data analysis of four annual multicentre prevalence studies in the Netherlands. Int J Nurs Stud 104: 103437
Lichterfeld-Kottner, A., El Genedy, M., Lahmann, N. et al (2020) Maintaining skin integrity in the aged: A systematic review. International Journal Nursing Studies 103: 103-509.
Metin, A., Dilek, N., Bilgili, S.G. (2018) Recurrent candidal intertrigo: challenges and solutions. Clinical Cosmet Investigation Dermatology. April 17;11:175-185.
McNichol, L.L., Ayello, E.A., Phearman, L.A., Pezzella, P.A., Culver, E.A. (2018) Incontinence-Associated Dermatitis: State of the Science and Knowledge Translation. Advanced Skin Wound Care. November 31(11):502-513.
Voegeli D (2020) Intertrigo: causes, prevention and management. Br J Nurs 29(12): S16-22.
Woo, K.Y., Beeckman, D., Chakravarthy, D. (2017) Management of Moisture-Associated Skin Damage: A Scoping Review. Advanced Skin Wound Care. November;30(11):494-501.