Incontinence-Associated Dermatitis: How to Tell It Apart from a Pressure Injury

Quick answer: incontinence-associated dermatitis (IAD) is skin damage caused by prolonged contact with urine or stool, and it is often mistaken for a pressure injury. A Ghent University case-control study of 206 ICU patients (NCT02996357) set out to identify which patients are most at risk. Results are not posted, but the prevention basics are well established: clean gently, protect the skin, and manage the moisture at source.

What is IAD, and why is it confused with pressure injury?

IAD is a form of moisture-associated skin damage. Repeated exposure to urine or stool raises the skin's pH, breaks down its barrier function, and the enzymes in stool then digest the softened surface. What you see is redness, often with a poorly defined border, that may go on to weep, erode or become secondarily infected with candida.

It gets misdiagnosed as a pressure injury constantly, and the distinction matters because the treatment differs:

• IAD appears where moisture sits: the buttocks, groin, perineum, inner thighs, skin folds. Edges tend to be diffuse and the damage is usually shallow and patchy.
• Pressure injury appears over a bony prominence such as the sacrum or heel. Edges tend to be more defined and the damage can extend deep into tissue.

The two also coexist. IAD damages the skin barrier, and damaged skin tolerates pressure and shear far less well, which is one reason IAD is treated as a pressure injury risk factor rather than a separate nuisance. For the offloading side of the problem, see what the evidence says about preventing pressure injuries.

What did the study look at?

University Ghent registered NCT02996357, a matched case-control study running from October 2016 to May 2017 in ICU patients with faecal incontinence. It enrolled 206 patients and assessed 19 candidate risk factors at a single time point, drawing on direct skin assessment, patient records, observation and routine bloods.

The factors examined were broad, and read as a list of the things that plausibly matter at the bedside: illness severity (APACHE II), mechanical ventilation, dialysis, infection, fever, antibiotics, steroids, malnutrition, diabetes, low haemoglobin, diarrhoea, Clostridioides difficile, the type of continence products used, whether washing was done with water or with wipes and cleansers, mechanical chafing, and diminished cognitive awareness.

Two honest caveats. This was an observational design, so anything it finds is an association, not proof of cause. And the registry shows no posted results, so nobody should quote a risk factor ranking from it today.

What actually prevents IAD?

The measures below are standard continence skin care and do not depend on this study's results:

• Manage the source. Treating diarrhoea, reviewing medications and constipation management, and containing output does more than any cream.
• Clean gently, not vigorously. Soap and water plus friction strips the barrier further. A pH-balanced perineal cleanser and patting dry is the standard approach.
• Apply a barrier. Zinc oxide, dimethicone or a barrier film puts a layer between skin and effluent. Apply it thinly and consistently rather than heavily and occasionally. We explain how these work in the role of skin barrier films in preventing IAD and pressure injuries.
• Get the absorbent product right. An overly occlusive or wrongly sized product traps moisture against skin. Fit and breathability matter.
• Inspect the skin daily, including inside folds, which is where damage is missed.

When should someone seek help?

Ask a doctor or a wound and continence nurse to review if the skin is broken or weeping, if there is a bright red rash with small satellite spots (which suggests candida and usually needs an antifungal rather than a thicker barrier), if there is pain, odour, fever or spreading redness, or if the area is not improving after several days of consistent care. New or worsening incontinence itself deserves assessment rather than just better pads.

The honest summary

A properly designed study asked which ICU patients with faecal incontinence go on to develop skin erosion. Until its results are published, the answer stays where clinical guidance already is: protect the barrier, manage the moisture, and look at the skin every day.

This article is general information, not medical advice. Skin assessment and wound diagnosis need to be done in person. Please consult your doctor or a wound, ostomy and continence nurse about your own situation.

Browse adult incontinence products and skin and wound care supplies at www.emis.asia.

Related reading: The Hidden Cost of Overnight Incontinence: Managing IAD vs Using the PureWick System, Diapers, Indwelling Catheter or External Collection?, or browse our adult incontinence care range.