Incontinence-Associated Skin Damage: Prevention and Care

What IAD looks like

IAD affects skin that has been exposed to moisture, and typically appears in the area covered by the pad or brief. Signs range from mild to severe:

• Redness: a diffuse, pink to bright red area, with poorly defined edges, sometimes patchy. On darker skin, redness may be harder to see; look for a purple, grey, brown or darker patch, shininess, warmth or swelling, and ask about tenderness.
• Shiny, glazed or "wet" skin.
• Burning, itching or soreness, making the person wince during cleaning.
• Swelling or tenderness.
• Small blisters or fluid-filled bumps.
• Superficial erosions: raw, shallow areas where the top layer of skin has come away, often weeping.
• Peeling or cracking skin.
• Secondary infection: red spots at the edge (satellite lesions) suggesting a fungal infection such as candida; yellow crusts or pus suggest bacterial infection.

It usually spreads across the buttocks, groin folds, genital area, inner thighs and lower back, in a mirror-image pattern, and may extend to the rim of the anus.

Why it happens

• Wetness softens the skin (maceration) and weakens its barrier.
• Urine raises the skin's pH and contains ammonia from urea breakdown, particularly when mixed with stool.
• Stool, particularly loose stool, contains enzymes that digest skin proteins. Diarrhoea and frequent loose stool are especially damaging.
• Friction and rubbing from pads, cleaning and clothing.
• Heat and lack of airflow under occlusive products.
• Fungal and bacterial overgrowth in a warm, moist environment.
• Infrequent changes, harsh soaps and alcohol wipes.
• Poor nutrition, dehydration, diabetes, poor circulation, steroid or immune-suppressing treatment and ageing skin.
• Immobility.

IAD versus pressure ulcers

It is important to tell the two apart, since treatment differs, though they often occur together.

IAD - Caused by moisture and irritants. - Usually over a wide, diffuse area with indistinct edges, in the groin, buttock folds and inner thighs. - Redness, shiny skin, superficial, shallow damage; typically no dead tissue or deep wound. - Often a mirror-image pattern. - Painful, burning, itchy.

Pressure ulcers - Caused by pressure and shearing over bony areas such as the tailbone, hips, heels and elbows. - Usually a well-defined area, often over a bony prominence, and may be a patch of persistent redness that does not blanch when pressed, a dark purple or maroon area, a blister or a deeper crater. - Can extend to the deeper layers, with dead tissue, depth, slough or black scab.

See pressure ulcers: stages, wound care and prevention and preventing bedsores at home. If you cannot tell, ask a nurse. Any dark, deep or black area, or any skin over a bony point that does not fade with gentle pressure, needs prompt professional assessment.

Prevention: the daily routine

### 1. Manage the incontinence itself

• Seek assessment and treatment of the underlying cause; see incontinence in older adults: causes and types.
• Use toileting routines and bladder training where possible; see bladder training and timed toileting.
• Treat constipation and diarrhoea; see bowel incontinence and constipation in later life and diarrhoea and dehydration in seniors.
• Choose well-fitting, appropriately absorbent, breathable products; see pull-ups or briefs: choosing the right product.

### 2. Change promptly

• Change after each bowel movement, and when wet, not just at fixed times.
• Check often; use wetness indicators if available.

### 3. Cleanse gently

• Use warm water and a soft cloth, or alcohol-free, fragrance-free wipes or a skin-friendly no-rinse cleanser; avoid soap and harsh wipes.
• Pat dry; never rub.
• See wipes and perineal hygiene done gently.

### 4. Protect

• Apply a thin layer of barrier cream or film as advised; see barrier creams and skin care under pads.

### 5. Check the skin daily

• Look at all of the skin in the covered area, including folds, and record changes.

### 6. Support the skin from within

• Make sure the person eats well and drinks enough; see hydration for older adults, malnutrition in older adults and how much protein do seniors need.
• Manage diabetes and other conditions.

### 7. Keep the environment friendly to skin

• Use breathable linen, no plastic against skin, fewer layers, and wrinkle-free beds; see bed linen for sensitive older skin and mattress protectors for incontinence.
• Keep rooms cool; see summer heat and bedridden care.
• Reposition regularly; see turning a bedridden patient and positioning a bedridden parent.
• Use pressure-relieving surfaces for people at risk; see air mattress for pressure sores.

Caring for IAD at home

If the skin is red or sore, act early:

1. Increase the frequency of checks and changes, and clean immediately after soiling. 2. Cleanse very gently with warm water and a soft cloth; do not scrub; consider a skin cleanser designed for the purpose. Use a squeezable bottle to rinse rather than rubbing. 3. Pat dry fully, or use a cool setting on a hair dryer held well away if skin is very sore, or let air dry for a few minutes. 4. Apply barrier product in a thin layer, as the nurse advises. For weeping or raw skin, the nurse may suggest a different product, such as one that is applied to broken skin, or a film-forming barrier. 5. Give the skin air: where practical and private, allow periods without a pad, on top of a disposable underpad, under supervision, while keeping warm and covered. Ask the nurse. 6. Do not apply steroid, antifungal or antibiotic creams unless prescribed. Do not use home remedies on broken skin. 7. Avoid plastic and tight clothing. 8. Relieve pain as the doctor advises. 9. Keep nails short to avoid scratching. 10. Check progress daily. Mild IAD often improves within days with good care; if there is no improvement in three to five days, or it worsens, call the nurse or doctor.

Infection signs

• Fungal (yeast) infection: bright red rash with small red bumps or pustules spreading at the edges, particularly in folds, itchy or burning. It needs an antifungal prescribed by a doctor or nurse.
• Bacterial infection: increased pain, swelling, warmth, yellow crusts, pus, a foul smell, fever.
• Spreading redness, red streaks, fever, confusion, shivering or feeling very unwell are emergencies; see knowing when to call the doctor.

Special situations

• Dementia: the person may not report pain, may resist cleaning, may pick at the skin; calm routines and a gentle approach help; see incontinence and dementia: routines and reassurance.
• Diarrhoea: a stool management plan, perhaps with a doctor's input on cause, is key, since loose stool is the most damaging.
• Catheter or stoma: extra care around the sites; see catheter care basics for families.
• Diabetes: slower healing, higher infection risk.
• Skin folds and obesity: moisture is trapped; dry folds and use moisture-wicking cloth as advised.
• Dark skin: redness may be less visible; use touch for warmth and swelling, and look for shine and colour change.
• Palliative care and end of life: skin may be fragile; comfort-focused care; see palliative care at home: what it is and how to arrange it.

When to ask a professional

Ask a nurse or doctor to assess any skin that is raw, blistered, weeping, very sore, or that does not improve in a few days. Ask for an assessment of pressure injury risk. Ask a doctor about diarrhoea, fungal infection and underlying causes of incontinence. Seek urgent help for fever, spreading redness, pus, a dark, deep or black wound, severe pain, confusion or no urine for many hours; call 112 for emergencies.