If we are honest with ourselves and others, many of us have experienced some form of incontinence. We may have had some soreness, redness, or irritation in the area around our genitals, thighs, and abdomen. This skin issue is one of the most common and preventable conditions I have seen, called incontinence-associated dermatitis, or IAD. While it often starts with mild redness, soreness, or irritation, it can quickly progress to painful skin breakdown if not addressed early. It is similar to diaper rash in young children, as both are caused by prolonged exposure of the skin to urine and/or stool. Over the years, caring for and educating individuals on incontinence-associated dermatitis has become a passion of mine. We can learn to reduce the skin-related complications associated with it through several simple steps.
What Causes Incontinence-Associated Dermatitis
Incontinence-associated dermatitis (IAD) is a form of moisture-associated skin damage caused by repeated exposure to urine, stool, or both. IAD presents as inflammation of the skin with or without erosion in areas exposed to moisture. It is most commonly seen in the perineal region, buttocks, inner thighs, and genital areas. IAD is not an allergic reaction or a pressure injury/bedsore. It is caused by a combination of chemical and physical irritation from urine and stool, not by pressure on the skin, as in pressure injuries.
IAD develops when three things work against your skin at the same time:
- Moisture that keeps the skin wet and soft in a bad way.
- Chemical irritation from urine and stool contains substances that actively break skin down. Urine increases skin pH, making it more alkaline. Stool introduces digestive enzymes that actively break down proteins and lipids in the skin.
- Friction through movement, clothing, and cleaning can rub already-weakened skin.
When all three are happening together, the skin often begins to show subtle signs. We may experience pain, burning, and itching in the affected areas, which can disrupt sleep, affect mood, and reduce overall quality of life. Without intervention, the skin barrier begins to fail. Once that barrier is compromised, damage accelerates.
Step-by-Step Breakdown of IAD Development
1. The Skin Gets Waterlogged
Repeated or extended exposure to urine or stool keeps the skin wet and causes it to become overly soft and fragile, a process called maceration. You probably have seen it before, after a long shower or bath, where your skin, especially your fingers or toes, looks shriveled. Macerated skin is weaker than normal and is prone to damage when exposed to friction.
2. pH Imbalance
A slightly acidic surface supports our skin barrier. The pH of our skin is disrupted by repeated contact with urine and stool, and skin bacteria convert urea in our urine into ammonia, which helps contribute to this pH shift. This disrupts the natural acid mantle, weakening the skin’s defense system.
3. Chemicals in Stool Start Breaking Down the Skin
Stool contains digestive enzymes, the same substances used to break down food. These enzymes can start to break down your skin with prolonged exposure. Similar to urine, it can increase your skin pH. This increase in pH, along with the enzymatic damage, reduces our skin’s protective barrier function, raising the risk of bacterial infection. This is why fecal incontinence tends to cause more skin damage than urinary incontinence alone.
4. Even Gentle Friction Can Cause Harm
Once our skin starts to weaken, it becomes fragile and sensitive to touch. This fragile state makes it more vulnerable to friction from items such as clothing, body worn absorbent products, bed linens, and even cleansing products. This means even gentle care can now cause damage.
5. Redness, Inflammation, and Open Areas Develop
The skin becomes red, inflamed, and painful. Erosion is the loss of the superficial layer of the skin. It results in shallow, open areas that may appear moist and are often painful and sensitive. At this point, the condition has moved beyond prevention and into active skin injury.
Recognizing the Stages of IAD And What to Do
The stage at which you catch IAD helps determine how you can help prevent the issue from getting worse. Early signs are easy to miss, but they are your best opportunity to act. Let me walk you through what each stage looks like and what actually works.
Early Stage is Your Window of Opportunity
Our skin is still intact, but it is starting to show signs of an issue. Look for light pink or red discoloration, skin that feels warm to the touch, and/or complaints of burning or itching. This is the most important stage. Act here, and you may prevent breakdown entirely.
Moderate Stage is Time to Step It Up
The redness deepens, and the skin becomes more reactive. Signs include bright redness with visible inflammation, swelling, or warmth, and/or increased pain and sensitivity during care. The skin is weakening. The goal now is to stop it from getting worse.
Severe Stage when The Skin Has Broken Down
This is when real damage is visible. You may see shallow open or weeping areas, raw, moist-looking skin, and/or significant pain, especially during cleansing. At this stage, the skin is what we call denuded,meaning the protective outer layer is gone, leaving tender tissue exposed. This requires stronger intervention and close attention.
Prevention Through a Wound Care Lens
From years of experience, I believe that prevention comes down to three steps done consistently. The steps are cleanse, protect, and reassess. While all these steps are important, protection is where I often see the biggest difference. Even the best cleansing routine cannot help skin that is left undefended between care episodes.
Gentle Cleansing
Gentle cleansing is not just a preference but is a necessity for IAD. No-rinse, pH-balanced cleansers are a great option for anyone. They help avoid additional skin damage from repeated exposure to water and traditional soap.
Recommended cleansers include:
- Medline Remedy Specialized No-Rinse Foam or Spray Cleanser
- Remedy Clinical Shampoo & Body Wash (requires rinsing)
- Medline Remedy Clinical Barrier Cream Cloths
Consistency is what allows the skin to recover. Even the best products will not work if they are not used regularly.
Tip: Pair no-rinse cleansers with a disposable dry cloth to reduce friction. Spray products are a great option when you need something fast, providing fewer steps, less friction, and the same protection. Keep a small kit with cleanser or cleansing barrier wipes, cloths, barrier cream, and body worn absorbent product (BWAP) all ready to go, whether you are at home or out. That kind of preparation makes consistency possible, and consistency protects skin.
Protection
Protection is often where we can stop IAD in its tracks and give our skin a chance to heal. If we consistently protect the skin in the early stage, we reduce the risk of breakdown altogether. Protection involves using a combination of body worn absorbent products and barrier creams. Choosing the right products does matter, and you should use products that match the skin’s condition. Body-worn absorbent products include briefs, protective underwear, pads, and liners designed to absorb urine or stool and protect skin and clothing. Barrier cream products containing petrolatum, dimethicone, or zinc oxide all provide a physical barrier against moisture and irritants. Each one serves a different purpose depending on severity.
Always take a moment to read the full ingredient list of any skin care product or body worn absorbent product before using it. Even products labeled as gentle or for sensitive skin can contain ingredients that may cause irritation or allergic reactions. If you or the person you are caring for has sensitive skin, try a small test area first and watch for redness, itching, or burning.
Choose the Right Body Worn Absorbent Product
The right product can help us reduce exposure to moisture, support skin integrity, and lower the risk of incontinence-associated dermatitis. It is important to choose an appropriate product to prevent complications. Some important considerations are that it fits well, absorbs effectively, and keeps moisture away from the skin rather than holding it against the body. Recommended products:
- While there are many brands available, I recommend Seni brand products based on experience.
Tip: A product that is too small, too large, or not absorbent enough can lead to leakage, friction, and prolonged skin contact with moisture, all of which increase the risk of skin breakdown. Seni has a great tool to help with sizing. With thoughtful selection and regular changes, these products can support comfort, dignity, and healthier skin.
Choose the Right Barrier Protection Product
For intact but irritated skin, start with a lighter dimethicone or petrolatum-based barrier. Recommended options include:
- Medline Remedy Specialized Prevent Silicone Cream
- Medline Remedy Olivamine Nutrashield Skin Protectant
- Coloplast Critic-Aid Clear Moisture Barrier Ointment
Dimethicone provides a clear, breathable light barrier that helps protect against moisture and reduces friction. It resists wash-off and works well for prevention and mild or moderate IAD, especially when cleansing is frequent. Also, compared to most zinc-oxide-based products, it is less likely to stain your clothes. The products are easy to apply and remove, which is important when care is frequent.
A petrolatum-based barrier provides a protective layer over the skin, helping shield it from moisture, irritants, and friction. It works by sealing the skin’s surface, preventing urine or stool from directly contacting and damaging it.
For Denuded or Open Skin, your skin needs stronger and longer-lasting protection. Zinc oxide-based creams provide a thick, typically white layer that helps block urine and stool. While they can be used for mild IAD, they tend to be more appropriate for moderate to severe IAD. Recommended options include:
- Medline Remedy Specialized Extra Thick or Clinical Zinc Oxide Paste
- Medline Remedy Specialized Zinc Oxide Skin Protectant Spray
- Medline Remedy Specialized Clear Zinc Ointment
- Boudreaux’s Butt Paste Maximum Strength
Tip: One technique that can make a difference is you do not need to fully remove the barrier at every cleansing. Remove only what is visibly soiled, then reapply as needed. Stripping the barrier completely each time leaves the skin unprotected and can cause additional friction damage.
Reassessment
When taking care of incontinence-associated dermatitis, or IAD, reassessment is something we should do often. Take a moment to slow down, look closely, and ask ourselves, Is our skin getting better, or is it trying to tell us that something has to change.
What to Look for and How to Adjust
- Skin color: Is redness starting to fade, or is it becoming brighter or spreading?
- Skin integrity: Is the skin still intact, or are we starting to see or feel open or denuded areas?
- Moisture: Does the skin feel too wet, or is it staying balanced between care?
- Pain: How painful is it? Does it burn or hurt more?
- Drainage: Is there any new weeping or fluid that was not there before?
Tip: The appearance of our skin can help guide what we do next. If the skin is getting worse, our skin likely needs additional support. The first step would be to try to switch to a thicker zinc-based barrier for better protection. Also, if the skin is getting too wet, try increasing how often you check and protect it. Remember, good care is not just about what you use but also about how often you reassess and adjust to stay proactive before complications arise.
When to Seek Medical Help
Incontinence-associated dermatitis is one of the most common but preventable forms of skin damage I have seen in wound care. Often, preventing risks comes down to early recognition and the right protective steps. However, if incontinence-associated dermatitis (IAD) is not improving and/or the skin continues to worsen, it’s important to seek evaluation from a healthcare professional. Early intervention from your provider can prevent further skin breakdown, reduce pain, and address potential complications from infection.
Signs of infection to watch include increasing redness or warmth, swelling, worsening pain or tenderness, foul odor, pus or unusual drainage, and skin that appears to be rapidly breaking down. Other important warning signs are fever, spreading areas of irritation, or changes in skin color, such as darkening or deep redness. If you have any concerns, we always recommend reaching out to your healthcare provider.