Sore skin with incontinence: recognising, preventing and treating IAD

Key facts at a glance

• Incontinence-associated dermatitis (IAD) is an irritation of the skin by urine and stool – not an allergy and not a pressure ulcer
• It begins as a diffuse, blanchable redness and can progress to open, weeping areas
• Three steps help: remove excreta immediately, cleanse gently without soap, apply skin protection
• Rubbing, cloth washcloths and doubled-up pads do harm
• With broken skin, pustules or whitish deposits, the area belongs in medical or nursing hands

Red, burning skin in the nappy area is so common with incontinence that it is often accepted as inevitable. It is not. It has a name, a cause and a clear counter-strategy – and the earlier you react, the simpler it is.

What is actually happening

The Hamburg Wound Centre defines it in its treatment standard as follows:

“Incontinence-associated dermatitis (IAD) is an irritant toxic contact dermatitis.”

In plain terms: the skin does not become ill, it becomes irritated – from outside, through constant contact with urine and stool. Three mechanisms work together here, as the international expert panel around Dimitri Beeckman describes in its best practice recommendation updated in 2026:

• Moisture. The top layer of skin swells. Swollen skin is more permeable to irritants and considerably more sensitive to friction – from clothing, pad or bedding.
• pH shift. Healthy skin is slightly acidic, with a pH of roughly 4 to 6. Bacteria on the skin convert the urea from urine into ammonia, which is alkaline. The acid mantle is lost.
• Digestive enzymes. Stool contains enzymes that break down proteins and fats – including those of the skin. This is why faecal incontinence is the stronger risk factor, and the combination with urine is the most unfavourable, because urine additionally activates the stool enzymes.

How widespread the problem is depends on the setting: the expert recommendation cites surveys ranging from around 4 percent of patients in Welsh hospitals to 21 percent of residents in Belgian nursing homes.

Who is particularly at risk

The Hamburg standard names as risk factors, among others:

• faecal incontinence or combined faecal and urinary incontinence
• liquid stool with a high frequency of emptying – the expert recommendation sets the threshold at three or more loose stools a day
• heavy skin moisture, for example with complete urinary incontinence
• occlusive, i.e. airtight, incontinence products
• older age, limited mobility, need for care
• medicines such as antibiotics or immunosuppressants
• poor skin, nutritional or hydration status

One point from the expert recommendation deserves emphasis: IAD can also develop when someone is not incontinent – as soon as excreta remain on the skin for other reasons, for example because the affected area can no longer be reached and cleaned independently after going to the toilet.

What it looks like – and how it is classified

The internationally used classification scheme is called GLOBIAD. It distinguishes according to two questions: is the skin still intact? And are there signs of infection?

• At risk – skin intact, no redness, but incontinence present
• Category 1A – redness with intact skin, without signs of infection
• Category 1B – persistent redness with clinical signs of infection
• Category 2A – skin loss, i.e. open areas, without signs of infection
• Category 2B – skin loss with signs of infection

Typical complaints are burning, stinging, itching and pain. In advanced IAD, the skin weeps, glistens and may bleed in pinpoints. According to the expert recommendation, signs of a fungal infection are small pustules at the edge of the reddened area and whitish scaling of the surrounding skin – then an antifungal is needed, skin protection alone is not enough.

Pressure ulcer or IAD? The most important difference

Both look similar to laypeople but need different treatment. The expert recommendation calls the confusion with a pressure ulcer a persistent, clinically significant problem. The Hamburg standard summarises the distinguishing features:

• Location. A pressure ulcer sits over a bony prominence – tailbone, sitting bone, heel. IAD sits where moisture reaches: buttocks, groin, perineum, skin folds, often mirrored on both sides.
• Shape. The pressure ulcer is locally confined with pronounced edges. IAD is diffuse, spread over an area, with irregular edges and often softened skin at the margin.
• Colour. The redness of a pressure ulcer cannot be blanched with a finger. IAD redness is blanchable and often uneven.
• Tissue. Dead tissue is possible with a pressure ulcer, not with IAD.

Both can be present at the same time – and IAD favours the development of a pressure ulcer, because softened skin offers less resistance to pressure and shear forces. Anyone who is unsure calls in a nursing professional or wound specialist instead of guessing.

Preventing and treating: three steps

1. Excreta away from the skin

The Hamburg standard requires: remove excreta immediately and dry the skin immediately. In everyday life this means aligning the changing rhythm to the incontinence, not the clock – and acting promptly after a bowel movement. Anyone choosing pads should look for breathable products with superabsorbent. The expert recommendation expressly advises against two common habits: layering several pads on top of each other and using sanitary towels. Both keep moisture on the skin. Why higher absorbency is not automatically better is explained in our article on pads, pants and briefs.

2. Cleanse gently – without soap

The expert recommendation is unambiguous here: no soap and water, because soap damages the skin further. Instead:

• a mild, pH skin-neutral, fragrance-free cleanser – for rinsing off or as a leave-on product – or a suitable incontinence wet wipe
• applied with a disposable wash mitt; reusable cloth washcloths increase friction and transfer germs
• when showering or bathing, only a mild wash gel, no bath additives, salts or disinfectants
• then pat dry carefully, do not rub – with special attention to skin folds

The Hamburg standard adds: use water sparingly and no alkaline soaps or products with anionic surfactants.

3. Apply skin protection

A skin protection product places a barrier between skin and excreta. The expert recommendation distinguishes:

• Skin barrier films based on acrylate terpolymers or silicones – transparent, the skin remains assessable; as spray, wipe or applicator
• Creams and ointments – effective only if they contain a recognised barrier ingredient, such as petrolatum, zinc oxide or dimethicone
• Zinc oxide pastes are not recommended for routine care: they are hard to remove, mix with stool and cover the skin so that changes can no longer be seen

Three rules apply to all products: apply as often as the manufacturer specifies; to all skin areas that may come into contact with excreta; and thinly – thick, greasy layers clog the pad so that it absorbs less liquid and the skin stays moist all the more.

For skin that is already broken, the expert recommendation names special elastomeric skin protection products, for example cyanoacrylate-based, that support the rebuilding of the epidermis. This is a decision for nursing professionals or wound specialists.

What else helps

The Hamburg standard lists further measures that may be considered depending on the situation: drainage aids such as urinary sheaths for men or faecal collectors and faecal management systems for severe faecal incontinence, breathable, absorbent bed pads and side or prone positioning for bedridden people. If there is no improvement, this includes clarifying a superinfection with bacteria or fungi – and then, if necessary, medically prescribed treatment, in the case of severe inflammation also with cortisone.

The German expert standard “Maintaining and promoting skin integrity in nursing care” of the DNQP formulates the goal for everyone involved as follows:

“Every person with a need for nursing support and a skin-related risk or problem addressed in this expert standard receives nursing interventions that maintain and promote skin integrity.”

For family carers this means: you may expect guidance on skin care from a home care service – the standard expressly provides for information, training and advice for family members.

When you should get help

• if the redness does not recede after a few days despite consistent care
• with open, weeping or bleeding areas
• with pustules at the edge or whitish deposits – suspected fungus
• with a redness that cannot be blanched – suspected pressure ulcer
• with fever or severe pain

Frequently asked questions

Is baby powder a good idea?

Powder is not one of the recommended forms of skin protection. The expert recommendation names skin barrier films as well as creams and ointments with a barrier effect – powder does not appear in it.

How often should I apply skin protection cream?

As often as the manufacturer states; many products are designed to last several changes. More important than the frequency is that the layer stays thin and covers all at-risk areas.

Can I use wet wipes?

Yes, if they are intended for incontinence care, fragrance-free and pH skin-neutral. The Hamburg standard expressly names wipes that additionally contain moisturising and skin-protecting substances.

Does the insurance fund pay for skin protection and cleansing foam?

Usually not. Skin care products are neither medical aids under Section 33 SGB V nor do they belong to consumable care aids – they are paid for privately. Absorbent aids are different: these are available on prescription. With a recognised care level, disposable gloves and bed protection pads are added from the care package.

How do I know whether it is a pressure ulcer?

Press on the redness with your finger. If it briefly turns pale, this suggests IAD. If it stays red unchanged, especially over a bone, this is a suspected pressure ulcer – then please seek nursing or medical advice immediately.

Your next step

We stock cleansing foam, wash lotions, disposable wash mitts, skin protection creams and skin protection spray from Hartmann and Seni as well as breathable pads, pants and briefs in all absorbency levels. With a care level, we put together disposable gloves and bed protection pads as a monthly care package for you.

Sources

• Incontinence-Associated Dermatitis: Moving prevention forward – Best Practice Update 2026, Beeckman D. et al., Wounds International, London 2026
• Treatment standard incontinence-associated dermatitis (IAD), WZ-BS-012 V02, Wundzentrum Hamburg e.V., 2017 (in German)
• Expert standard on maintaining and promoting skin integrity in nursing care, German Network for Quality Development in Nursing (DNQP), Osnabrück, May 2023 (in German)