PREVENTION AND MANAGEMENT

Overview

This topic covers management and prevention of incontinence associated dermatitis (IAD) in newborns and infants. 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 the adult and older adult populations, see “Incontinence Associated Dermatitis - Prevention and Management in Adults and Older Adults”.

Background

Incontinence-associated dermatitis (IAD) is a form of moisture-associated skin damage caused by prolonged exposure to urine and/or stool. In newborns and infants, IAD is commonly referred to as diaper dermatitis (DD) or diaper rash and presents as an irritant inflammatory skin lesion in areas covered by the diaper or directly adjacent to it.[1][2]

Skin in this population is particularly delicate and more susceptible to injury from excessive moisture, especially in areas like the diaper region. This condition can result in redness, irritation, and even ulceration of the skin if not properly managed. For details, refer to section 'Skin Characteristics in Newborns and Their Susceptibility to IAD' in topic " Incontinence Associated Dermatitis - Introduction and Assessment".

IAD management in newborns and infants requires a comprehensive, individualized treatment plan, tailored to the infant’s specific needs and risk factors. 

A thorough assessment of the newborn's or infant's skin condition should be performed to ensure effective care, including:

• Identification of underlying causes and assessment of risk factors contributing to the development of IAD: 
• Type and frequency of incontinence: Understanding the newborn’s or infant's pattern of urination and stooling can provide insight into the likelihood of skin exposure to damaging moisture and guide appropriate interventions.
• Other risk factors: Certain factors like skin sensitivity, the presence of other medical conditions, and the quality of care (e.g., diaper changing frequency) may increase the risk of IAD in newborns and infants. Identifying these factors can help in preventing and managing the condition.
• Differentiation from other skin conditions: Newborns and infants may also experience other types of skin issues such as fungal infections or allergic reactions. Differentiating IAD from these conditions is necessary, as they may require different treatment approaches.
• The most common skin injuries in neonates include pressure ulcers/injuries (PU/PIs), medical device–related pressure injuries (MDRPIs), and moisture-associated skin damage (MASD).[8]
• Within MASD, IAD represents the majority of cases, followed by peristomal MASD.[8]
• In infants, IAD typically presents as persistent erythema and/or superficial skin loss, with or without signs of secondary infection (Figures 1 to 4).[8]
• Identification of caregiver concerns: Understanding parents' and caregivers' concerns and providing appropriate guidance on proper diapering and skin care can help in preventing the recurrence of IAD.
• Categorization of IAD using a validated classification system, such as the Ghent Global IAD Categorization Tool (GLOBIAD) or the Buckley Diaper Dermatitis Severity Scale.[9] See section 'Classification Systems' in topic "Incontinence Associated Dermatitis - Introduction and Assessment".

IAD management prioritizes prevention, including frequent diaper changes and consistent application of barrier creams. When IAD develops, treatment is guided by severity - ranging from ongoing barrier protection for mild cases to short courses of low-potency topical corticosteroids for more severe presentations.[2][4][10]

An adequate prevention and/or management plan for IAD aims to:

• Treat the cause and other factors impeding healing
• Address caregiver's concerns
• Provide effective local wound care if IAD is already established
• Provide a structured skin care regimen
• Prevent new IAD

Fig. 1. Skin in the genital area with mild erythema and minimal irritation. By Simone Vidal, RN	Fig. 2. Skin of the perineal and gluteal region with exudative and ulcerated lesions. By Simone Vidal, RN
Fig. 3. Persistent redness with raised borders and satellite lesions extending beyond the diaper area. By Simone Vidal, RN	Fig. 4: Newborn with IAD in the genital region showing signs of infection.  By Simone Vidal, RN

Treatment Goals

• The main objectives of IAD treatment are to accelerate the regeneration of damaged skin and prevent recurring rashes.[3]

Treat the Cause and Co-factors Impeding Healing

Management and prevention of IAD begins with addressing the underlying factors that contribute to skin breakdown.[2] Prevention and treatment rely on many of the same core principles - frequent diaper changes, appropriate cleansing, use of barrier creams, and caregiver education.[2]

In infants, IAD often results from diaper occlusion, which prolongs skin contact with urine and stool. Ensuring air exposure when feasible, choosing highly absorbent diapers, and maintaining effective hygiene are key strategies for reducing irritation and protecting the skin barrier.[4]

• Infants at higher risk - such as those with frequent stools, diarrhea, antibiotic use, or prematurity - benefit the most from early preventive interventions aimed at minimizing skin damage. [5]
• When IAD develops, management focuses on healing inflamed or infected skin and preventing recurrence through appropriate cleansing, use of emollients, and targeted treatments such as low-potency corticosteroids, antifungals, or antibiotics when indicated.[6]

For all patients with or at risk of IAD [7]: 

• Minimize 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

Infants are physiologically incontinent, meaning they have not yet developed voluntary control over bladder or bowel function; therefore, managing moisture exposure through timely diaper changes is essential.

Frequency of diaper changes

• Frequent diaper changes reduce the time the skin is exposed to moisture and irritants, facilitating healing when IAD is already present.[11]  
• Diapers should be changed every 1 to 4 hours during the day and at least once at night. However, hygiene routines, including diaper changes, should be personalized to meet each patient’s needs. Along with changing the diaper, the entire area should be inspected.[4][12][13][14]
• For newborns, changing diapers every 2 hours is recommended due to their frequent eliminations.
• For older children, changes every 3 to 4 hours are often sufficient. 

Diaper design

• Advances in diaper technology - such as the development of breathable, superabsorbent diapers - have significantly improved skin conditions and reduced both the frequency and severity of IAD over the years.[3]
• Diaper design and absorbency play a key role in preventing and minimizing IAD.[3]
• Cloth diapers present a higher risk of IAD compared to disposable ones.[10]
• Cloth diapers usually require a plastic cover to contain liquids, which raises the temperature and increases moisture exposure.[15]
• Disposable diapers incorporate several design features that help protect the skin:
• Breathable outer layers: These layers contain microporous membranes that allow moisture vapor to escape. This reduces excessive moisture, prevents skin occlusion, and helps avoid leakage.[3]
• Superabsorbent polymers (SAPs): These polymers draw in and retain large amounts of liquid, keeping the skin drier for longer periods.[10]
• A commonly used SAP is sodium polyacrylate, which forms a gel when it contacts urine.
• The gel structure reduces direct moisture exposure, minimizes friction, and helps maintain an optimal skin pH.[3]

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][16][17]
• The regimen includes three key steps [7][16][18][17][19][20]:
• 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

Bathing

• Frequency: Skin hygiene begins with bathing, but daily baths and routine use of soaps can impair the development of the acid mantle, raise skin pH, and contribute to irritation and dryness. Bathing frequency should be individualized based on each newborn’s or infant's needs.[21]
• For preterm newborns: Avoid daily bathing and routine soap use. Bathe with water only 2–3 times per week.[15]
• For full-term newborns, infants, and older children: Baths may be performed with water and a gentle cleansing agent - liquid, neutral or slightly acidic pH, dye-free, and fragrance-free - used sparingly.[15]
• Bathing method: Baths should focus on cleaning areas that accumulate residue, such as the face, neck, folds, and diaper area. Limit bath duration to less than 5 minutes, especially if soap is used, to prevent overhydration and maceration of the skin. [12]
• For newborns weighing less than 1.5 kg: Use warm sterile water, which avoids disrupting the skin microbiota and reduces exposure to infectious agents, given the higher permeability of preterm skin.[21]

cleansing agents

• Skin cleansers generally come in one of two types: soap-based and synthetic detergents, or syndets.[22]
• The ideal cleaning agents for newborns are syndets (synthetic detergents), which are liquid, gentle, soap-free, fragrance-free, and have a neutral or slightly acidic pH. Syndets help preserve the acid mantle and do not irritate the skin or eyes. [12][21]
• Liquid cleansers containing emollients are more effective than water alone for removing urine and fecal residues and help prevent dryness. They also provide a protective effect for newborn and child skin.[12][21]

Skin hygiene 

• Baby wipes: Baby wipes are commonly used for diaper area cleansing due to their convenience. Wipes that are formulated for newborn and infant skin help maintain a healthy microclimate by supporting the moisture barrier, stabilizing skin pH, and reducing transepidermal water loss.[3][23]
• Recommended characteristics of baby wipes:
• Acidic pH to neutralize alkaline urine and maintain the skin’s natural acidity [3][23]
• Free of irritants, including alcohol, fragrances, essential oils, harsh soaps, and aggressive detergents [3][23]
• Safe preservatives: Because wipes are prone to microbial contamination, preservatives are necessary but should be appropriate for newborn and infant skin. Avoid preservatives known to cause allergic reactions.[3][23] 
• When wipes or specialized cleansing products are unavailable, hygiene can be performed with warm water and cotton, avoiding both soap and friction. A protective product should then be applied to help maintain or restore barrier function and elasticity.[10][15][24]
• For dried stool, cotton soaked in mineral oil can be used to loosen residue gently and minimize friction on the skin [3][23]

Protecting the Skin

Air Exposure

• Exposing the diaper area to air reduces the time the skin remains in contact with urine, feces, moisture, and other irritants. Removing the diaper allows the skin to air-dry and decreases friction from diaper materials. After cleaning the perineal area, time for air exposure should be allowed when feasible so the skin can dry naturally. This is a simple, safe, and effective measure to help minimize skin irritation.[4][25]

Barrier Creams

• For all newborns and infants, the application of a skin protectant or moisture barrier after cleansing is recommended to prevent or manage IAD (Grade 1C).[18][7]
• Barrier creams protect the diaper area by forming a superficial coating on the skin and supplying lipids to the intercellular spaces of the stratum corneum. This helps prevent direct exposure to moisture and irritants while supporting repair of the stratum corneum.[3]
• For types of skin protectants or barriers, refer to section 'Protecting the Skin' in topic " Incontinence Associated Dermatitis - Prevention and Management in Adults and Older Adults".

Powdered products

• For infants, the use of powders - particularly talc and starch-based powders - should be avoided in infants due to the risk of accidental inhalation.[12]
• Powders have absorbent and drying properties, provide a light protective layer, and help reduce friction. Commonly used ingredients include talc (magnesium silicate), zinc oxide, titanium dioxide, kaolin, and starch.[12] However, inhaled powder particles can cause airway irritation, chemical pneumonitis, granuloma formation, and in severe cases, pulmonary fibrosis.[12]

Restoring the Skin Barrier Function

Topical therapy is frequently reported for preventing and treating IAD in newborns and infants. Topical treatments for IAD include barrier emollients, breast milk, topical corticosteroids, antifungals and topic antimicrobials, depending on lesion severity.[6][11] Evidence highlights several effective product categories:

barrier emollients

Barrier emollients are commonly used in the diaper area for IAD prevention and treatment.[3][6]

• Mechanism of action: Emollients are emulsions containing lipids that [12]:
• Soften the skin and restore elasticity
• Prevent transepidermal water loss (TEWL)
• Form a lipid film that fills gaps between corneocytes, facilitating adhesion at the stratum corneum level
• Provide both humectant (water-attracting) and occlusive (water-sealing) effects
• Lubricate, hydrate, and protect dry or irritated skin
• Application considerations: Properly formulated emollients help maintain and restore barrier function and can reduce erythema when applied as a thin layer to the diaper area. Excess product in skin folds should be avoided, as it may interfere with evaporation and promote microbial overgrowth. [3]
• For preterm newborns, daily prophylactic use remains controversial due to the immaturity of their epidermal barrier and mixed evidence on outcomes.[12]
• Formulation types
• Ointments [12]:
• Emollients provide strong occlusion and lubrication emollients are occlusive and lubricating 
• May increase risks of acne, folliculitis, miliaria, or itching, especially in warm, moist areas or in atopic skin
• Creams and lotions [12]:
• Easier to spread and generally improve adherence
• Provide humectant benefits with less occlusion
• Products containing preservatives, dyes, fragrances, or other inactive ingredients may cause irritation or allergic contact dermatitis and should be avoided in infants.[12]
• Adjunctive barrier-supporting ingredients 
• Zinc oxide in an emollient base: Application of zinc oxide in an emollient base before diaper use has been shown to reduce the incidence of IAD by up to 45% in 70 neonates.[6][26]
• Products containing boric acid, camphor, phenol, benzocaine, and salicylates should be avoided in the diaper area due to the risk of systemic toxicity and/or methemoglobinemia.[3]

Breast Milk

• For newborns and infants with IAD, breast milk can be used to treat IAD with results typically observed within 3 to 7 days.[9][6] Compared to topical products like corticosteroids, breast milk is convenient and safe.[9]
• Benefits and mechanisms of action:
• Rich nutrient profile: Breast milk contains vitamins A, E, D, K, and B-complex, as well as proteins and calcium. These components help protect against dry skin, eczema, and skin fragility, supporting overall skin health.[27]
• Anti-inflammatory and antimicrobial properties: Breast milk includes natural antimicrobial proteins and immunologic factors that inhibit or kill a broad range of bacteria. It also helps create unfavorable conditions for microbial growth by influencing skin pH and microbiota composition.[28] 
• Breast milk combined with zinc oxide: Evidence suggests that combining breast milk with 25% zinc oxide for 7 days may accelerate healing in diaper dermatitis compared with 25% zinc oxide ointment alone.[9]
• Topical hindmilk (the high-fat portion of breast milk) in an emollient base: Applying an emollient mixed with topical hindmilk to the diaper area for 2 weeks has been shown to significantly reduce the incidence of IAD.[29]

Topical corticosteroids

• For infants with moderate to severe IAD, or cases that do not improve within 2 to 3 days of standard care, a low-potency topical corticosteroid may be considered for short-term use (e.g., hydrocortisone 0.5% applied twice daily for up to one week). When used, corticosteroid therapy should be combined with emollients and other preventive measures and limited to no more than one week to reduce inflammation, irritation, and discomfort. [3] 
• Safety considerations: High-potency corticosteroids must be avoided due to serious side effects such as localized skin atrophy, striae, and tachyphylaxis. In addition, systemic absorption of potent steroids, especially in occlusive conditions or skin folds, can lead to hypothalamic-pituitary-adrenal axis suppression, Cushing’s syndrome, growth delays, and other adverse effects in infants. Therefore, these medications should only be used under medical supervision.[3]

Infection and bioburden management

 For localized fungal and bacterial infections, topical medications can be used according to their prescribed dosage.[30]

• Fungal infections: Candida albicans is the most common fungal pathogen in the perineal region and skin folds. It typically presents with intense erythema, maceration, and satellite papulopustular lesions, which may occur on intact or eroded skin.[11] 
• Topical antifungals such as nystatin, clotrimazole, miconazole, ketoconazole, or ciclopirox can be applied with each diaper change to treat fungal infections in newborns, including those with very low birth weight. In severe or highly inflamed cases, a combination of topical antifungal therapy plus a mild low-potency corticosteroid may be used briefly to reduce inflammation.[3]
• Miconazole nitrate at 0.25% shows good skin tolerance and no resistance development during treatment.[31]
• Clotrimazole provides faster symptom relief than nystatin, although both have demonstrated a 100% healing rate. [32]
• Bacterial infection: For secondary bacterial infections, treatment may involve topical antimicrobial agents, topical antibiotics, or systemic antibiotics, depending on severity.
• For mild, localized infections, topical mupirocin applied twice daily for 5–7 days is typically effective. [3][33]
• For more severe infections, oral antibiotics may be required, particularly for conditions like perianal streptococcal dermatitis. [3][33]
• Caution: Topical antibiotics are active against gram-positive organisms, but they can disrupt normal flora, promoting gram-negative overgrowth and increasing risk of sensitization or allergic reactions. Their use should be limited and monitored.[11] 

Address Patient Caregiver Concerns

• Ensure that caregivers feel supported, and answer any questions they may have about how to care for the newborn's skin, what to watch for, and when to seek additional medical help.

Plan Reassessment

Ensuring caregiver competence and adherence is essential for successful IAD prevention and treatment.

• Schedule follow-up assessments to monitor the newborn’s progress, confirm that appropriate care is being provided, and adjust the treatment plan as needed.
• Evaluate whether the caregiver has the knowledge and skills required to manage IAD effectively. Consider the following:
• Are diaper changes being performed as recommended?
• Are skin care products being applied correctly and consistently?
• Is the caregiver monitoring for signs of irritation or infection?

Adjunctive Therapy

• For infants with moderate to severe IAD, or cases that do not improve within 2 to 3 days of standard care, a low-potency topical corticosteroid may be considered for short-term use (e.g., hydrocortisone 0.5% applied twice daily for up to one week), combined with emollients and other preventive measures.[3] 
• 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

Parental and Caregiver Education

Educating parents and caregivers on proper diaper area hygiene is essential for preventing IAD. Because IAD is typically preventable, caregivers should receive clear guidance on how to reduce risk through appropriate cleansing, skin care, and diapering practices.[4] Education should cover the causes, preventive measures, and treatment strategies for IAD, including the items below [3]:

• Bathing guidance:
• General newborn bathing: Baths should be kept brief (≤5 minutes), especially when soap is used. Prolonged exposure to water and soaps can cause maceration and weaken the skin barrier.[12]
• Preterm newborns (<1.5 kg): Use warm sterile water for bathing to avoid disrupting the skin microbiome and to gently remove bodily fluids. Because premature skin is more permeable and vulnerable to infection, sterile water reduces exposure to harmful pathogens.[21]
• Cleansing products for bathing: The ideal cleaning agents for bathing are Syndets (synthetic detergents) or soap-free cleansers. These should be liquid, gentle, free of fragrances, and have a neutral or slightly acidic pH that does not harm the skin or eyes, nor alter the protective acidic mantle of the skin. Liquid cleansing agents with added emollients are superior to plain water for hygiene, removal of fecal and urinary residues, and preventing skin dryness.[12][21]
• Baby wipes: Baby wipes are commonly used due to their convenience. However, those containing preservatives or fragrances may lead to contact sensitivity and should be avoided.[12][15]