Skip to main content
NCBI home page
Springer logoLink to Springer
. 2025 Jul 4;42(8):745–754. doi: 10.1007/s40266-025-01227-z

Incontinence-Associated Dermatitis in Older Adults: A Critical Review of Risk Factors, Prevention and Management

Jan Kottner 1,✉, Joachim Dissemond 2
PMCID: PMC12313743  PMID: 40615652

Abstract

Prolonged and repeated exposure of the skin to urine and/or faeces may lead to incontinence-associated dermatitis (IAD). IAD is an irritant contact dermatitis characterised by pain, erythema, maceration, erosion, scaling and very often associated with secondary infection. Older adults who are incontinent are at high IAD risk. Several differential diagnoses must be separated from IAD, with allergic contact dermatitis being the most common in older people. The main prevention and treatment principles are to reduce or to avoid the exposure of the skin to urine and stool. The type of incontinence should be assessed first and strategies to enhance continence implemented. Especially in older adults, high absorbency incontinence products should be used and changed regularly to reduce overhydration of the epidermis. Protective skin care products and mild cleansing should be applied. Weeping erosions, excoriations or infection should be treated with appropriate topical products. The short-term and controlled use of corticosteroids or external urine or stool collection devices or indwelling urinary catheters might be considered in severe cases. Owing to demographic changes, the management of incontinence and associated IAD will become more important. This will be especially relevant in primary care for older adults.

Key Points

Many older adults are affected by incontinence-associated dermatitis characterised by cutaneous inflammation and pain.
Main management principles are to reduce or to avoid the exposure of the skin to urine and stool.
Incontinence-associated dermatitis can be prevented and treated by promoting continence, using high absorbency incontinence products and mild skin cleansing and skin protection products.
Open in a new tab

Introduction

Many older adults are affected by incontinence, which is defined as the involuntary loss of urine and/or stool [1, 2]. The prevalence of incontinence in geriatric and long-term care settings is high, occurring in approximately 60–80% of older adults [3–6]. Prolonged and repeated exposure of the skin to urine and/or faeces may lead to incontinence-associated dermatitis (IAD). IAD causes inflammation of the skin, which is clinically characterised by erythema, maceration, erosion, scaling and very often associated with secondary infection [3, 7, 8]. Other clinical symptoms include pruritus, burning and pain especially during incontinence care or mobilisation [3, 7]. Depending on the setting, the definition of IAD, and applied diagnostic criteria IAD prevalence in older people range from 3 to 30% [3–6, 9] and cumulative incidence range from 3 to 26% [3, 5, 10]. The aim of this review is to summarize and critically discuss our recent understanding of IAD and how to prevent and treat this skin condition in older adults. In terms of options for prevention and treatment, we focus mainly on methodologically high-quality systematic reviews and guidelines.

Aetiology

IAD is an irritant contact dermatitis provoked by acute or prolonged and repeated contact with urine and/or stool [3, 11]. The underlying process of IAD development is shown in Fig. 1. Urine and stool on the skin surface lead to overhydration and destruction of the stratum corneum and keratinocytes [12, 13]. The enzyme urease, which is produced by bacteria on the skin (including Staphylococcus epidermidis, which is part of normal skin microbiota), converts urea into ammonia. As soon as ammonia is dissolved in water the skin surface pH increases, which reduces the permeability barrier and the stratum corneum cohesion [14–16]. Recent findings also suggest that ammonia may directly damage the skin [15]. This leads to the release of cytokines initiating an inflammatory response in the epidermis and dermis [8, 17, 18]. Compared with urine exposure alone, urine in combination with bacteria and/or digestive enzymes in the stool lead to a characteristic epidermal and dermal inflammation, including epidermal thickening, endothelial damage and a kind of intracutaneous ‘digestion’ [19, 20]. An alkaline skin surface pH also enhances the activity of proteolytic enzymes from stool and within the stratum corneum, leading to an increased desquamation of the corneocytes [15, 21]. In addition, frequent skin cleansing procedures and occlusion due to incontinence material or due to prolonged lying or sitting promote cutaneous inflammation and thus IAD development [3, 22].

Fig. 1.

Fig. 1

Open in a new tab

Model of incontinence-associated dermatitis development

Assessment

Incontinence-Associated Dermatitis Risk

To successfully prevent IAD, risk assessment is very important. Every incontinent person is, by definition, at risk of developing IAD, but not every incontinent person develops IAD [23]. Positive associations have been described between the presence of IAD and various person-related variables including obesity, diabetes mellitus or higher age [24–26]. Taking only high-quality longitudinal studies into account, moderate quality evidence indicates that increased stool frequency, including diarrhoea, limited mobility and friction/shear problems are risk factors for IAD development [27]. Low-quality evidence indicates that female sex, older age and vasopressor use increases IAD risk [27]. Similar risk factors have been identified specifically for critically ill patients [28, 29]. Evidence from clinical studies also suggests that ageing leads to structural and functional skin changes, increasing susceptibility to maceration [30]. Overall, these findings suggest that older people who are incontinent are at very high IAD risk.

Diagnosing Incontinence-Associated Dermatitis

The diagnosis of IAD is made by clinical examination and on the basis of the patient’s medical history. Since IAD is a contact dermatitis, it shows typical signs of sharply demarcated skin inflammation in the area of exposure, including the convex areas of the buttocks, the perineal or the perianal skin areas. Skin folds might be affected and must be inspected (Fig. 2). Acute IAD is characterised by maceration, erythema, oedema, pain and pruritus. In darker-pigmented skin, acute IAD may appear as purple discoloration [31, 32]. Later vesicles and blisters may develop, leading to painful, irregularly shaped sometimes large painful erosions. Chronic IAD is characterised by skin thickening, scaling, post-inflammatory hyperpigmentation, and lichenification, which is an accentuation of skin markings [3, 7, 33].

Fig. 2.

Fig. 2

Open in a new tab

Incontinence-associated dermatitis indicated by sharply demarcated erythema, a shiny appearance of the skin surface and maceration. A pressure ulcer is located above the sacral area

IAD is very often associated with secondary infection (most often Candida albicans) clinically indicated by white scaling, purulent exudate and satellite papules and pustules (Fig. 3) [8, 31, 32]. A fungal infection can sometimes be difficult to detect. If in doubt, a microbiological sample must be taken and analysed [8]. Evidence suggests that Candida albicans colonisation is common, particularly in older adults, but associations between colonisation, type of incontinence and IAD are unclear [34]. Similarly to other wounds, there might be factors transforming colonisation into infection in IAD, which are unknown so far [34, 35].

Fig. 3.

Fig. 3

Open in a new tab

Severe incontience-associated dermatitis with erythema, maceration, irregular erosions and satellite papules and pustules

Several IAD severity scales and classifications have been proposed [36]. A widely used assessment instrument is the Ghent Global IAD Categorization Tool (GLOBIAD), which distinguishes between inflammation with erythema without erosions (category 1) and with erosions (category 2) [32]. It has been translated into many languages and it is freely available [37].

One of the most important differential diagnoses is allergic contact dermatitis, which occurs frequently, especially in older people [38]. There is a variety of ingredients that are found in skin care or continence products which can cause sensitisation and subsequent contact allergies [3, 39, 40]. Compared with irritant contact dermatitis, allergic contact dermatitis is less clearly demarcated, and the inflammation extends beyond the exposed skin areas. Acute clinical signs include erythema, vesicles and blisters while chronic forms may include lichenification, cracks or fissures. If exposure to urine and stool is interrupted, IAD resolves immediately. Allergic contact dermatitis takes considerably longer to heal, provided the triggering allergen is avoided [3, 33]. Irritant contact dermatitis such as IAD is associated with a weakened skin barrier, which is in turn a risk factor for allergic contact dermatitis. As frequent skin cleansing and skin care procedures are conducted owing to incontinence, contact with potentially allergenic substances is also increased [40]. It is often preservatives, natural cosmetics or fragrances in these preparations that cause contact allergies.

Another differential diagnosis is intertriginous dermatitis or intertrigo [41]. It is also a form of irritant contact dermatitis, but it occurs in the skin folds only owing to repetitive friction between two skin surfaces. Sweating or other body fluids contribute to intertrigo development (Fig. 4) [3, 41, 42]. A distinction between IAD and intertrigo is clinically possible owing to the different anatomical localisations and the lack of contact with urine or stool in intertrigo. Intertrigo is characterised by erythema and erosions occurring in mirror image locations at opposing skin surfaces (kissing lesion). It is often associated with pruritus and malodour due to the bacterial or fungal growth in the deep skin folds. However, both IAD and intertrigo can also be present at the same time in the groin or rima ani area.

Fig. 4.

Fig. 4

Open in a new tab

Intertriginous dermatitis or intertrigo at the abdominal skin fold

Another frequent possibility of confusion is with pressure ulcers/injuries in the sacral skin area [8]. Pressure ulcerations are caused by prolonged local deformation of the skin and underlying soft tissues leading to tissue death [43]. Category 2 pressure ulceration is defined as partial thickness loss of the dermis, presenting as a shallow ulcer with a red or pink wound bed without slough or as a serum-filled or serosanguinous blister which may rupture [44]. Compared with IAD, the borders of the pressure ulceration are clearly demarcated, and the wound is round to oval. Pressure ulcers/injuries are usually located over bony prominences, whereas IAD is always located in the area of exposure to urine and stool [8, 33]. Black necrotic tissue or high-volume exudate characterising deeper pressure ulceration never occurs in IAD. In older geriatric patients, IAD and pressure ulcers often occur together (Fig. 1).

Prevention

Because of the high IAD risk in older incontinent people, prevention is the key to success. The main prevention principle is to reduce or to avoid the exposure of the skin to urine and stool. This goal can be achieved through three strategies: promotion of continence, use of incontinence products and skin protection. These interventions should be accompanied by education and counselling for the persons at IAD risk and their formal and informal carers [45].

Promoting Continence

The first step should be a careful assessment to classify the type of incontinence, which may be stress, urge, functional or mixed [46–48]. Depending on the type of incontinence, first-line recommendations to promote urinary and faecal continence include weight loss in obese patients, toileting routines, pelvic floor muscle exercises or adapted fluid or food intake strategies [47, 49, 50]. Second-line treatments include medications or surgical interventions [47, 49, 50] but invasive options are less preferable, especially in geriatric and long-term care patients [47], and the complete restoration of continence may not be a realistic treatment goal. In any case, the environment should be adapted so that mobile persons can reach commode chairs or a toilet independently or with assistance [46, 48].

Continence Products

Continence products can be defined as those that are used to contain bladder or bowel leakage (either inside or outside the body) or to drain the bladder [51, 52]. There is a huge variety of products available, including absorbent products such as briefs or pads, urine collection devices, catheters, anal plugs and many more. In older incontinent individuals, absorbent products are widely used but no product works best for everyone [51]. Performance characteristics meeting the type, frequency and volume of urine and/or stool and the individual acceptability should be carefully considered. Especially in older people, products such as topsheets with larger pore sizes, and those with superabsorber and breathable materials are preferred to reduce overhydration of the stratum corneum [51–54]. A practical, independent and freely available decision-making support for the selection of suitable products is the Continence Product Advisor [55]. Ultimately, individual shared decisions should be made, in which personal preferences as well as the costs or reimbursement of costs should be considered.

In addition to selecting the right absorbent product, regular changes are important for promoting skin health. The main problem is the accumulation of heat and moisture between the skin and the product, especially when the absorbent capacity is exhausted. Another unwanted side effect is possible reflux from the absorbent core back to the skin (‘rewetting’) [56]. Reflux is the proportion of fluid that may come back into contact with the skin surface from the inner absorbent core and may contain dissolved substances that should not normally come into direct contact with the skin. This phenomenon may further increase the risk for irritant contact and the development of allergic dermatitis [38, 54, 56]. Change times must be patient centred and not on the basis of clinical routines [52], checks should be done every 2–3 h [48]. After faecal incontinence episodes, products must be changed immediately, because the pads/briefs cannot wick away stool [48, 52]. In clinical practice, the change is probably less frequent than is necessary and acceptable to patients [57].

Skin Protection

Topical Leave-On Products

Exposure to urine or stool can be reduced by using skin-protecting products, which are also called ‘skin barrier products’, ‘skin barriers’ or just ‘skin protectants’ [48]. There is a huge variety of different topical products consisting of various ingredients on the market. In general, a distinction can be made between film-forming and lipophilic leave-on products [58]. Film-forming products include polymers such as siloxane or cyanoacrylate, leading to a type of coating or shielding of the skin surface, protecting against chemical (urine, stool) but also mechanical (friction, shear) irritation [31, 59, 60]. Silicones typically found in barrier products are water-resistant and water vapor permeable [59].

Lipophilic leave-on products, often called ‘barrier creams’, consist of petrolatum, paraffin, waxes or similar lipophilic ingredients that also provide a physical and chemical barrier [61]. Above all, petrolatum has strong skin-protecting and occlusive properties [62, 63]. In contrast to widespread assumptions, petrolatum does not completely block the skin surface, and it is not comedogenic [64, 65]. Lipophilic products may also be combined with zinc oxide (e.g. ‘zinc oxide cream’) showing anti-inflammatory properties. Depending on the proportion of zinc oxide in the formulation and on the substantivity product, removal might be difficult and visual inspection of the IAD area might be impaired [61].

Empirical evidence indicates that skin protecting leave-on products help to prevent IAD but there is little evidence about the comparative effectiveness of different ingredients or products [58, 61, 66]. It is important to note, that single ingredients alone do not provide skin protection, but it is always the entire formulation that provides possible effects [67, 68]. Many skin protection products contain mixtures of film-forming (e.g. dimethicone) and lipophilic ingredients (e.g. [66, 69]). It is therefore recommended to use a protective skin product as opposed to no product for IAD prevention, especially for people at high IAD risk [3, 8, 48, 51, 70].

Similarly to surfactants in skin cleansers, emulsifiers found in many skin care products may damage the skin barrier [71, 72]. When selecting products, care should also be taken to ensure that they do not contain any known allergenic substances such as lanolin, parabens, fragrances or ‘natural products’ such as tea tree oil [3, 40, 48, 73]. The manufacturer’s instructions should be strictly adhered to.

Skin Cleansing

Incontinence requires frequent skin cleansing. It is recommended to cleanse the skin after each incontinence period [48, 74]. Water is an effective skin cleanser, but to solve lipophilic components surfactants are needed. Surfactants lower the surface tension between hydrophilic and lipophilic phases and make the ‘dirt’ on the skin surface soluble in water. There are various types of surfactants and combinations used in body washes or skin cleansers, which are generally referred to as soap, whether it is not always soap in the chemical sense [75]. In addition to the desired cleansing effect, both water and soap damage the skin. This includes the dissolution of lipids in the stratum corneum, the damage of proteins and an increase in the skin surface pH, leading to dryness and inflammation (Fig. 1) [3, 72, 76, 77]. Water alone is a penetration enhancer which leads to increased permeability of the stratum corneum [78]. As the skin is already exposed to increased moisture owing to exposure to urine and stool, the application of water reinforces this unwanted effect. This effect is stronger; the more often the skin is washed, the more soap is used.

To reduce these side effects, the skin should be cleaned carefully, using weak wiping pressure [79], and only when absolutely necessary. Low irritating and non-alkaline surfactants (e.g. amphoteric, cationic instead of anionic) should be preferred [80]. To avoid the exposure to traditional washing with water and cleansers, non-rinse cleansers or wet wipes may be preferred [70]. Non-rinse cleansers usually combine cleansing and skin protective (e.g. dimethicone) agents [48, 74]. Wet wipes are composed of a basesheet made of polyester, viscose or cotton fibre and a liquid cleanser formulation within a package to protect the formulated product. In the case of firmly adhering soiling (e.g. stool), this should be softened by applying a moist washcloth or a wet wipe for a few minutes. Similarly to the use of protecting leave-on products, a number of ingredients in cleansers (including wet wipes) may induce contact allergies [38, 81]. After cleansing, the skin must be completely dry before putting on new incontinence material or clothing.

Treatment

The IAD treatment follows the same strategies as prevention, with the promotion of continence, use of appropriate continence products and skin protection. Depending on the severity of the condition, additional measures may be necessary.

Mild IAD

Early stages of IAD are characterised by inflammation including erythema, mild pain or itching, and maceration. As long as the epidermis is still intact, lipophilic and film-forming leave-on products should be used constantly. Periods of occlusion should be avoided or reduced to a minimum [48]. This could be achieved for example by selecting continence products with higher absorbent capacity [82] or by exposing the affected skin areas to air (e.g. after each incontinence episode) by positioning the individual in semi-prone positions regularly [48, 74].

Moderate-to-Severe IAD

Weeping erosions and excoriations should be treated with hydrophilic zinc-containing or film-forming products, for example, which are explicitly intended for this application by the manufacturer [74]. Strongly adhesive zinc preparations should not be used, as they hinder continuous wound inspection and complete removal is hardly possible. In the case of very severe and pronounced inflammation, topical glucocorticoids may be considered for a short time under the supervision of dermatologists [3] but not for routine treatment [74]. The use of water must be reduced as much as possible, and traditional soap must not be used at all [8].

As described before, occlusion must be limited, and the affected skin areas should be exposed to air regularly. If individuals are bedridden, the additional use of a support surface that influences the microclimate (e.g. low-air-loss) can be considered to support IAD healing [22, 48]. In case of very severe IAD that does not improve with treatment, the short-term use of external urine or stool collection devices or indwelling urinary catheters might be considered [48, 74].

Infections

There is a continuum from contamination to local or systematic infection [35]. If local signs of fungal infection, including satellite lesions and/or white scaling, are detected or a fungal infection was confirmed by a microbiological examination, a topical antifungal therapy should be initiated [8, 74]. This may include miconazole, clotrimazole, nystatin or other antifungal agents. Depending on the microbiological results, other topical antimicrobial substances (e.g. polyhexanide) must be used accordingly. In case of severe ulceration, protocols for infected wounds should be followed [8, 35]. The use of antimicrobial or antimycotic substances under occlusive skin protection products has been recommended in the past [83], but it is unclear whether this applies to all products currently available. In any case, manufacturer instructions must be followed.

Conclusions

The number and proportion of older people is expected to increase worldwide. This is likely to be associated with increasing prevalence of functional declines, such as incontinence, increasing the risk for IAD. Owing to its high clinical importance, basic management principles of IAD were only recently included in the World Health Organization (WHO) Integrated Care for Older People (ICOPE) guidance [84]. This approach aims to facilitate the reorientation of health and social services towards more person-centred and coordinated care that supports the optimisation of intrinsic capacity and functional ability for older people living in the community [84]. Since the majority of older people live in the community, IAD prevention and treatment should be integral part of primary care delivered by nurses or other qualified healthcare professionals in this setting [9, 45, 85].

Despite progress in IAD prevention and treatment, several challenges remain. For example, healthcare professionals may have limited knowledge of, and resources for, state-of-the-art continence and skin care, as well as patient education [45, 72, 86, 87]. In the future, ways must be found to provide adequate care for an ever-growing group of older people despite limited skills and resources. There is also limited evidence about the comparative effectiveness of skin cleansing, protection and treatment interventions. Reasons include non-comparable product terminology and heterogeneity of study designs and outcomes [7, 72, 86]. A transparent classification of skin cleansing and caring products need to be developed in the future to enable evidence-based product selection and decision making. Currently it also impossible to make recommendations regarding cost-effectiveness [88].

Research is currently focusing on improving continence care, including the implementation of moisture sensors or digital assistive technology [89, 90]. In the future, it will be critical not only to look at feasibility, but also whether these innovations improve patient outcomes. As already established in paediatrics, absorbent continence products that continuously release small amounts of skin protectants [91, 92] or products directly inhibiting urease [15] could also play a role in the future. However, it is to be expected that the basic principles of IAD management will remain. Therefore, every individual with incontinence should receive appropriate continence promotion, incontinence management and skin protecting skin care regimens. All in all, it is the combination of various individual interventions (‘care bundle’) that promotes or restores skin integrity in older people with incontinence.

Funding

Open Access funding enabled and organized by Projekt DEAL.

Declarations

Funding

No sources of financial assistance were used to assist with the preparation of the manuscript.

Conflicts of interest

J.K. obtained funding from the Federal Ministry of Education and Research, Germany, for conducting a clinical trial about IAD prevention (funding code 01KG2020). J.D. received financial support for lectures, consultations and/or studies from the following companies: 3M, Coloplast, Convatec, Curea, Flen Pharma, Hartmann, Lohmann&Rauscher, Mölnlycke, Smith&Nephew and Urgo. There was no funding for the preparation of this manuscript.

Availability of data and material

Not applicable.

Ethics approval

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Code availability

Not applicable.

Author contributions

J.K. and J.D. designed and drafted the manuscript and are accountable for all aspects of the work.

References

  • 1.World Health Organization. ICD-11 for mortality and morbidity statistics ME07 faecal incontinence. 2025. https://icd.who.int/browse/2025-01/mms/en#790417430. Accessed 17 June 2025.
  • 2.World Health Organization. ICD-11 for mortality and morbidity statistics MF50.2 urinary incontinence. 2025. https://icd.who.int/browse/2025-01/mms/en#766129123. Accessed 17 June 2025.
  • 3.Dissemond J, Assenheimer B, Gerber V, Hintner M, Puntigam MJ, Kolbig N, et al. Moisture-associated skin damage (MASD): a best practice recommendation from Wund-D.A.CH. J Dtsch Dermatol Ges. 2021;19(6):815–25. [DOI] [PubMed] [Google Scholar]
  • 4.Volzer B, El Genedy-Kalyoncu M, Fastner A, Tomova-Simitchieva T, Neumann K, Sill J, et al. Prevalence and associations of xerosis cutis, incontinence-associated dermatitis, skin tears, pressure ulcers, and intertrigo in aged nursing home residents: a representative prevalence study. Int J Nurs Stud. 2023;141: 104472. [DOI] [PubMed] [Google Scholar]
  • 5.Long MA, Reed LA, Dunning K, Ying J. Incontinence-associated dermatitis in a long-term acute care facility. J Wound Ostomy Continence Nurs. 2012;39(3):318–27. [DOI] [PubMed] [Google Scholar]
  • 6.Boronat-Garrido X, Kottner J, Schmitz G, Lahmann N. Incontinence-associated dermatitis in nursing homes: prevalence, severity, and risk factors in residents with urinary and/or fecal incontinence. J Wound Ostomy Continence Nurs. 2016;43(6):630–5. [DOI] [PubMed] [Google Scholar]
  • 7.Van den Bussche K, Kottner J, Beele H, De Meyer D, Dunk AM, Ersser S, et al. Core outcome domains in incontinence-associated dermatitis research. J Adv Nurs. 2018;74(7):1605–17. [DOI] [PubMed] [Google Scholar]
  • 8.Beele H, Smet S, Van Damme N, Beeckman D. Incontinence-associated dermatitis: pathogenesis, contributing factors, prevention and management options. Drugs Aging. 2018;35(1):1–10. [DOI] [PubMed] [Google Scholar]
  • 9.Kottner J, Fastner A, Lintzeri DA, Blume-Peytavi U, Griffiths CEM. Skin health of community-living older people: a scoping review. Arch Dermatol Res. 2024;316(6):319. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Volzer B, El Genedy-Kalyoncu M, Fastner A, Tomova-Simitchieva T, Neumann K, Hillmann K, et al. Enhancing skin health and safety in aged care (SKINCARE trial): a cluster-randomised pragmatic trial. Int J Nurs Stud. 2024;149: 104627. [DOI] [PubMed] [Google Scholar]
  • 11.World Health Organization. ICD-11 for mortality and morbidity statistics EK02.22 irritant contact dermatitis due to incontinence. 2025. https://icd.who.int/browse/2025-01/mms/en#326384712. Accessed 17 June 2025.
  • 12.Nakagami G, Sanada H, Kitagawa A, Tadaka E, Maekawa T, Nagase T, et al. Incontinence induces stratum corneum vulnerability and impairs the skin barrier function in the perianal region. Dermatology. 2006;213(4):293–9. [DOI] [PubMed] [Google Scholar]
  • 13.Warner RR, Stone KJ, Boissy YL. Hydration disrupts human stratum corneum ultrastructure. J Investig Dermatol. 2003;120(2):275–84. [DOI] [PubMed] [Google Scholar]
  • 14.Kohta M, Koyanagi H, Inagaki Y, Nishikawa K, Kobayashi N, Tamura S, et al. Selective detection of urease-producing bacteria on the genital skin surface in patients with incontinence-associated dermatitis. Int Wound J. 2023;20(8):3289–97. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Owen EJ, Heylen RA, Stewart K, Winyard PG, Jenkins ATA. The multi-factorial modes of action of urease in the pathogenesis of incontinence associated dermatitis. Skin Health Dis. 2024;4(3): e349. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Choi EH. Gender, age, and ethnicity as factors that can influence skin pH. Curr Probl Dermatol. 2018;54:48–53. [DOI] [PubMed] [Google Scholar]
  • 17.Perkins MA, Osterhues MA, Farage MA, Robinson MK. A noninvasive method to assess skin irritation and compromised skin conditions using simple tape adsorption of molecular markers of inflammation. Skin Res Technol. 2001;7(4):227–37. [DOI] [PubMed] [Google Scholar]
  • 18.Koudounas S, Bader DL, Voegeli D. Investigating the release of inflammatory cytokines in a human model of incontinence-associated dermatitis. J Tissue Viability. 2021;30(3):427–33. [DOI] [PubMed] [Google Scholar]
  • 19.Mugita Y, Minematsu T, Huang L, Nakagami G, Kishi C, Ichikawa Y, et al. Histopathology of incontinence-associated skin lesions: inner tissue damage due to invasion of proteolytic enzymes and bacteria in macerated rat skin. PLoS ONE. 2015;10(9): e0138117. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Horinouchi A, Mugita Y, Tomida S, Takizawa C, Haba D, Sanada H, et al. Incontinence-associated dermatitis-like skin changes induced by the application of absorbent pads containing bacteria and artificial urine in rats. Exp Dermatol. 2024;33(11): e70013. [DOI] [PubMed] [Google Scholar]
  • 21.Wohlrab J, Gebert A, Neubert RHH. Lipids in the skin and pH. Curr Probl Dermatol. 2018;54:64–70. [DOI] [PubMed] [Google Scholar]
  • 22.Kottner J, Black J, Call E, Gefen A, Santamaria N. Microclimate: a critical review in the context of pressure ulcer prevention. Clin Biomech (Bristol). 2018;59:62–70. [DOI] [PubMed] [Google Scholar]
  • 23.Deprez J, Kottner J, Eilegard Wallin A, Ohde N, Baath C, Hommel A, et al. What are the prognostic factors for the development of incontinence-associated dermatitis (IAD): a protocol for a systematic review and meta-analysis. BMJ Open. 2023;13(7): e073115. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Rodriguez-Palma M, Verdu-Soriano J, Soldevilla-Agreda JJ, Pancorbo-Hidalgo PL, Garcia-Fernandez FP. Conceptual framework for incontinence-associated dermatitis based on scoping review and expert consensus process. J Wound Ostomy Continence Nurs. 2021;48(3):239–50. [DOI] [PubMed] [Google Scholar]
  • 25.Campbell JL, Coyer FM, Osborne SR. Incontinence-associated dermatitis: a cross-sectional prevalence study in the Australian acute care hospital setting. Int Wound J. 2016;13(3):403–11. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Kottner J, Blume-Peytavi U, Lohrmann C, Halfens R. Associations between individual characteristics and incontinence-associated dermatitis: a secondary data analysis of a multi-centre prevalence study. Int J Nurs Stud. 2014;51(10):1373–80. [DOI] [PubMed] [Google Scholar]
  • 27.Deprez J, Ohde N, Eilegard Wallin A, Baath C, Hommel A, Hultin L, et al. Prognostic factors for the development of incontinence-associated dermatitis (IAD): a systematic review. Int Wound J. 2024;21(7): e14962. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Wang G, Wang X, Wang H, Wang L, Li W. Risk factors for incontinence-associated dermatitis in critically ill patients with incontinence: a systematic review and meta-analysis. J Wound Ostomy Continence Nurs. 2024;51(4):313–23. [DOI] [PubMed] [Google Scholar]
  • 29.Jiang H, Shen J, Lin H, Xu Q, Li Y, Chen L. Risk factors of incontinence-associated dermatitis among critically ill patients: a systematic review and meta-analysis. Front Med (Lausanne). 2023;10:1146697. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Minematsu T, Yamamoto Y, Nagase T, Naito A, Takehara K, Iizaka S, et al. Aging enhances maceration-induced ultrastructural alteration of the epidermis and impairment of skin barrier function. J Dermatol Sci. 2011;62(3):160–8. [DOI] [PubMed] [Google Scholar]
  • 31.Bermudez NM, Sa BC, Yaghi M, Hargis A, Elman SA. Incontinence-associated dermatitis: a practical guide for the consulting dermatologist. Curr Dermatol Rep. 2023;12(4):291–5. [Google Scholar]
  • 32.Beeckman D, Van den Bussche K, Alves P, Arnold Long MC, Beele H, Ciprandi G, et al. Towards an international language for incontinence-associated dermatitis (IAD): design and evaluation of psychometric properties of the Ghent Global IAD Categorization Tool (GLOBIAD) in 30 countries. Br J Dermatol. 2018;178(6):1331–40. [DOI] [PubMed] [Google Scholar]
  • 33.Kottner J, El Genedy-Kalyoncu M, Dissemond J. Incontinence-associated dermatitis: a frequent and overlooked problem in older people. MMW Fortschr Med. 2024;166(15):48–51. [DOI] [PubMed] [Google Scholar]
  • 34.Campbell JL, Coyer FM, Mudge AM, Robertson IM, Osborne SR. Candida albicans colonisation, continence status and incontinence-associated dermatitis in the acute care setting: a pilot study. Int Wound J. 2017;14(3):488–95. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Dissemond J, Rembe JD, Assenheimer B, Barysch-Bonderer M, Gerber V, Kottner J, et al. Systematics, diagnosis and treatment of wound infections in chronic wounds: a position paper from WundDACH. J Dtsch Dermatol Ges. 2025;23(5):565–574. [DOI] [PMC free article] [PubMed]
  • 36.De Meyer D, Gabriel S, Kottner J, Van Damme N, Van den Bussche K, Verhaeghe S, et al. Outcome measurement instruments for erythema associated with incontinence-associated dermatitis: systematic review. J Adv Nurs. 2019;75(11):2393–417. [DOI] [PubMed] [Google Scholar]
  • 37.Ghent University Hospital. Incontinence—associated dermatitis (IAD) tools. 2025. https://www.skintghent.be/en/onderzoek/Tools/2/incontinence-associated-dermatitis-iad. Accessed 17 June 2025.
  • 38.Foureur N, Vanzo B, Meaume S, Senet P. Prospective aetiological study of diaper dermatitis in the elderly. Br J Dermatol. 2006;155(5):941–6. [DOI] [PubMed] [Google Scholar]
  • 39.Bender JK, Faergemann J, Skold M. Skin health connected to the use of absorbent hygiene products: a review. Dermatol Ther (Heidelb). 2017;7(3):319–30. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Eubel J, Diepgen TL, Weisshaar E. Allergic diseases in the genital area. Hautarzt. 2015;66(1):45–52. [DOI] [PubMed] [Google Scholar]
  • 41.World Health Organization. ICD-11 for mortality and morbidity statistics EK02.20 intertriginous dermatitis due to friction, sweating or contact with body fluids. 2025. https://icd.who.int/browse/2025-01/mms/en#937488272. Accessed 17 June 2025.
  • 42.Everink IHJ, Kottner J, van Haastregt JCM, Halfens R, Schols J. Skin areas, clinical severity, duration and risk factors of intertrigo: a secondary data analysis. J Tissue Viability. 2021;30(1):102–7. [DOI] [PubMed] [Google Scholar]
  • 43.Gefen A, Brienza DM, Cuddigan J, Haesler E, Kottner J. Our contemporary understanding of the aetiology of pressure ulcers/pressure injuries. Int Wound J. 2022;19(3):692–704. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.World Health Organization. ICD-11 for mortality and morbidity statistics EH90.1 pressure ulceration grade 2. 2025. https://icd.who.int/browse/2025-01/mms/en#1944913975. Accessed 17 June 2025.
  • 45.Woodward S, Graham T, Sooriah S, Beeckman D, Chatterton C, Fader M, et al. Prevention and treatment of incontinence-associated dermatitis through a codesigned manual (PREVENT-IAD): a study protocol for a feasibility cluster randomised controlled trial with a nested process evaluation. BMJ Open. 2024;14(12): e092338. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Dowling-Castronovo A, Long J, Bradway C. Urinary incontinence in the older adult. In: Boltz M, editor. Evidence-based geriatric nursing protocols for best practice. New York: Springer; 2021. p. 439–66. [Google Scholar]
  • 47.Assmann SL, Keszthelyi D, Kleijnen J, Anastasiou F, Bradshaw E, Brannigan AE, et al. Guideline for the diagnosis and treatment of faecal incontinence—a UEG/ESCP/ESNM/ESPCG collaboration. United Eur Gastroenterol J. 2022;10(3):251–86. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.British Columbia Provincial Nursing Skin & Wound Committee. Guideline: assessment, prevention and treatment of moisture associated skin damage (MASD) in adults and children. 2019. Source: https://www.clwk.ca/get-resource/moisture-associated-skin-damage-masd/. Accessed 17 June 2025.
  • 49.Naumann G, Aigmuller T, Bader W, Bauer R, Beilecke K, Betschart Meier C, et al. Diagnosis and therapy of female urinary incontinence. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015/091, January 2022): part 1 with recommendations on diagnostics and conservative and medical treatment. Geburtshilfe Frauenheilkd. 2023;83(4):377–409. [DOI] [PMC free article] [PubMed]
  • 50.Maeda K, Mimura T, Yoshioka K, Seki M, Katsuno H, Takao Y, et al. Japanese practice guidelines for fecal incontinence part 2-examination and conservative treatment for fecal incontinence—English version. J Anus Rectum Colon. 2021;5(1):67–83. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 51.Murphy C, Fader M, Bliss DZ, Buckley B, Cockerell R, Cottenden A, et al. Management using continence products: report of the 7th international consultation on incontinence. Continence-Neth. 2023;8:101049. 10.1016/j.cont.2023.101049.
  • 52.Gray M, Kent D, Ermer-Seltun J, McNichol L. Assessment, selection, use, and evaluation of body-worn absorbent products for adults with incontinence: a WOCN society consensus conference. J Wound Ostomy Continence Nurs. 2018;45(3):243–64. [DOI] [PubMed] [Google Scholar]
  • 53.Mugita Y, Koudounas S, Nakagami G, Weller C, Sanada H. Assessing absorbent products’ effectiveness for the prevention and management of incontinence-associated dermatitis caused by urinary, faecal or double adult incontinence: a systematic review. J Tissue Viability. 2021;30(4):599–607. [DOI] [PubMed] [Google Scholar]
  • 54.Marsman DS, Rai P, Felter SP. Dermal safety evaluation: use of disposible diaper products in the elderly. In: Farage MA, editor. Textbook of ageing skin. 2nd ed. Berlin: Springer; 2015. p. 1457–71. [Google Scholar]
  • 55.International Consultation on Incontinence (ICI), International Continence Society (ICS), University of Southampton, London UC. Continence Product Advisor. 2025. www.continenceproductadvisor.org. Accessed 17 June 2025.
  • 56.Dey S, Purdon M, Kirsch T, Helbich H, Kerr K, Li L, et al. Exposure factor considerations for safety evaluation of modern disposable diapers. Regul Toxicol Pharmacol. 2016;81:183–93. [DOI] [PubMed] [Google Scholar]
  • 57.Fernando J, Wagg A. What wait time in a soiled pad is acceptable to older patients and their direct caregivers? J Wound Ostomy Continence Nurs. 2017;44(6):562–7. [DOI] [PubMed] [Google Scholar]
  • 58.El Genedy-Kalyoncu M, Fastner A, Volzer B, Raeder K, Neumann K, Lahmann NA, et al. Comparison of two skin protection regimes for the prevention of incontinence-associated dermatitis in geriatric care (PID): a study protocol for an exploratory randomised controlled pragmatic trial. BMJ Open. 2022;12(9): e065909. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 59.De Paepe K, Sieg A, Le Meur M, Rogiers V. Silicones as nonocclusive topical agents. Skin Pharmacol Physiol. 2014;27(3):164–71. [DOI] [PubMed] [Google Scholar]
  • 60.Gefen A. The bioengineering theory of the key modes of action of a cyanoacrylate liquid skin protectant. Int Wound J. 2020;17(5):1396–404. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 61.Woo K, Hill R, LeBlanc K, Schultz G, Swanson T, Weir D, et al. Technological features of advanced skin protectants and an examination of the evidence base. J Wound Care. 2019;28(2):110–25. [DOI] [PubMed] [Google Scholar]
  • 62.Wigger-Alberti W, Elsner P. Petrolatum prevents irritation in a human cumulative exposure model in vivo. Dermatology. 1997;194(3):247–50. [DOI] [PubMed] [Google Scholar]
  • 63.Rieger T, Teichmann A, Richter H, Schanzer S, Sterry W, Lademann J. Evaluation of barrier creams—introduction and comparison of 3 in vivo methods. Contact Dermatitis. 2007;56(6):347–54. [DOI] [PubMed] [Google Scholar]
  • 64.Lehmann L, Gloor M, Schlierbach S, Gehring W. Stability and occlusivity of dermatological ointments. Z Hautkr. 1997;72:585–90. [Google Scholar]
  • 65.Kamrani P, Hedrick J, Marks JG, Zaenglein AL. Petroleum jelly: a comprehensive review of its history, uses, and safety. J Am Acad Dermatol. 2024;90(4):807–13. [DOI] [PubMed] [Google Scholar]
  • 66.Pather P, Hines S, Kynoch K, Coyer F. Effectiveness of topical skin products in the treatment and prevention of incontinence-associated dermatitis: a systematic review. JBI Database Syst Rev Implement Rep. 2017;15(5):1473–96. [DOI] [PubMed] [Google Scholar]
  • 67.Patini G. Problems with skin protectants part I: a discussion. Cosm Toilet. 2014;129(8):16–24. [Google Scholar]
  • 68.Surber C, Kottner J. Skin care products: what do they promise, what do they deliver. J Tissue Viability. 2017;26(1):29–36. [DOI] [PubMed] [Google Scholar]
  • 69.Zhai H, Brachman F, Pelosi A, Anigbogu A, Ramos MB, Torralba MC, et al. A bioengineering study on the efficacy of a skin protectant lotion in preventing SLS-induced dermatitis. Skin Res Technol. 2000;6(2):77–80. [DOI] [PubMed] [Google Scholar]
  • 70.Fastner A, Hauss A, Kottner J. Skin assessments and interventions for maintaining skin integrity in nursing practice: an umbrella review. Int J Nurs Stud. 2023;143: 104495. [DOI] [PubMed] [Google Scholar]
  • 71.Rajkumar J, Chandan N, Lio P, Shi V. The skin barrier and moisturization: function, disruption, and mechanisms of repair. Skin Pharmacol Physiol. 2023;36(4):174–85. [DOI] [PubMed] [Google Scholar]
  • 72.Kottner J, Surber C. Skin care in nursing: a critical discussion of nursing practice and research. Int J Nurs Stud. 2016;61:20–8. [DOI] [PubMed] [Google Scholar]
  • 73.Cohen SR, Cardenas-de la Garza JA, Dekker P, Haidari W, Chisolm SS, Taylor SL, et al. Allergic contact dermatitis secondary to moisturizers. J Cutan Med Surg. 2020;24(4):350–9. [DOI] [PubMed] [Google Scholar]
  • 74.Doughty D, Junkin J, Kurz P, Selekof J, Gray M, Fader M, et al. Incontinence-associated dermatitis: consensus statements, evidence-based guidelines for prevention and treatment, and current challenges. J Wound Ostomy Continence Nurs. 2012;39(3):303–15 (quiz 16–7). [DOI] [PubMed] [Google Scholar]
  • 75.Friedman M, Wolf R. Chemistry of soaps and detergents: various types of commercial products and their ingredients. Clin Dermatol. 1996;14(1):7–13. [DOI] [PubMed] [Google Scholar]
  • 76.Ananthapadmanabhan KP, Mukherjee S, Chandar P. Stratum corneum fatty acids: their critical role in preserving barrier integrity during cleansing. Int J Cosmet Sci. 2013;35(4):337–45. [DOI] [PubMed] [Google Scholar]
  • 77.Castanedo-Cazares JP, Cortes-Garcia JD, Cornejo-Guerrero MF, Torres-Alvarez B, Hernandez-Blanco D. Study of the cytotoxic and irritant effects of skin cleansing soaps. Gac Med Mex. 2020;156(5):418–23. [DOI] [PubMed] [Google Scholar]
  • 78.Williams AC, Barry BW. Penetration enhancers. Adv Drug Deliver Rev. 2012;64:128–37. [DOI] [PubMed] [Google Scholar]
  • 79.Konya I, Yoshida M, Watanabe C, Morita A, Yano R. Effects of consecutive bed bathing with weak versus ordinary pressure on skin barrier recovery of hospitalised older adults: a within-person randomised controlled trial. J Tissue Viability. 2024;33(3):504–10. [DOI] [PubMed] [Google Scholar]
  • 80.Ananthapadmanabhan KP, Subramanyan K, Nole G. A global perspective on caring for healthy stratum corneum by mitigating the effects of daily cleansing: report from an expert dermatology symposium. Br J Dermatol. 2013;168(Suppl 1):1–9. [DOI] [PubMed] [Google Scholar]
  • 81.Petrovic T, Poljarevic J, Nikolic S, Stojkovic-Filipovic J, Mihajlovic-Lalic LE. A review of the key ingredients in industrial formulations of baby wet wipes. Int J Dermatol. 2024;63(12):1668–75. [DOI] [PubMed] [Google Scholar]
  • 82.Sugama J, Sanada H, Shigeta Y, Nakagami G, Konya C. Efficacy of an improved absorbent pad on incontinence-associated dermatitis in older women: cluster randomized controlled trial. BMC Geriatr. 2012;29(12):22. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 83.Farage MA, Miller KW, Berardesca E, Maibach HI. Incontinence in the aged: contact dermatitis and other cutaneous consequences. Contact Dermatitis. 2007;57(4):211–7. [DOI] [PubMed] [Google Scholar]
  • 84.World Health Organization. Integrated care for older people (ICOPE): guidance for person-centred assessment and pathways in primary care, 2nd edn. (WHO) Geneva; 2024.
  • 85.Kottner J. Nurses as skin care experts: do we have the evidence to support practice? Int J Nurs Stud. 2023;145: 104534. [DOI] [PubMed] [Google Scholar]
  • 86.Kottner J, Beeckman D. Doing more good than harm: in search of best skin care practice: a special issue. Int J Nurs Stud. 2024;153: 104725. [DOI] [PubMed] [Google Scholar]
  • 87.Cowdell F, Heague M, Dyson J. Barriers and facilitators to skin hygiene care and emollient use in residential care homes: instrument design and survey. Int J Older People Nurs. 2023;18(4): e12550. [DOI] [PubMed] [Google Scholar]
  • 88.Cunich M, Barakat-Johnson M, Lai M, Arora S, Church J, Basjarahil S, et al. The costs, health outcomes and cost-effectiveness of interventions for the prevention and treatment of incontinence-associated dermatitis: a systematic review. Int J Nurs Stud. 2022;129: 104216. [DOI] [PubMed] [Google Scholar]
  • 89.Hofstetter S, Ritter-Herschbach M, Behr D, Jahn P. Ultrasound-assisted continence care support in an inpatient care setting: protocol for a pilot implementation study. JMIR Res Protoc. 2023;13(12): e47025. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 90.Xu K, Fujita Y, Lu Y, Honda S, Shiomi M, Arie T, et al. A wearable body condition sensor system with wireless feedback alarm functions. Adv Mater. 2021;33(18): e2008701. [DOI] [PubMed] [Google Scholar]
  • 91.O'Connor RJ, Visscher MO, Narendran V, Wang Y, Wiesemann F, Carr AN. Clinical evaluation of a diaper containing a shea butter-based emollient and impact on diapered skin erythema. Pediatr Dermatol. 2025;42(3):532–538. [DOI] [PMC free article] [PubMed]
  • 92.Reick S, Müller G, Hering T. Nursing interventions in children with diaper dermatitis (incontinence-associated dermatitis)-a systematic review. Monatsschr Kinderh. 2021;169(9):844–53. [Google Scholar]

Articles from Drugs & Aging are provided here courtesy of Springer

RESOURCES