Age-Related Skin Changes Increasing the Risk of IAD

• Elderly skin, which is drier, thinner, and less elastic, becomes more prone to damage, especially when combined with incontinence (Figure 2). To reduce this risk, increased personal hygiene and skin care are essential. [24] 
• • Skin changes:  
  • • Reduced skin moisture : in elderly skin, the stratum corneum consists of 70% proteins, 15% lipids, and 10% water, indicating a loss of moisture compared to adult skin. Lipids and water are crucial for maintaining the skin's barrier function and elasticity. [22]
    • • Throughout life, the "natural moisturizing factor" (NMF) changes due to a reduction in intercellular lipids with age, leading to a lower number of corneocytes and a a thinner lipid matrix that surrounds the corneocytes (Figure 3).  [10][23]
    • Structural fragility: aging skin is characterized by reduced collagen and elastin replenishment, flattening of the dermoepidermal junction, thinning of the dermis, and loss of subcutaneous fat - causing stretching and a wrinkled appearance. [25]  
    • • The fragility of the dermoepidermal junction increases the likelihood of friction injuries during skin cleansing.
      • A thinner dermis results in decreased blood vessels, nerve endings, and collagen, leading to diminished sensation, temperature regulation, elasticity, and moisture retention.   [24]   
    • Glandular changes: glandular changes include reduced sweat gland activity, sebaceous gland hyperplasia with decreased sebum production, increased skin surface pH, greater transepidermal water loss, and reduced skin moisture. [25] Dryness due to lower sebum production results in cracks, itching, and prolonged healing time. [24]
  • Urinary changes:  
  • • Incomplete bladder emptying is another common alteration in the elderly due to reduced bladder elasticity. In women, weakened pelvic floor muscles further exacerbate the problem. These physiological changes in skin and bladder function, coupled with comorbidities and limited mobility, heighten the risk of incontinence and skin damage. [2]

• Moisture exposure and skin barrier breakdown: excess moisture causes overhydration of keratinocytes and lipid layer disruption, resulting in corneocyte swelling and increased stratum corneum thickness. [10] These changes reduce barrier function and increase permeability to irritants such as urine, feces, and microorganisms like Candida albicans and Staphylococcus aureus. [2] [10][26][27]  The consequences include  [10][26][27] :
• • Accelerated transepidermal water loss (TEWL)
  • Reduced skin elasticity and resilience
  • Increased microbial colonization
  • Greater susceptibility to friction injuries and mechanical damage
• Effects of urine and feces on the skin: 
• • Feces: contain enzymes (i.e. proteases and lipases) that break down proteins and lipids in the stratum corneum, increasing the risk of IAD. Liquid stool is particularly damaging, especially in hospitalized or immobile patients.[20][10]
  • Urine: contains urea, which is converted into ammonia by urease-producing bacteria. Ammonia raises skin pH, leading to lipid barrier damage, increased TEWL, and higher susceptibility to irritants and microorganisms. [10]
  • Combined exposure: urine and feces together have a synergistically harmful effect, intensifying skin irritation, maceration, and inflammation. [3]  
  • Patients with incontinence experience alterations in the perineal microclimate (Figure 4), predisposing the skin to damage caused by pressure, friction from the diaper/brief, and shear forces during the cleaning process. Frequent washing with soaps that disrupt the skin’s natural pH, prolonged diaper/brief use, and the layering of bed covers or skin protectants can impair the diaper/brief’s ability to absorb moisture. [28]
• Maceration and acid mantle disruption: skin maceration occurs with prolonged moisture exposure, resulting in soft, whitish, swollen skin with weakened structural integrity. This environment damages the intercellular lipid layers within the stratum corneum, and fosters increased pH, loss of barrier function, and increased friction injury risk. However, the exact duration of exposure needed to cause maceration has not been clearly established. [26][27]   The inflammatory response triggered by the invasion of irritants and microorganisms (e.g., Candida albicans ) leaves the skin vulnerable to skin breakdown.  [29]
• • Disruption of the acid mantle compromises the skin’s defenses, leading to erythema, pain, and increased susceptibility to breakdown from friction, shear, and prolonged exposure to urine or feces (Figure 5). Elevated pH accelerates barrier damage by activating enzymes that degrade protective lipids and impair repair processes, which are essential for maintaining the integrity of the skin barrier and repairing damage caused by prolonged exposure to urine or feces. [10][30]

Newborns

Skin Characteristics in Newborns and Their Susceptibility to IAD

• Skin development by gestational age: the development of the skin is closely linked to gestational age. As pregnancy progresses, both the thickness and number of epidermal layers increase. Structural changes, such as an increasingly wavy dermoepidermal junction, also occur. By approximately 34 weeks of gestation, a well-developed epidermis is typically present, though complete maturation of the stratum corneum varies between 30 and 37 weeks.   [31] Characteristics include: 
• • Full-term newborns (born between 37–41 weeks of gestation): skin is thin, fragile, and sensitive.
  • Preterm newborns (born before 37 weeks of gestation): skin is even thinner, often transparent, with visible superficial veins and reduced resistance to mechanical stress (Figure 6).   [32]  Preterm skin exhibits functional immaturity and barrier deficits  [32][33] :
  • • Weaker dermoepidermal cohesion, with fewer anchoring fibers
    • Reduced collagen and elastin content
    • Immature skin appendages
    • Underdeveloped hypodermis
    • Increased transepidermal water loss and i ncreased permeability, reducing its ability to protect against irritants and microbes
    • Higher risk of percutaneous absorption, colonization, and infection
    • Impaired thermoregulation
    • Greater susceptibility to trauma

Figure 6: Newborn with IAD in the genital region showing signs of infection. Source: Nurse Simone Vidal

• Barrier function of the skin: the stratum corneum is composed of corneocytes, which regulate water loss through the skin. This layer also contains lipids, mainly free fatty acids, cholesterol, and ceramides, which combine with water to form an endogenous emollient. Lipids and proteins protect the stratum corneum by forming an impermeable barrier that regulates natural water loss and provides an acidic, xeric environment that prevents microbial invasion. [10][33]
• • The physiological regulation of the skin depends on the skin's pH, which can be compromised in an alkaline environment.
  • • At birth, newborn skin is neutral in pH
    • Within days, it acidifies to pH<5.5, forming the acid mantle, which strengthens barrier integrity
    • In preterm infants, this acidification may take several weeks, delaying acid mantle formation and increasing susceptibility to microbial invasion, topical agent absorption, and injury.   [34][35]
  • Interestingly, despite their skin immaturity, preterm newborns may experience fewer perineal skin lesions compared to full-term infants. This is attributed to  [35]:
  • • Lower intestinal transit, resulting in reduced fecal exposure
    • Fewer baths and less frequent use of cleansers that alter skin pH and increase permeability

Moisture exposure-related skin changes increasing the risk of IAD in  Newborns:

• Newborn skin is structurally and functionally immature, making it particularly susceptible to environmental and behavioral stressors after birth. Factors that may affect skin integrity include fluctuations in ambient temperature, inconsistent hydration, and prolonged contact with astringent substances or surfaces, such as diapers/briefs.  [36]
• • In the first two weeks of life of full-term infants, the epidermal barrier function is still incomplete, resulting in increased skin permeability. This immaturity makes the skin more vulnerable to mechanical damage, especially in areas exposed to moisture and friction, such as the diaper/brief region. Over time, the skin gradually develops greater impermeability and resilience. [37]
  • In preterm infants, the stratum corneum is notably thinner and less effective than in full-term infants or adults. This increases the risk of infection and systemic toxicity due to enhanced percutaneous absorption of substances, placing preterm neonates at greater risk for IAD.  [38]
• Diapers: in neonates, IAD commonly arises from diaper occlusion, which prolongs skin contact with urine and feces. Urine contains urea, which is metabolized by urease-producing bacteria into ammonia, disrupting the skin’s acid mantle and increasing skin pH. The resulting alkaline environment activates fecal enzymes (proteases and lipases) that degrade the proteins and lipids of the stratum corneum, weakening the barrier and promoting skin breakdown. [39] Increased skin pH leads to  [10]:
• • Overhydration of the stratum corneum
  • Excessive permeability to irritants and pathogens
  • Increased bacterial colonization
  • Damage to lipid structures, further compromising barrier function
• Additional contributors to IAD in newborns include:
• • Antibiotic use, which alters stool consistency and increases the risk of dermatitis when combined with diaper/brief use. [34]
  • Friction during hygiene, which combined with maceration significantly increases skin permeability and susceptibility to irritants and pathogens. [26][27][40]

Microbial Colonization and Secondary Infection in IAD

ASSESSMENT

This section focuses on elements that need to be included in a comprehensive assessment of patients with IAD.   

• All patients with urinary and/or fecal incontinence should undergo regular skin assessments for signs of IAD - at least once daily, and more often if incontinence episodes are frequent. [5][4]
• Assessment for IAD should be integrated into routine skin assessments and carried out within the framework of a pressure injury prevention and continence care program. [5]
• Initial patient assessment should include a comprehensive clinical history and physical examination, with visual inspection of the perineal area to rule out other pathologies (e.g., allergies, atrophic vaginitis). Assessment should also cover mobility, dexterity, and cognitive function, along with urinalysis, a frequency–volume chart, and bowel diary, a post-void residual urine test and a review of the patient’s medication history. [6]
• Primary goals of assessment are:
• 1. To identify risk factors for development of IAD or that may impede healing
  2. To rule out other types of lesions, which may require different treatments. 
  3. To identify pertinent patient's/caregivers' concerns
  4. To develop a comprehensive care plan

History

The non-exhaustive checklist below highlights relevant factors that should be assessed when taking history of a patient at risk or with IAD. Risk factors for development of IAD are indicated with the icon 

Chief Complaint and History of Present Illness

• Age: higher prevalence is observed at the extremes of age: in newborns, children, and the elderly. However, individuals of any age can be affected. [43] 
• History/type of incontinence: urinary, fecal, or both
• Location of the lesions: the area affected by IAD can vary significantly, extending beyond the perineum, depending on the skin's exposure to urine and/or feces. [5][38]
• • In urinary incontinence, IAD typically affects the folds of the labia majora in women, the scrotal area in men, and the inguinal region. In bedbound patients, it also can affect the buttocks. It may also extend to the pubic region and thighs.
  • Fecal IAD originates in the perianal area, usually involves the buttocks, and can spread to the genital/inguinal area, the sacrococcygeal area and the posterior thighs.
• Pain: patients with IAD may experience physical discomfort due to pain, itching, burning, or tingling. [44]
• History of prior treatment/prevention

Medications

• Steroids, antibiotic therapy, immunosuppressants  [5][16][17]
• Laxatives

Social History

• Caregiver availability
• Inability to perform personal hygiene [5]

Review of Systems

• General:
• • Critical illness [5]
  • Nutrition status: poor nutrition status, hypoproteneinemia  [5][16][17]
  • Fever [16]
• Endocrine: diabetes mellitus [16]
• Gastro-intestinal/Genito-urinary
• • Fecal/urine incontinence  [5][16][17]
  • • Frequency of evacuation, stool characteristics, use of containment/collection supplies (e.g., incontinence underwear, etc)
    • Use of urine collection devices (e.g, catheters)
    • Higher overall Perineal Assessment Tool (PAT) score
  • Urinary tract infections
• Neurological:
• • Cognitive impairment  [5]
• Musculoskeletal:
• • Compromised mobility [5]
• Skin: poor skin condition (e.g due to aging/steroid use/diabetes). [5]

Structured Risk Assessment 

Risk Factors for the Development of Incontinence Associated Dermatitis

• Clinicians might opt to utilize risk assessment scales as tools (e.g. Perineal Assessment Tool) for the early recognition of risks and complications related to IAD.  [7]
• • Perineal Assessment Tool (PAT): this validated tool can help identify at-risk patients and encourage proactive nursing interventions for IAD prevention (see Table 3). [45] 
  • • Each risk factor is scored between 1 (least risk) and 3 (most risk), with one option selected per factor. Total PAD scores can range from a score of 4-6 (low risk) to a score of 7-12 (high risk). [45][46]

Patients'and caregivers' concerns

• Ability to transfer/ turn and reposition assist
• Affordability of care and products
• Psychological and social functioning. [44]

Physical Examination

A focused physical examination that includes the following is recommended:

Skin Assessment

• Assess skin that may be affected:  perineum, inner thighs, buttocks, peri-genital region, under pannus, lower back, lower abdomen, and gluteal folds, for the items below (Figure 8) [5][44]: 
• • Maceration
  • Erythema
  • Presence of lesions (vesicles, papules, pustules, etc)
  • Erosion or denudation
  • Signs of fungal or bacterial skin infection
• The assessment of the region affected by IAD does not vary by age group but requires expertise in evaluating lesions based on skin color variations.
• • In individuals with lighter skin tones, IAD initially presents as erythema, which can range from pink to red.
  • For patients with darker skin tones, skin color changes may not be visible, making it difficult to identify and differentiate the affected area. The borders of the erosive areas are often hard to delineate and can be irregular. The skin may appear pale or darker, purple, dark red, or yellow (Figure 8). [5][10]
  • • In dark-colored skin, the affected area is harder to visualize, but the presence of maceration is a key indicator of injury. Maceration is directly linked to these lesions and is characterized by skin whitening after prolonged contact with moisture. [2][3]

Figure 8. Incontinence-Associated Dermatitis in the scrotal region and adjacent areas.

Infection

• Assess for signs and symptoms of infection, including:
• • Fever
  • Erythema
  • Drainage
  • Odor
  • Increase in wound size or depth
  • Signs of fungal or bacterial skin infection

Diagnosis

• The diagnosis of IAD is based on the clinical and visual assessment of the skin in the entire diaper/brief area and adjacent regions, including the suprapubic region, abdominal folds, inguinal region, and gluteal folds, followed by classification. [5][8]

Differential Diagnosis

• It may be challenging to correctly differentiate IAD from other conditions, including pressure ulcers/injuries (PUs/PIs), contact dermatitis (e.g., from textiles or skin products), infectious lesions (e.g., herpes simplex), or moisture-related skin damage such as intertrigo (see Table 4). [5]
• • To help distinguish IAD from other conditions, it is important to note that if the patient is not incontinent, the condition is not IAD.  [5]
  • Pressure Ulcers/Injuries: IAD is frequently associated with PU/PI in patients with dual incontinence. The damaged skin and excessive moisture exposure increase vulnerability to prolonged pressure (Figures 9 and 10). Misdiagnosing IAD as stage 1 or 2 PU/PI delays appropriate treatment. [28] See topic " Pressure Ulcers/Injuries - Introduction and Assessment".
  • Intertrigo dermatitis: although ITD and IAD share similar precipitating factors, ITD may occur in areas not directly affected by incontinence. ITD typically presents with erythema and scaling, and secondary Candida intertrigo may be suspected when satellite lesions are present.  [21]
  • Periwound skin damage: may present with a varying degree of skin maceration, erythema, edema, inflammation, blistering,  excoriation, and erosion, caused by prolonged skin contact with wound exudate. [21]
  • Peristomal moisture-associated skin damage: peristomal MASD is inflammation and erosion of the skin related to moisture that begins at the stoma/skin junction and may  extend outward. [21]

Figure 9. Association of IAD and Stage 2 Pressure Injury  Source: Courtesy of Nurse Sabrina Andrade

Figure 10. Association of IAD and Unstageable Pressure Injury

Classification Systems

• Clinicians might opt to utilize the Ghent Global IAD Categorization Tool (GLOBIAD) for assessing and classifying IAD into categories (See Table 5, Figures 11-14)  [4][10][8]:
• • Rationale: Multiple instruments have been developed to assess risk factors and aid in the diagnosis of IAD. Although several have demonstrated validity, they  are not routinely used in nursing practice, partly due to limited evidence of their impact on clinical decision-making or nursing care improvement.  A systematic review  evaluated the competence of existing scales, examining included risk factors, reliability, validity, and patient populations tested. Results indicated that several IAD assessment tools are all reliable, valid, and suitable for use in clinical practice (see Appendix, ' IAD Assessment Instruments'). [4] Among the evaluated scales, the GLOBIAD demonstrated a high level of diagnostic accuracy in discriminating erythematous skin and skin loss.  [4]

Table 5. Ghent Global IAD Categorization Tool  [8]

Ulcer Healability 

• 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.
• The healability of Incontinence-Associated Dermatitis (IAD) largely depends on the severity of the condition, the timely implementation of appropriate interventions, and the overall health of the patient. In its early stages, IAD is highly treatable and can often be reversed with proper skin care, such as regular cleansing, the use of moisture barriers, and addressing the underlying incontinence. The skin's ability to heal is typically good when these measures are employed promptly, as long as there is no secondary infection.
• In severe cases, where the skin is significantly damaged or compromised, healing may take longer. The presence of infection, poor nutritional status, or other underlying health issues (e.g., immobility, diabetes) can hinder recovery and make the healing process more complicated. In such cases, a multidisciplinary approach involving wound care specialists, proper management of incontinence, and the use of advanced wound care products is essential for promoting healing.
• For details on ulcer healability, refer to topic " How to Determine Healability of a Chronic Wound".

Documentation

Assessment and documentation of continence status should also include deviations from  normal bladder and/or bowel function and any follow-up actions.

• Accurate assessment and diagnosis of incontinence-associated dermatitis (IAD) are essential to ensure:
• • Patients receive appropriate and timely treatment
  • Clinical documentation is complete and accurate
  • Quality reporting and correct reimbursement are supported
• For all patients with urinary and/or fecal incontinence, regular skin assessments for signs of IAD are recommended at least once daily, and more frequently if incontinence episodes are recurrent.
• Findings and any required interventions should be documented in the patient’s healthcare record. Documentation should also capture continence status, including deviations from normal bladder and/or bowel function, as well as any follow-up actions taken.

Documentation checklist 

Subjective

• Patient’s report:  patient's level of discomfort and its characteristics (sensitive, burning, etc.).  Specific location of affected area(s). 
• Incontinence history: presence of urinary incontinence, fecal or dual incontinence and frequency of episodes throughout the day. Factors that worsen the incontinence.  Interventions to manage incontinence. 
• Other symptoms: Burning, itching sensation if present. Fever or chills.  Other skin irritations.

Objective

• Location: affected areas (buttocks, perineum, inner thighs). [48]
• Severity: degree of erythema, maceration, blisters or open sores.
• Appearance: redness, swelling, shiny skin in the affected area. Moisture level of skin.
• Extent: localized to the perineal region or extending toward other regions such as the  inner thighs.
• Exudate:  amount, color, odor. 
• Signs of infection: fever, increased redness or drainage. 

IAD Assessment Instruments