ABSTRACT
OBJECTIVE
To study the effect of liquid dressing and ostomy powder on the treatment of incontinence-associated dermatitis (IAD).
METHODS
The authors searched PubMed, Web of Science, CNKI (China National Knowledge Internet), and Google Scholar databases for literature through July 28, 2022. After literature screening, two investigators independently extracted data from the included studies and applied the Newcastle-Ottawa Scale to assess the quality of the included studies. The χ2-based Q statistic test and the I2 statistic were used to measure the heterogeneity of the included studies. Publication bias was measured with funnel plots and the Egger test. Sensitivity analysis was conducted by eliminating each study one by one.
RESULTS
Four high-quality studies were included in the meta-analysis, involving a total of 307 participants. The meta-analysis results showed that compared with traditional care, treatment with liquid dressing and ostomy powder significantly improved the effective rate (pooled odds ratio, 21.42; 95% CI, 8.58 to 53.44), shortened the healing time (pooled mean difference, −10.73; 95% CI, −12.92 to −8.54), and reduced the recurrence rate (pooled mean difference, −2.03; 95% CI, −2.30 to −1.77) of IAD. Among the included studies, no publication bias was detected. Sensitivity analysis results confirmed the robustness of the pooled estimates.
CONCLUSIONS
Treatment with liquid dressing and ostomy powder has clinical value for patients with IAD.
KEYWORDS: incontinence-associated dermatitis, irritant contact dermatitis, liquid dressing, meta-analysis, ostomy powder
INTRODUCTION
Incontinence-associated dermatitis (IAD) is a common complication among patients with incontinence. As a form of moisture-associated skin damage, IAD occurs because of long-term exposure of the skin to urine, feces, or both.1 It results in skin inflammation characterized by redness, swelling, or blister formation as well as discomfort, itching, tingling, and burning in the affected areas.2 The common anatomic locations of IAD include perianal skin, buttocks, genitalia, posterior thigh, and inner thigh.3 The epidemiology of IAD varies across studies and patient populations. The prevalence and incidence of IAD were reported as 22.8% and 7.6%, respectively, in a long-term acute care unit, whereas the incidence in critical care patients was 29% to 36%.4–6
Incontinence-associated dermatitis impairs the skin barrier function because the chemical irritants in urinary and fecal incontinence disrupt the acid mantle, resulting in an increased alkaline skin pH.7 Aggressive cleansing activities accompanied by excessive friction also aggravate the skin damage.8 Therefore, structured skin care protocols aimed at cleansing, moisturizing, and protecting the skin using quality products are particularly important in the prevention and treatment of IAD.9
Previous studies have reported the widespread use of various skin care products such as pastes, lotions, and films to prevent and treat IAD;10,11 however, the efficacy and effectiveness of these products have not been well delineated. Two available products are liquid dressings and ostomy powder. A liquid dressing (Figure 1A) forms a liquid barrier film on the skin surface, reducing the skin’s coefficient of friction and preventing water loss.12 Ostomy powder (Figure 1B) absorbs moisture.
Figure 1.
PHOTOS OF (A) LIQUID DRESSING AND (B) OSTOMY POWDER
In this meta-analysis, the authors investigated the effect of liquid dressing and ostomy powder on the treatment of IAD. The treatment effect was graded into recovery, improvement, or ineffectiveness; the effective rate includes recovery and improvement. The authors compared effective rates, time to healing, and recurrence rates by product type.
METHODS
Data Collection
The authors searched electronic databases (PubMed, Web of Science, CNKI [China National Knowledge Internet], and Google Scholar) for relevant articles published prior to July 28, 2022, using the keywords as follows: (incontinent-associated dermatitis OR moisture-associated skin damage) AND (nursing care OR nursing interventions) AND (the prevalence rate of incontinence OR incontinence-associated dermatitis) AND (liquid dressings and stomatostomy).
Studies that met the following inclusion criteria were included in the meta-analysis: (1) original publications studying IAD; (2) study participants were hospitalized patients with IAD; (3) outcomes described at the end of treatment included the effective rate, time to healing, and recurrence rate; and (4) studies used assessment tools or a clear definition to determine IAD. Studies were excluded if they had incomplete data; were reviews, letters, comments, or case reports; were redundant publications or used the same study population (if so, only the most recent publication or the one with the most comprehensive data or the highest quality was included in the meta-analysis); or did not contain the outcomes of interest.
Data Extraction
Two investigators independently extracted the following data from the included studies into an Excel (Microsoft Corp) file: first author, publication year, region of study, study design, number of participants, and outcomes. The investigators applied the Newcastle-Ottawa Scale (NOS) to assess the quality of the included studies.13 If opinions were divided, consensus was reached by discussing with another investigator.
Statistical Analysis
The meta-analysis was performed using R (version 4.2.1; The R Foundation). Odds ratios and CIs were calculated to determine effect sizes. The χ2-based Q statistic test and the I2 statistic were used to measure the heterogeneity of the included studies.14 If the heterogeneity was significant (P < .05 or I2 > 50%), the random-effects model was applied to calculate the pooled estimates; otherwise, the fixed-effects model was used.15 Publication bias was detected using funnel plots and the Egger test.16 The authors conducted a sensitivity analysis to verify the robustness of the pooled estimates.
RESULTS
Literature Search
A total of 610 articles were retrieved from the databases: 190 from PubMed, 170 from Web of Science, 130 from Google Scholar, and 120 from CNKI. After removing 300 duplicates, 310 articles remained. These were screened for relevance, and 170 were excluded. The remaining 140 articles underwent full-text screening, and 136 articles were excluded. The four articles that met the inclusion criteria were included in the meta-analysis (Figure 2).17–20
Figure 2.
FLOWCHART OF LITERATURE SEARCH AND STUDY SELECTION
Abbreviation: CNKI, China National Knowledge Internet.
Characteristics of the Included Studies
All studies were carried out in China between 2015 and 2018. A total of 307 patients with IAD were included in the studies, of whom 155 patients were in the treatment groups, and 152 patients were in the control groups (Table 1). In one study, all patients were women. Three studies involved a total of 244 patients with mild, moderate, or severe IAD, of whom 123 patients in the treatment group were treated with liquid dressing and ostomy powder, and 121 patients in the control group received traditional skin care. The study by Chen et al20 did not describe disease severity. In most studies, ostomy powder was applied first, followed by a liquid dressing. All four included studies scored 8 or 9 on the NOS, indicating that they were of high quality (Supplemental Table; http://links.lww.com/NSW/A156).
Table 1.
CHARACTERISTICS OF THE INCLUDED STUDIES
| Author (Year) | Location | Newcastle-Ottawa Scale Score | Group | N | Men, n (%) | Women, n (%) | Age, Mean ± SD, y |
|---|---|---|---|---|---|---|---|
| Sun et al17 (2018) | China | 9 | Liquid dressings and ostomy powder | 40 | 24 (60) | 16 (40) | 75.1 ± 5.6 |
| Control | 40 | 23 (57.5) | 17 (42.5) | 74.2 ± 4.5 | |||
| He18 (2017) | China | 9 | Liquid dressings and ostomy powder | 35 | 20 (57.1) | 15 (42.9) | 61.9 ± 4.2 |
| Control | 35 | 18 (51.4) | 17 (48.6) | 61.4 ± 4.1 | |||
| Jin19 (2016) | China | 9 | Liquid dressings and ostomy powder | 48 | 0 (0) | 48 (100) | 57.1 ± 34.1 |
| Control | 46 | 0 (0) | 46 (100) | 57.9 ± 36.9 | |||
| Chen et al20 (2015) | China | 8 | Liquid dressings and ostomy powder | 32 | NR | NR | 65.06 ± 8.2 |
| Control | 31 | NR | NR | 65.01 ± 8.6 |
Abbreviation: NR, not reported.
Meta-analysis Results
The heterogeneity of the effective rate among studies was not significant (I2 = 0%, P = .98), so pooled estimates were calculated using the fixed-effects model (Table 2). As depicted in Figure 3, the effective rate of treatment with liquid dressing and ostomy powder was better than in the control group (pooled odds ratio, 21.42; 95% CI, 8.58 to 53.44).
Table 2.
META-ANALYSIS RESULTS
| Incontinence Model | Sample Size | Test of Association | Model | Test of Heterogeneitya,b | Egger Testc | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Cases | Control | Odds Ratio (95% CI) | Z | P | Q | P | I2, % | t | P | ||
| Effective rate | 107 | 106 | 21.42 (8.58 to 53.44) | 6.95 | <.001 | Fixed | 0.17 | .98 | 0 | 0.621 | .671 |
| Healing time | 107 | 106 | −10.73 (−12.92 to −8.54) | −9.61 | <.001 | Random | 7.04 | .07 | 57.4 | 0.642 | .624 |
| Recurrence rate | 107 | 106 | −2.03 (−2.30 to −1.77) | −14.98 | <.001 | Fixed | 3.92 | .27 | 23.4 | 0.816 | .512 |
aRandom-effects model was used when P < .05 for the heterogeneity test; otherwise, the fixed-effects model was used.
bP < .05 is considered statistically significant for Q statistics.
cThe Egger test was used to evaluate publication bias, and P < .05 is considered statistically significant.
Figure 3.
FOREST PLOT OF THE EFFECTIVE RATE OF TREATMENT
There was significant heterogeneity of healing time among studies (I2 = 57%, P = .07), so the authors used the random-effects model to compute pooled estimates for this variable. As seen in Figure 4, length of time to healing was shorter with liquid dressing and ostomy powder compared with traditional skin care (pooled mean difference, −10.73; 95% CI, −12.92 to −8.54).
Figure 4.
FOREST PLOT OF THE HEALING TIME OF TREATMENT
To determine pooled estimates for the recurrence rate, the authors used the fixed-effects model because the heterogeneity among the studies was not significant (I2 = 23%, P = .27). As depicted in Figure 5, the recurrence rate was lower in the treatment group than in the control group (pooled mean difference, −2.03; 95% CI, −2.30 to −1.77).
Figure 5.
FOREST PLOT OF THE RECURRENCE RATE OF TREATMENT
Publication Bias
The funnel plot was visually symmetrical (Figure 6), and the Egger test did not detect any publication bias (P > .05; Table 2).
Figure 6.
FUNNEL PLOT OF PUBLICATION BIAS ASSESSMENT
Sensitivity Analysis
Sensitivity analysis was performed by eliminating each study one by one and pooling the three remaining studies. Each time a study was removed, the meta-analysis estimates were not significantly affected, confirming the stability of the results.
DISCUSSION
Four studies comprising 307 participants were included in this meta-analysis. The total quality of the included studies was high. The meta-analysis showed that, in comparison with standard care, treatment with liquid dressing and ostomy powder improved the effective rate, shortened the healing time, and reduced IAD recurrence. Risk assessment of publication bias and sensitivity analysis demonstrated the effectiveness and stability of the findings.
The pathophysiology of IAD is multifactorial.21 The normal pH of healthy skin ranges from 4 to 6. However, prolonged contact with chemical irritants in urine (eg, ammonia) and stool (eg, enzymes) impairs this protective acid mantle and increases the skin pH.22 When skin pH becomes alkaline, the number of pathogenic bacteria increases, along with the risk of bacterial colonization. Further, skin lipids are altered and skin permeability increases, impairing the skin barrier function.23–26 In addition, moisture increases the coefficient of friction and makes the skin more susceptible to injury from friction during cleansing.23 Hence, excessive skin care, such as frequent cleansing and vigorous friction, may exacerbate the clinical manifestation of IAD.
A structured skin care regimen consisting of skin cleansing, moisturization, and protection plays a key role in IAD prevention and treatment.27 When incontinence occurs, immediately cleaning off the urine or stool and gently drying the skin will prevent absorption of the liquid into the skin.9 Moisturization is intended to repair the damaged skin barrier, increase the water content, and decrease transepidermal water loss. Skin protectants provide a barrier between the skin surface and irritants.11,28
In a systematic review, Pather et al29 attempted to establish the effectiveness of topical skin products in treating and preventing IAD. Evidence suggested that skin care regimens containing skin protectants contribute to the treatment and prevention of IAD; however, those authors could not conduct a meta-analysis because of the large variation among studies (including interventions, outcomes, measurement tools, etc). Inadequate clinical data regarding product efficacy and effectiveness in treating IAD underline the need for meta-analysis to improve clinical treatment.
In the present study, the authors focused on the effectiveness of liquid dressing and ostomy powder in treating IAD. The liquid dressing used in the included studies is a film-forming liquid acrylate. It quickly forms a long-lasting, waterproof, and antifriction film that protects the surface of the skin from various physical and chemical irritations and reduces maceration and bacterial infection.30 The main component of ostomy powder is carboxymethylcellulose sodium, which has strong hydrophilicity. After interaction with water, it forms a gelatinous membrane that blocks urine and stool from macerating the skin and removes bacterial toxin products and cellular debris.31
Limitations
Only four articles met the inclusion criteria for this meta-analysis, and the sample sizes were relatively small. Although the authors searched both Chinese and English databases, the included studies were all conducted in China, which may mask any regional differences in clinical efficacy. Relevant studies published in other languages were not considered.
CONCLUSIONS
Treating IAD with liquid dressing and ostomy powder in comparison with standard care significantly improves the effective rate, shortens the length of time to healing, and reduces recurrence. More large-scale, randomized controlled trials across multiple regions are recommended to confirm these findings.
Supplementary Material
Footnotes
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.ASWCjournal.com).
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