Celebrating the Discovery of Insulin and Pressure Injury Awareness Day, and Reexamining Irritant Contact Dermatitis Due to Incontinence

In November, two significant global health concerns are highlighted: diabetes and pressure injuries. World Diabetes Day is celebrated on November 14, the birthday of Sir Fredrick Banting.1 It took a team to make insulin a reality. John Macleod provided the lab space at the University of Toronto for Dr Banting, a surgeon, to work with Charles Best, a research student at the University of Toronto where in 1921 this innovative group were able to isolate insulin. Insulin was later purified by James Collip, a Canadian biochemist. Dr Banting and his co-discoverers sold the patent for insulin for CAD $1 because Banting wanted insulin to be available for all. However, more than 100 years later, the high cost of insulin remains a reality, even though in the US, Medicare now caps the monthly cost of insulin at USD $35.2 Despite subsidies, some persons with diabetes in North America struggle with the cost of insulin. The Cape Town Declarations were formulated at the 2016 Would Council of Enterostomal Therapists Congress because the high cost of insulin and lack of access has reached an acute crisis in Africa. An analytic fact sheet from the World Health Organization (WHO) has identified diabetes as the silent killer in Africa.3 An estimated 24 million people were living with diabetes in Africa in 2021, and this number is projected to increase to 55 million by 2045.3 The WHO also estimates that more than half of the persons with diabetes (54%) are not diagnosed; the WHO is targeting a goal of 80% diagnosed by 2030.3 Between 2011 and 2021, the African region recorded a 5-fold increase in type 1 diabetes among children and teenagers younger than 19 years, with cases surging from 4 per 1,000 to 20 per 1,000.3 Despite these alarming numbers, Africa has the second-lowest expenditures on diabetes, accounting for only 1% of global diabetes costs. Even in South Africa where insulin is subsidized, the average cost of insulin alone for the lowest paid government worker represents over 3 days wages for a monthly supply.4 Other African countries have higher insulin costs and lower availability leading to premature deaths. Many persons with diabetes in Africa who require insulin die prematurely: an urgent solution is needed. This journal issue contains new evidence that clinicians will want to read about diabetic foot ulcer treatment strategies. Gomez and colleagues summarized 11 controlled clinical trials that investigated the efficacy of platelet rich plasma (PRP) to promote healing of chronic DFUs. They concluded that while further research is needed, PRP is an adjuvant for healing chronic DFUs. Additional thought-provoking case reports include Frost and colleagues’ treatment of fungal osteomyelitis of a diabetic foot infection caused by an unusual organism, Trichhosporon asahii. Also noteworthy is the case series by Cimaroli and co-authors healing outcomes in 50 wounds, including some DFUs, by using an extended wear transforming powder dressing. Further, Lin and colleagues remind us to look at the whole wounded person’s quality of life including those with diabetes. The National Pressure Injury Advisory Panel (NPIAP), European Pressure Ulcer Advisory Panel (EPUAP) and other organizations have designated November 21, 2024, as a global awareness day to prevent pressure injuries (PIs). Visit the NPIAP website for free educational materials for professionals and a patient guide about PI prevention. The EPUAP website has additional educational materials including a video in several languages. For the fifth year in a row, Dr Berlowitz and his colleagues have provided an update on recent PI literature. From the over 700 new PI articles published in English in 2023, they selected six research articles to summarize for this year’s review. Topics include: the SKINCARE trial for health and safety in care of older persons; continuous bedside pressure mapping to reduce PI; antibiotic treatment of osteomyelitis complicating PIs; PI prevention devices to manage older persons after hospital discharge; visual classification by nurses of PI stages using a deep learning model; and a meta-analysis of topical application of Periplaneta americana liquid (known as KangFuXin in China) in treatment of PIs. This year, the authors also included review articles on risk assessment, an NPIAP paper on PI assessment in persons with dark skin tones, and emerging issues of PI progression related to social determinants of health. We look forward to the 2025 release of the 4th edition of the EPUAP/NPIAP/PPPIA International PI Guideline. Make plans now to attend the NPIAP 2025 Conference, “Zeroing in on pressure injury prevention: Raise the Bar!” taking place February 27 and 28, 2025 in Dallas, Texas, US with preconference on February 26, 2025. In the second Clinical Management Extra article in this issue, Dr Donna Bliss and colleagues—including your coeditors and Dr Shakira Brathwaite, a skin of color dermatology resident at the University of Toronto—examine moisture-associated skin damage due to incontinence among patients with skin of color, and have updated current clinical challenges with fecal, urinary, and dual incontinence. Dermatologists have traditionally divided contact dermatitis into irritant contact dermatitis (approximately 80% of cases) and allergic contact dermatitis (approximately 20%) of cases. Contact allergies can occur to topical antimicrobial agents (eg, neomycin, mupirocin, gramicidin, polymyxin) or incipient components of creams or ointments. It is rare to document an allergy to topical nystatin or the “azole” (clotrimazole, miconazole, etc) antimicrobial agents. The new World Health Organization International Classification of Diseases 11 has reclassified the former “moisture-associated skin damage due to incontinence” to now be termed “irritant contact dermatitis due to incontinence.” Drs Ayello and Sibbald, when reviewing a study of contact irritant dermatitis due to incontinence in patients with brown skin, noted that erythema (red skin) was not usually obvious, and that hyperpigmentation was a common finding, but some patients can have residual hypopigmentation. These changes are due to an increased concentration of eumelanin in the melanosomes of persons with black or brown skin, which causes erythema to look darker but postinflammatory erythema may be lighter. Inflammation disrupts the dermal‒epidermal junction where the melanocyte is displaced from the epidermal base. The release of melanosomes leads to pigment change: acutely, usually hyperpigmentation, but postinflammation there may be loss of melanosomes with hypopigmentation in some patients. Separately, both Dr Bliss and Dr Dimitri Beeckman along with their colleagues created validated instruments for contact irritant dermatitis due to incontinence. Dr Bliss and colleagues developed a weighted 4-point scale for irritant contact dermatitis due to fecal incontinence, urinary incontinence, or dual incontinence (ICD-FIUIDI). This scale distinguishes among normal skin, pink skin with possible slight hypo- or hyperpigmentation, and red skin with potential hypo- or hyperpigmented characteristics. The third and fourth characteristics are rash and skin loss: A skin rash is any area of irritated or swollen skin, which, with this tool, should be distinguished from the pink or red skin in the first two criteria. Skin loss associated with incontinence would include erosion (loss of epidermis with an epidermal base) but not an ulcer (loss of epidermis with a dermal or deeper base). This tool has 14 areas to examine with a score on each area that can be monitored for improvement or worsening of the condition along with a summed total score. Several materials related to the tool are available for download.5 The Ghent Global Incontinence Associated Dermatitis Categorization Tool (GLOBIAD),6 developed under the leadership of Dr Beeckman and international colleagues has two main categories. The first describes persistent red skin (1A), noting that patients with dark skin tones may have paler or darker than normal or purple coloration. The second category describes additional skin loss that illustrates an erosion and not an ulcer (2A). Each category has an additional area for secondary infection (1B & 2B). The GLOBIAD Monitoring Tool (GLOBIAD-M) adds two additional criteria, edema and maceration, with the suggestion that these should be documented daily with palpation of the lesion(s). There is also an 11-item patient-reported pain numeric rating. Other symptoms suggested to be reported including itching, tingling, and burning. The monitoring enablers associated with this tool are freely available.6 As emphasized in the article, there needs to be more representation of skin of color (a term that has evolved in Canada over the past 10 years) in illustrations of incontinence-associated contact irritant dermatitis, along with in assessment and treatment criteria. The presence of incontinence associated dermatitis may heighten the PI risk along with facilitating overt superficial or covert deep and surrounding infection risk. This is just one of many dermatologic conditions with skin of color that has not been adequately studied and reported in the literature. Elizabeth A. Ayello, PhD, MS, RN, CWON, MAPWCA, FAAN R. Gary Sibbald, MD, Med, FRCPC (Med Derm), FAAD, MAPWCA, JM

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