Perineal Dermatitis – A Complete Guide

Perineal dermatitis also known as incontinence-associated dermatitis, irritant dermatitis, moisture lesions, and diaper rash is an inflammation of the skin in the perineum (area between the tops of the thighs), perigenital areas, buttocks, gluteal fold, thighs, lower back, lower abdomen, and skin folds (groin, under the large abdominal apron, etc.).

Perineal dermatitis can cause changes in the skin barrier including burning, itching, discomfort, pain, vesiculation, or tingling in the affected areas.

Pain may be present where the epidermis is intact.

In individuals with light skin, perineal dermatitis appears as erythema which can range from pink to red. In individuals with darker skin tones, the skin may be darker, purple, paler, dark red, or yellow. The affected area has poorly defined edges and may be patchy or continuous over large areas.

The perineal areas are examined for erythema, maceration, signs of fungal or bacterial skin infection, erosion or denudation, and the presence of lesions (vesicles, papules, pustules, etc.).

Your doctor might rule out other look-a-like conditions like:

• Pressure ulcers

• Heat rash, or miliaria

• Erythrasma

• Psoriasis

• Herpes

• Another form of dermatitis

Incontinence causes perineal dermatitis. When the skin is exposed to urine or feces regularly, it becomes inflamed. The condition is worse for those with fecal incontinence, as stool can irritate the skin more than urine.

In many cases, perineal dermatitis is caused by:

• Frequent episodes of incontinence

• The creation of ammonia by fecal and urinary incontinence

• An increase in the skin’s pH level

• Skin erosion from bacteria breaking down protein in keratin-producing cells

• Poor skin conditions (like aging skin, diabetes, steroid use, and others)

• Raised body temperature (pyrexia)

• Diminished Cognitive Awareness

• Pain

• Poor nutritional Status

• Compromised mobility

• Overhydrating the skin

• Frequent cleaning of the affected area with soap and water

• Friction caused by absorbent pads or other materials, including bed linens and underwear

• Prolonged exposure to feces and urine

• Medications

• Critical illness

• Not cleaning the exposed area properly

• Application of thick ointments

• Use of abrasive washcloths

In some cases, perineal dermatitis may be complicated by fungal dermatitis.

Additional causes of skin irritation should be considered if diaper rash is recalcitrant. These causes may include allergies or skin sensitivities to ingredients in diapers, wipes, or other topical products. Food sensitivities, underlying disease processes, and medication reactions may also play a role in persistent perineal dermatitis.

The only way to treat perineal dermatitis is to prevent it in the first place. Incontinence can be managed or prevented by causative factors, such as diapers, disposable briefs, evacuation, urinary catheterization, absorbency, smooth pads, an improved aperture film plus feminine pad, and a review of patient toileting techniques. However, one researcher said that using a pad instead of a diaper is a better way to promote air flow and decrease the area of skin contact from urine and fecal matter.

Incontinence management for urinary and fecal incontinence is another factor that should be taken because both are the two main causes of perineal dermatitis. Fecal collection devices can significantly reduce the incidence of perineal dermatitis. Examples include anal pouches connected to negative-pressure suction devices, anal pouch collection devices, anal catheters/tubes connected to negative-pressure suction devices, and anal catheter/tube collection devices. A retraining Foley catheter can be used for urine incontinence but is optional. Examples of non-invasive strategies are wearing a condom catheter, using a soft pad, reviewing the patient’s toileting habits, and putting on a diaper.

The way to decrease moisture damage and chemical irritation to the skin is by cleansing the affected area after each episode of urination and defecation. This process includes medical material removal, cleaning techniques, cleansing products, and water or waterless applications. There are researchers who state that a bandage or gauze dressing applied to the buttock area should remain in place for over 24 hours before removal and cleaning. Moreover, olive oil or any oil of choice should be used to help in removing the bandage and peel back the bandage when removing it, not pulling upward on the skin. Cleansing should start either immediately after incontinence, as quickly as possible, at least 2x a day, or after each episode of incontinence. The cleansing product should not contain chemical color, lotion, alcohol, or perfume. Some researchers suggested that the pH for skin cleansing should range from 4.0 to 6.0. Wet cloths and towels, soap and warm water, and alkaline soap were not advised but one researcher recommended using wet towels. however, liquid soap for children was preferred. A disposable wash basin should be used for cleaning the skin to reduce cross-infection. Rubbing, wiping, and rinsing were actions to be avoided. In contrast, the tapping technique and no-rinse cleansers, such as sprays, liquids, soaps, and foams, and gentle blotting of moisture should be used to reduce the cause or risks of skin breakdown.

There are two products that can be used, ie. skin moisturizers and skin barriers. The skin moisturizing products included a lotion without chemical colors, alcohol, perfumes/fragrances, and moisturizers or emollients. The skin barriers could be ointments, pastes, creams, and sprays.

There are researchers who suggested using the products at every episode of incontinence, three times a day (as needed), or applying it for 14 days. They also recommended that the barrier products might be of concern because they could block the pores of the incontinence pads and prevent the absorption of moisture.

Topical moisture barrier products come in many forms:

• Clear liquid films

• Clear creams and ointments

• Thick, opaque, zinc-based preparations

• Carboxymethylcellulose (CMC) or pectin-based powders

Skin cleaning wipes that contain dimethicone or other moisture barriers can be used.

For skin that is intact and free from breakdown, clear barrier products offer lighter protection and allow frequent assessment of the skin.

You can use hydrogel or petroleum-based products and products containing zinc oxide, dimethicone, glycerin, and acrylate terpolymer.

Spray films can help because they dried quickly on the skin surface and reduced the risk of skin tearing on dressing removal.

Body positioning helps to decrease the surface area of skin irritation. It helps to decrease area of irritation promote airflow, and prevent pressure ulcers. One researcher recommended placing the person on either the right or left side instead of on the back to prevent and decrease the severity of IAD. This helps to decrease the area of skin contact from urine and feces.

Tissue recovery is faster when the food you eat is full of nutrients, especially protein. So patients should eat foods high in protein to prevent perineal dermatitis and promote wound healing.

Apply a thick layer of zinc-based cream (diaper rash creams) to the perineal area at all times and it should be reapplied with each diaper change. It is often taught to apply diaper cream like cake icing. It is not necessary to remove all of the cream with every diaper change. Make sure to be consistent with frequent application

When treating denuded skin, the go-to treatment is “crusting.” Crusting has gained popularity as an effective treatment for IAD in the diaper area.

Crusting involves sprinkling stoma powder on the denuded areas and then sealing them by applying a skin barrier film. When the film dries in 10 seconds, another layer of powder and skin barrier film should be applied, creating a durable layer of protection to promote healing and prevent further breakdown. Zinc-based barrier cream should then be applied over the layer of “crust.” With diaper changes, the soiled layer of barrier products should be gently skimmed off, and more cream should be applied. Crusting should be repeated on remaining denuded areas when all products wear off the skin or after bathing.

For severe cases of perineal dermatitis, including those that are chronic or have other factors that exacerbate breakdown or prevent healing, a cyanoacrylate film can help. This film can be applied to denuded skin in the perineal area to promote healing. Cyanoacrylate film creates a purple film on the wounds and skin that dries quickly, but care should be taken to separate skin folds and not touch the skin or allow any material to touch the skin while the film dries. The film will wear off over hours to days as the skin heals. It should not be picked or peeled off prematurely. The film can be reapplied as needed to areas that remain open. This treatment can work for even the most severe cases of perineal dermatitis. You can clean the skin with a hypochlorous acid solution soak for at least 60 seconds before applying cyanoacrylate film. There are case studies that support the use of hypochlorous acid soaks for the treatment of perineal dermatitis in infants.

People who develop perineal dermatitis are also more likely to develop pressure ulcers or bed sores. This is seen in older adults or people who have a medical condition that limits their ability to switch positions.

The symptoms for bed sores are usually the same as for perineal dermatitis:

• Broken skin

• Inflammation

• Pain or tenderness

If you think you’re developing bed sores, see your doctor. Mild bed sores can be successfully treated over time. Treatment for more severe bed sores focuses on symptom management.

Too many layers of cloth or product:

• Increases friction and shearing

• Increases heat

• Increases moisture and prevents airflow

• Impairs microclimate

• Negates the effect of the active mattress

• Increases PI risk.

Perineal dermatitis can also lead to secondary skin infections. These are typically caused by Candida albicans or Staphylococcus.

If you develop a secondary infection, you may experience:

• itching

• burning

• pain during urination

• rash

• unusual discharge

• 3M:
  • Cavilon Advanced Skin Protectant
  • Cavilon Durable barrier cream
  • Cavilon No Sting Barrier Film

• Medi Derma:
  • S barrier cream
  • Pro Foam and Spray Incontinence Cleanser

• Boudreaux’s Butt Paste | Maximum Strength with 40% zinc oxide

• LBF Barrier Cream

• Xenaderm ointment

• No-rinse cleansing foam plus moisturizer products

• No-rinse pH-balanced liquid cleanser and barrier cream products

• Skin Basics Zinc and Castor Oil Cream

• Other diaper rash creams you can buy online