What Is Incontinence-Associated Dermatitis (IAD)?

Incontinence-associated dermatitis (IAD) is a type of irritation that happens when the skin stays in contact with urine or stool for too long. This moisture and exposure break down the skin’s natural barrier, leading to discoloration, pain, and sometimes infection. IAD most commonly affects the skin around the buttocks, thighs, and genital area.

IAD can show up quickly and initially may look like a rash or sunburn. The symptoms can vary in intensity, depending on how long the skin is exposed and whether there’s also friction or infection.

IAD can start as a discolored area primarily in the perineum (skin between the genitals and anus), perirectal (skin surrounding the rectum), or groin, including the upper inner thigh areas, says Rose Murphree, DNP, a clinical assistant professor at the Neil Hodgson Woodruff School of Nursing at Emory University in Atlanta.

“In severe cases, it can extend upward onto the lower back or sacral areas [at the bottom of the spine], and it may have small spots in the periphery,” says Dr. Murphree.

On a person with light skin this dermatitis can be red; for someone with dark pigmented skin tone, it may appear ashy (gray) in color or even a darker skin tone than the surrounding tissue. “The area of discoloration may be in patches or appear as a large single area that is affected,” Murphree says.

• Itching, which may indicate a fungal infection
• Burning or stinging, especially if the outer area of the skin is broken
• Soreness or pain in affected areas
• Raw or tender skin
• Moist, oozing patches or blisters in severe cases
• A bad odor if skin is infected

IAD happens when skin is exposed to moisture, especially from urine and stool, for extended periods. This constant wetness, combined with friction from movement or clothing, damages the skin.

“I frequently see mild incontinence-related dermatitis in patients who are new to incontinence. Often, they just recently started wearing a pad or a disposable undergarment,” says Elizabeth Kiracofe, MD, a dermatologist at AIRIA Comprehensive Dermatology in Chicago.

Friction from adult diapers, clothing, or bed surfaces can increase the risk of IAD. So can bacteria that transform urine into ammonia, which can increase skin pH and irritation.

“Sometimes people with incontinence-associated dermatitis also have decreased sensation in the area, and so they’re not aware that they’re feeling wetness,” Dr. Kiracofe says.

Moderate to severe IAD is more likely in older adults who have limited mobility or live in long-term care facilities.

In this case, it’s not just prolonged exposure to urine, but also stool, which can cause the skin — particularly the epidermis, the skin’s outer layer — to be very vulnerable, says Murphree.

That’s because the same enzymes that digest food in the small intestine are still present in stool, though in a smaller amount, and those can break down skin tissue. “Stool, even solid stool, contains proteolytic enzymes that can ‘eat’ our skin,” Murphree says.

• Older age or limited mobility
• Female sex
• Diabetes or dementia
• Overweight or obesity
• Smoking
• Adult diapers or pads worn for too long after they are soiled
• Inadequate or infrequent bathing

A healthcare provider usually diagnoses IAD by looking at the skin and asking questions about symptoms and bathroom habits — a history of urine or stool leakage helps confirm the diagnosis.

A simple tool called the Ghent Global Incontinence-Associated Dermatitis Categorization Tool assesses IAD severity by considering factors including color, location, lesions, and symptoms.

• Pressure ulcers (bedsores)
• Allergic skin reactions
• Fungal or bacterial infections
• Psoriasis or seborrheic dermatitis (discolored, itchy, and scaly patches that can be on the scalp, face, or oily areas of the body)
• Lichen sclerosus, a chronic skin condition that mainly affects the genital and anal area, causing white patches, itching, and pain

The main goal of treatment is to manage incontinence, practice careful and thorough skin hygiene, protect the skin, reduce irritation, and treat any infection.

Over-the-counter moisturizers and barrier creams designed for sensitive skin can help hydrate and protect the skin.

Barrier products include:

• Petroleum jelly
• Silicone-based products
• Soft zinc oxide creams

“The same ointments you would use on a baby’s bottom, you can use on an adult’s bottom,” says Murphree.

When cleansing, use pH-balanced no-rinse cleansers and limit the use of perfumed products, as these can be irritating to the skin and cause more damage, she adds.

Topical antibiotics or antifungals can treat infections caused by bacteria or yeast.

A prescription cream may be necessary in more serious cases or when over-the-counter options don’t work.

For people who spend most of their day in a bed or a chair, turning or other frequent repositioning is vital: It can reduce the risk of damaged skin that leads to the development of a pressure injury, which could get infected, says Murphree.

Preventing IAD is easier than treating it. “For people who have no issues with mobility, it usually just takes some education about changing pads or disposable underwear more often so that the dampness doesn’t irritate the skin,” says Kiracofe.

For older adults who require a caregiver, prevention relies on first identifying the underlying cause. “If the older person has confusion, dementia, or other mental conditions, checking on the person’s brief regularly is the best approach,” says Murphree.

If the person is able to walk, utilizing a “pant and pad” combination may be helpful, especially for women, says Murphree.

“This approach uses a regular pair of underwear and then adds an incontinence pad that has superabsorbent polymer products within the pad that helps wick or pull the urine away from the skin,” she says.

Another option is for a caregiver or other helper to offer to assist the person in making a trip to the bathroom every one to two hours, she notes.

Murphree recommends the following additional tips to prevent IAD:

• Clean the skin gently and often. Use soap-free, fragrance-free cleansers instead of regular soap, which can irritate the skin.
• Dry the skin carefully. Pat the area dry — don’t rub.
• Apply barrier products regularly. Use creams after every cleaning.
• Change incontinence products frequently. Don’t let moisture sit against the skin.
• Avoid tight clothing and rough fabrics. These can rub against sensitive skin.
• Watch for signs of infection. These include skin discoloration that spreads, oozing, or a bad smell.

With proper care, mild IAD can start to improve in just a few days, while more serious cases may take one to two weeks, provided the skin remains clean and protected. Severe cases can take longer to heal.

If symptoms don’t improve, or if they worsen, it’s important to consult with a healthcare provider.

“Recurrence can absolutely be prevented. It’s just about being aware and vigilant about when you’re noticing that wetness,” says Kiracofe.

IAD can affect about 4 to 6 percent of people who experience an extended stay in a hospital or nursing home.

If left untreated, incontinence-associated dermatitis can lead to more serious health issues. While IAD itself can be painful and uncomfortable, complications can increase the risk of infection and more skin damage.

Significant Itching IAD can be very itchy and inflaming to the skin, leading to scratching. “I always say it’s not my patient’s fault for scratching — it’s my job to figure out what’s making them itchy so that we can solve that with the right care and medications,” says Kiracofe.

Skin Infections Damaged skin is more vulnerable to bacteria and yeast, which makes the skin even more prone to infection and breakdown. In the worst cases this can expose deeper structures in the body: muscle, ligaments, and possibly even bone.

Reduced Quality of Life Ongoing pain, itching, and the embarrassment that can come with incontinence and skin damage may cause anxiety, sleep problems, and withdrawal from social activities.

The Takeaway

• Incontinence-associated dermatitis (IAD) is a treatable skin condition caused by prolonged exposure to urine or stool.
• It usually happens in people with incontinence and can be more common in people who are bed- or wheelchair-bound or have other mobility limitations.
• Early signs include skin discoloration, pain, and itching.
• Remedies for incontinence-associated dermatitis include hygiene, barrier creams, and treatment for any infections.