ABSTRACT
Incontinence‐associated dermatitis (IAD) is an irritant contact dermatitis from prolonged contact with urine or feces, which can significantly impact patient comfort and quality of life. [1][2][3] IAD is one of the four clinical types of moisture-associated skin damage (MASD) and is considered preventable.[4] This topic covers management and prevention of incontinence associated dermatitis (IAD) for the adult and older adult population. For an introduction and assessment of IAD including epidemiology, risk factors, etiology, pathophysiology, history, physical examination, diagnosis, differential diagnoses, documentation and ICD-10 coding, see topic "Incontinence Associated Dermatitis - Introduction and Assessment". For management and prevention of IAD in newborns, see “Incontinence Associated Dermatitis - Prevention and Management in Newborns”.
Prevention and Treatment Summary
- The primary goal for treatment or prevention of IAD is to manage incontinence.[5] While working towards this goal, a structured cleansing and protection regimen is essential.[5][6]
- Interventions are similar for both prevention and management of IAD.[7]
An adequate prevention and/or management plan for IAD aims to:
Plan reassessment: for patients with IAD, daily documentation and skin assessments with each incontinence episode are essential to monitor healing. Visible improvement and pain reduction should occur within 3-5 days of initiating an appropriate structured skin care regimen, with complete resolution typically within 1–2 weeks. If continence issues persist or the skin does not improve, consult a specialist continence advisor where available.[7]
When to refer to specialists:
- Urologist or gastroenterology specialist to assess and manage reversible causes of urinary or fecal incontinence
- Nurse specialized in continence for assessment and recommendations on how to manage incontinence
- Nutritionist for nutritional optimization
- Infectious disease in cases of IAD with secondary infection
- Social work for economical, social support
- Psychologist/ mental health professional for depression and other psychological issues
ICD-10 Coding: See section on 'Coding' in "incontinence Associated Dermatitis - Introduction and Assessment"
PREVENTION AND MANAGEMENT
Overview
This topic covers management and prevention of incontinence associated dermatitis (IAD) for the adult and older adult population. For an introduction and assessment of IAD including epidemiology, risk factors, etiology, pathophysiology, history, physical examination, diagnosis, differential diagnoses, documentation and ICD-10 coding, see topic "Incontinence Associated Dermatitis - Introduction and Assessment". For management and prevention of IAD in newborns, see “Incontinence Associated Dermatitis - Prevention and Management in Newborns”.
Background
Proper management of IAD prevention and treatment leads to improved patient comfort and reduced hospital stays.[8][9]
IAD is a type of moisture associated skin damage caused by prolonged exposure of skin to urine and/or stool. As such, it is best managed with customized treatment plans based on the patient’s input and based on a comprehensive assessment that:
- Identifies underlying causes and assesses risk factors contributing to the development of IAD, including type and frequency of incontinence. See section 'Risk Factors' in topic "Incontinence Associated Dermatitis - Introduction and Assessment".
- Differentiates from other types of moisture-associated dermatitis, wounds and skin conditions, which may require different treatments.
- Identifies pertinent patient's/caregiver's concerns.
- Categorizes IAD using a validated classification system, such as the Ghent Global IAD Categorization Tool (GLOBIAD). See section 'Classification Systems' in topic "Incontinence Associated Dermatitis - Introduction and Assessment".
- Determines ulcer prognosis or "healability", that is, the potential of the ulcer to heal with conservative treatment only. For details, see 'Ulcer healability' in "Incontinence Associated Dermatitis - Introduction and Assessment".
The high incidence of IAD in the elderly highlights the need for effective interventions to prevent dermatitis in incontinent and dependent patients. When developing and implementing preventive and management interventions for IAD, special attention should be given to incontinent elderly patients who are at risk of pressure injuries.[10]
An adequate prevention and/or management plan for IAD aims to:
- Treat the cause and other factors impeding healing
- Assess patient's and caregiver's concerns
- Provide effective local wound care if IAD is already established
- Provide a structured skin care regimen
- Prevent new IAD
Algorithm 1. Incontinence Associated Dermatitis - Assessment, Prevention and Management [7]
Treatment Goals
- The primary goal for treatment or prevention of IAD is to manage incontinence.[5] While working towards this goal, a structured cleansing and protection regimen is essential.[5][6]
- IAD is generally healable with early intervention and appropriate care, more severe cases or those with complicating factors may require more intensive and prolonged treatment.
Treat the Cause and Co-factors Impeding Healing
Interventions are similar for both prevention and management of IAD.[7] See Algorithm 1 above.
For all patients with or at risk of IAD [7]:
- Address incontinence by identifying and treating reversible causes (e.g., urinary tract infection, constipation, use of diuretics) to minimize or ideally eliminate skin exposure to urine and/or feces.
- Implement a structured skin care regimen to protect affected areas and support restoration of the natural barrier function of the skin. See section 'Local Wound and/or Skin Care Regimen' below.
Details and evidence on interventions for prevention and management of IAD are listed below.
Incontinence Management
- For all patients with incontinence, conduct a comprehensive assessment to determine the underlying cause and risk factors. See section 'Assessment' in topic "Incontinence Associated Dermatitis - Introduction and Assessment".
- A thorough evaluation of bladder and kidney function for urinary incontinence, as well as bowel and colon function for fecal incontinence, is necessary for elderly patients at risk of IAD.
- For reversible causes of incontinence, non-invasive interventions (e.g., toileting techniques and nutritional/fluid management) can be implemented alongside incontinence products designed to effectively contain and manage fluids (e.g. incontinence briefs, urine or fecal diversion devices).[7][5]
Superabsorbent Incontinence Briefs
- For ambulatory patients or those sitting out of bed, absorbent incontinence products such as adult briefs may be used to help maintain dry skin and reduce contact between skin and moisture.[7][11]
- Rationale: the prevention or management of IAD includes regular changes of absorbent briefs to limit skin exposure to urine and feces.[10] Infrequent diaper changes and prolonged exposure to urine and stool increase the risk of developing IAD. A significantly higher prevalence has been observed in patients with fewer than six diaper changes per day. [12]
- Brief selection: because briefs can trap moisture against the skin, they must be correctly sized and changed promptly and as often as needed to maintain skin integrity and patient comfort. When selecting briefs, consider [13][14]:
- Absorption capacity and volume to be absorbed
- Saturation period and ability to retain urine without leakage or return to the skin
- Fit, odor control, and timing for initiation of use
- Product Characteristics: superabsorbent briefs should include [15]:
- An absorbent layer with pH-controlling fibers
- A highly breathable outer material
- Effective frontal absorption and liquid retention to prevent urine from returning to the skin’s surface
- Technological advances, such as wetness sensors in diapers and humidity-sensing mattresses, can support timely cleaning and reduce moisture exposure - particularly in patients with prolonged immobility [12]
- Use of skin protectants should be carefully managed to avoid blocking the brief’s absorption channels.[7][16]
Urine and Fecal Diversion Devices
- For patients in the acute care setting, prevention and management of IAD may include the use of devices to divert urine and/or feces (Figures 1 to 4). These devices keep urine and feces away from the skin, reduce moisture exposure, minimize odor, lessen the workload for the nursing staff, and prevent environmental contamination.[17][18] However, their use should be carefully evaluated due to potential complications such as bladder infections, penile ulcers, or anal mucosa erosion.[17][18][19] The use of skin protectants and superabsorbent diapers should be considered when there is a risk of leakage around these devices. [20]
- Urine Diversion Devices:
- External collection systems: non-invasive devices that manage urinary incontinence by channeling urine away from the body through an externally placed catheter (e.g., PureWick™ System, UriCap Female).
- Internal urinary catheters (e.g. indwelling urinary catheter): may be used to divert urine to a collection bag and minimize skin contact with urine. However, they should be considered only as a last resort due to the increased risk of hospital-acquired infections.[7]
- Fecal Diversion Devices: for bedridden or immobilized patients with liquid or semi-liquid stools and widespread IAD, clinicians might opt for fecal diversion devices, such as fecal management systems or external fecal pouches.[7] These diversion devices provide temporary fecal containment, effectively protecting wounds from fecal contamination, reducing the risk of skin breakdown, and limiting infection spread.
- Fecal management system: successful use also depends on sufficient anal sphincter tone to maintain device placement.[21]
- Contraindications include recent colon or rectal surgery within the last year, rectal or anal injuries, significant hemorrhoids, severe rectal or anal stenosis, suspected or confirmed rectal mucosal damage, confirmed rectal or anal tumors, fecal impaction, or solid stools that could obstruct the device. The fecal management system is not intended for use beyond 29 days or in pediatric patients.[22]
- External fecal pouches: If a fecal management system is unavailable, a fecal pouch can be applied.[7] A wafer with an adhesive backing is attached to the skin around the anus and connected to a collection bag.
Local Wound and/or Skin Care Regimen
IAD treatment involves skin cleansing, protection with barrier creams, hydration promotion, and the management of existing lesions and infections. Interventions are similar for both prevention and management of IAD.[7]
Structured Skin Care Regimen
- A structured skin care protocol should be in place for every patient at risk of IAD.[7][5][23]
- The regimen includes three key steps [7][5][6][23][24][10]:
- Cleansing: gently cleanse the skin to remove urine and/or feces - the primary irritants that contribute to IAD. Cleansing should be performed before applying any skin protectant and should be part of the patient’s routine care.
- Protecting: apply a skin protectant to minimize or prevent exposure to urine, feces, and friction, helping maintain skin barrier integrity.
- Restoring: promote skin hydration to repair and strengthen the protective barrier by retaining and increasing water content, reducing transepidermal water loss, and restoring or enhancing intercellular lipid structure.
Cleansing
- For all patients with incontinence, cleansing the skin with a skin cleanser with a pH range similar to normal skin is recommended at least once daily and after each episode of fecal incontinence, to prevent or manage IAD (Grade 1C).[7][6]
- Rationale: cleansing the skin to remove irritants is essential for the prevention and management of IAD. Low-certainty evidence from a systematic review supports the use of skin cleansers over soap and water for this purpose.[6] Standard soap is alkaline and can disrupt skin pH, damage corneocytes, and impair the skin barrier. Cleansing with water alone may also compromise barrier function, as shown by increased transepidermal water loss, a sensitive indicator of barrier health.[7]
- Type of cleanser:
- Skin cleansers contain surfactants that reduce surface tension, allowing debris (e.g., oil, feces, dead skin cells) to be removed with minimal friction. Several surfactant categories exist, and most cleansers combine more than one. Non-ionic surfactants are preferred because of their mildness. Manufacturers should be able to provide information on surfactant composition. See Table 1.
- To effectively remove irritants without damaging the skin, cleansers should be mildly acidic (close to the skin's natural pH), gentle, and moisturizing.[17][21] The choice of hygiene products should be based on pH, and antimicrobial products should be avoided during cleaning procedures.[25][26][27] There is no evidence that any single cleanser is superior; however, best practice recommendations include [7][6][11]:
- Use no-rinse cleansers specifically formulated for incontinence care whenever possible, as they are less irritating and help preserve the skin barrier.
- Many available skin cleansers do not require rinsing with water and often contain moisturizers, eliminating the need for multiple products in the care routine. [17][28]
- Given the frequent need for skin hygiene, no-rinse wet wipes can be a suitable option, as they are more effective in removing both gram-negative and gram-positive bacteria compared to soap and water.[20]
- When skin cleansers are not available, gentle soap and water may be used.
- Soaps can also be used for skin hygiene but are often composed of alkaline substances that alter the skin’s natural acidic pH, potentially removing skin lipids and affecting its barrier function, leading to dryness.
- If gentle soap is unavailable, plain water is may be used, though this represents the minimum standard of care.
- Cleansing method: cleansing should focus on the genital, perianal, and inguinal regions. Additional care measures for aging or fragile skin include [25]:
- Avoiding overly frequent or aggressive cleansing.
- Gently patting the skin dry with a soft, absorbent towel, without rubbing, or leave the skin exposed to air for a few minutes to allow it to dry completely.
- Barrier products should then be applied to protect against constant moisture exposure, according to manufacturer's instructions.
- If lesions are present: lesions should be irrigated with saline solution, and appropriate dressings applied according to wound characteristics. Clinicians should also assess the need for urine and/or fecal diversion devices to protect the skin. [11][25]
Table 1. Types of Surfactants [7]
| Surfactant Type | Examples |
Non-ionic: - Uncharged
- Generally less irritating than anionic surfactants
| - Polyethylene glycol (PEG)
- Acyl-polygylcoside (APG)
- Polysorbates
- Octoxynols
|
Anionic: - Negatively-charged
- High pH
| - Sodium lauryl sulfate (SLS)
- Sodium laureth sulfate
- Sodium sulphosuccinate
- Sodium stearate
|
Amphoteric: - Positively- and negatively-charged
- Generally less irritating than anionic surfactants
| |
Protecting the Skin
- For all patients with incontinence, the application of a skin protectant or moisture barrier after cleansing is recommended to prevent or manage IAD (Grade 1C).[7][6]
- Rationale: After cleansing, skin should be protected to prevent IAD. Skin protectants, also known as moisture barrier products, are essential in IAD treatment and prevention as they shield the stratum corneum from moisture and irritation caused by prolonged exposure to urine and feces. These products allow the skin to recover from previous damage.[21] Low-certainty evidence from a systematic review suggests that combining a skin cleanser with a skin protectant/barrier may be more effective in preventing IAD than using a cleanser alone.[6]
- Types of skin protectants or barriers: barrier products are available in various forms, including creams, films, ointments, and pastes (See Table 2). Common ingredients include petrolatum, zinc oxide, acrylate polymers, and dimethicone (See Table 3).[21]
- Barrier products protect against excess moisture and safeguard the stratum corneum from exposure to irritants. They maintain normal transepidermal water loss and prevent maceration from prolonged exposure. [20]
- The performance of a skin protectant product depends on its overall formulation, not solely on the active skin-protecting ingredient(s). General characteristics of the ideal product for prevention and management of IAD are summarized in Table 4.
- Skin protectants containing petrolatum and dimethicone provide protection against irritants and maceration while promoting skin hydration.
- Zinc oxide-based protectants shield the skin from irritants but offer limited hydration.
- Durable barrier films create a polymer-based acrylate barrier and are resistant to washing. As a result, the product only needs to be reapplied after every third episode of incontinence. This product is free of fragrances and parabens, reducing skin inflammation and patient discomfort.[29]
- Caution: some occlusive barrier products may disrupt normal skin moisture regulation by trapping excess moisture and reducing transepidermal water loss. Their effectiveness depends on formulation, application technique, amount, and frequency of use. Additionally, certain opaque formulations can make it difficult to inspect the skin, potentially delaying recognition of skin changes. For instance, while petrolatum and zinc oxide provide effective moisture protection, these products be used with caution, as they can reduce diaper absorbency and leave the skin vulnerable to excess moisture. Product buildup may require friction for removal, increasing the risk of skin damage.[21]
- Ointments, pastes, or thick creams are preferred to minimize skin irritation, as other formulations may be irritating. [12]
Table 2. Types of Skin Protectants or Barriers to Prevent or Manage Incontinence Associated Dermatitis
| Type of Skin Protectant/Barrier | Description | Components | Sample Commercial Brands |
| Creams | - Emulsions of oils/lipids + water
- Provide protective barrier
| - Contain petrolatum, zinc oxide, dimethicone alone or in combination (may be listed as "active" ingredients on the label, depending on the country's regulations)
| - Assurance Barrier Cream, Baza Protect Cream
|
| Ointments | - Semi-solid, often petrolatum-based
- Greasier than creams; strong occlusive barrier
| | - Walgreens Moisture Barrier Ointment
|
| Pastes | - Thick, adheres well to moist/denuded skin; harder to rub off
| - Mixture of absorbent material (e.g., carboxymethylcellulose) + ointment base
| - Remedy Phytoplex Z‑Guard Skin Protectant Paste
|
| Lotions | - Lighter consistency; less occlusive
| - Liquids with suspended inert or active ingredients
|
|
| Films | - Liquids containing a polymer (e.g., acrylate-based) dissolved in solvent → forms transparent protective coating on skin upon application [30]
- Some products only need to be reapplied after every third episode of incontinence. [29]
- Free of fragrances and parabens, reducing skin inflammation and patient discomfort
| - Acrylate polymers, silicone fluids
| - Cavilon No Sting Barrier Film
|
Table 3. Common Ingredients of Skin Protectants or Barriers [7]
| Principal Skin Protectant Ingredient | Description | Notes |
| Petrolatum (petroleum jelly) | Derived from petroleum processing Common base for ointments | - Forms an occlusive layer, increasing skin hydration
- May affect fluid uptake of absorbent incontinence products
- Transparent when applied thinly
|
| Zinc oxide | White powder mixed with a carrier to form an opaque cream, ointment or paste. | - Can be difficult and uncomfortable to remove (e.g. thick, viscous pastes)
- Opaque, needs to be removed for skin inspection
|
| Dimethicone | Silicone-based; also known as siloxane | - Non-occlusive, does not affect absorbency of incontinent products when used sparingly
- Opaque or becomes transparent after application
|
| Acrylate terpolymer | Polymer forms a transparent film on the skin | - Does not require removal
- Transparent, allows skin inspection
|
Table 4. General Characteristics of the Ideal Product for Prevention and Management of Incontinence Associated Dermatitis [7]
General characteristics of the ideal product for prevention and management of IAD |
- Clinically proven to prevent and/or treat IAD
- Close to skin pH (Note: pH is not relevant to all products, e.g. those that do not contain hydrogen ions, including some barrier films)
- Low irritant potential/hypoallergenic
- Does not sting on application
- Transparent can be easily removed for skin inspection
- Removal/cleansing considers caregiver time and patient comfort
- Does not increase skin damage
- Does not interfere with the absorption or function of incontinence management products
- Compatible with other products used (e.g. adhesive dressings)
- Acceptable to patients, clinicians and caregivers
- Minimizes number of products, resources and time required to complete skin care regimen
- Cost-effective
|
Restoring the Skin Barrier Function
- For patients with dry skin, the use of moisturizers is recommended to help restore and maintain skin barrier function.[6] For overhydrated or macerated skin, moisturizers should be avoided, as they can trap or attract additional moisture and worsen skin breakdown.[7]
- Rationale: The stratum corneum normally contains 10–15% moisture. Both excessive moisture and dryness can impair barrier function. Dry skin is prone to superficial breaks, scaling, flaking, and fissuring, increasing susceptibility to irritants. In severe cases, xerosis may present with inflammation, irritation, and pruritus.[5] Moisturizers support the skin barrier by sealing microfissures, reducing transepidermal water loss, increasing water content, and restoring the lipid barrier, while leaving a protective film on the skin.[7][5]
- Types of moisturizers: skin care products are diverse and can contain a very wide range of ingredients with many different properties. Many moisturizers combine emollients and humectants, but not all are capable of skin barrier repair.[7]
- Emollients: primarily composed of lipids and oils, which improve repair, hydration, and skin permeability.
- Dimethicone-based products, especially those containing 3% dimethicone, provide both moisture barrier protection and hydration.[11]
- Humectants: attract and bind water to the skin; may have some emollient properties.[16][28] In particular, a humectant is not recommended for overhydrated or macerated skin, as it may increase moisture retention.
- Adjunctive barrier-supporting ingredients that may be added to moisturizers include [5]:
- Ceramides and essential fatty acids: barrier-repair / lipid-replenishing agents (may have some emollient properties)
- Vitamins and antioxidants: combat against damaging effects of reactive oxygen species radicals.
- Topical products with anti-inflammatory, pro-healing, or antibacterial properties (e.g., marigold, henna, aloe vera, manuka honey, dexpanthenol, taurine, aluminum subacetate): may be used ti support healing, as long as their use does not result in allergic contact dermatitis.[12]
- Moisturizer application method [25]
- Apply a thin layer to minimize excess moisture, especially in skin folds.
- Do not rub the product vigorously; apply gently to avoid friction-related skin injury.
- Reassess skin regularly to adjust product type and frequency as needed.
Infection and bioburden management
In cases of IAD with secondary infection, treatment should target the causal agent.[12]
- Assessment: when infection is clinically suspected, microbiological testing should be considered to guide targeted therapy. Given the rise in antimicrobial resistance, the use of topical antimicrobials should be judicious.[7] For details on assessment of secondary infection, see section 'Microbial Colonization and Secondary Infection in IAD' in topic "Incontinence Associated Dermatitis - Introduction and Assessment"
- Topical treatment: For localized fungal and bacterial infections topical medications can be used according to their prescribed dosage.[25]
- Fungal infection (most often Candida albicans): true fungus (dermatophytes) has a red active margin, and yeast (Candida) is associated with satellite papules and pustules (Figure 5).[31] For suspected or confirmed candidiasis (i.e., beefy red plaques, pustules, or satellite lesions are present), initiate topical antifungal therapy. Apply antifungal creams or powders containing polyenes, azoles, or allylamines.[20] A thin layer of antifungal powder may be applied, followed by a skin protector (e.g., acrylate film). [20] Once clinical signs of fungal infection have resolved, transition from antifungal ointment to an appropriate moisturizing barrier cream.[25]
- Bacterial infection: consider topical mupirocin or systemic antibiotics based on severity; obtain a bacterial culture to guide therapy.[12]
- Reassessment: If there is no improvement and systemic symptoms develop, hospitalization may be necessary for [11][25]:
- Use of devices to divert urine and feces
- Systemic antibiotics and antifungals, based on culture results
Fig. 5. Persistent redness with clinical signs of infection, with satellite lesions suggesting candidiasis.
Address Patient Concerns
For all patients with IAD, the following concerns should be adequately addressed to improve quality of life and functional capacity.
Pain control
- Analgesics: clinicians might opt to follow the World Health Organization (WHO) Pain Ladder for cancer patients, with modifications for wound care. Benefits and harms of each step should be considered. In summary: [32]
- Step 1: A non-opioid analgesic (e.g., NSAID) with or without an analgesic adjuvant. Adjuvants include tricyclic antidepressants, anticonvulsants, antihistamines, benzodiazepines, steroids, and phenothiazines.
- Step 2: If pain is not controlled: Continue the initial medication and add an opioid, such as codeine or tramadol, and an adjuvant
- Step 3: If pain is not controlled: discontinue second step medications and initiate a more potent oral narcotic
Itching and/or burning
- Assess the skin for signs of irritation or infection if the patient reports itching or burning, which may result from prolonged moisture exposure or friction. Initiate appropriate treatment based on the evaluation.
Odor
- Appropriate hygiene/cleaning after incontinence episodes is required.
Loss of independence
- Acknowledge the emotional and psychological impact of incontinence and the potential loss of independence.
- Discuss options that may help patients maintain autonomy, such as assistive devices, home modifications, or caregiver support.
- A multi-disciplinary approach, including social work support, may be beneficial for addressing this concern.
Depression
- Screen for signs of depression in patients managing incontinence or other chronic conditions, as these issues can contribute to feelings of sadness, frustration, or isolation.
- Provide referrals for counseling or therapy and consider pharmacologic interventions as needed.
Plan Reassessment
- For patients with IAD, daily documentation and skin assessments with incontinence episodes are essential to monitor healing. Lesions should be irrigated with skin cleanser, and an appropriate dressing applied according to the lesion’s characteristics. The clinician should also evaluate the need for urine or fecal diversion devices if not already in place. [11][25]
- Visible improvement and pain reduction should occur within 3-5 days of initiating an appropriate structured skin care regimen, with complete resolution typically within 1–2 weeks. If continence issues persist or the skin does not improve, consult a specialist continence advisor where available. [7]
Adjunctive Therapy
- For more severe or unresponsive IAD without signs of secondary infection, low- to mid-potency topical steroids can be applied twice daily for 3–5 days. [12]
- Low-potency steroid ointments are preferred due to typical anogenital location and lower risk of adverse effects.
- Nonsteroidal options (e.g., calcineurin inhibitors) may be considered in refractory cases but have limited evidence and are not approved for children <2 years.
- For severe or unresponsive cases of IAD with secondary fungal or bacterial infection, treatment should be guided by culture results. See topic "Wound Culture - Swabs, Biopsies, Needle Aspiration".
PATIENT EDUCATION - FOR CLINICIANS
- Educate patients and caregivers on [25]:
- Etiology-focused interventions to address contributing factors.
- Cleansing techniques, emphasizing gentle care to protect the skin barrier.
- Moisturizer and barrier cream application: apply gently without rubbing to avoid friction-related injury (Writers, 2018).[19]
- Caregiver involvement:
- When patients are unable to perform self-care, hygienic skin care should be provided or assisted by a caregiver, family member, or healthcare professional.
- Caregivers should receive clear guidance on [13]:
- Skin cleansing
- Brief changing
- Hydration and skin protection
- Appropriate frequency of care procedures
- For patient education on pressure ulcer/injuries see “Pressure Ulcer/Injuries” Patient Education Handout. For nutrition guidance, refer to “Nutrition for Wound Healing” Patient Education Handout
