Editor's Note: Moisture Associated Skin Damage (MASD) and related conditions affect many patients, especially older adults with incontinence, each year. Numbers of those with Incontinence-associated dermatitis (IAD), a subcategory of MASD, can be staggering, with some reports indicating that 50% of those with incontinence suffer from IAD.¹ So, how can wound care providers better prevent and manage these conditions for patients with incontinence and other risk factors?

Professor Dimitri Beeckman, RN, MSc, PhD, FEANS, FAAN explains MASD and its related conditions, identification, prevention, and management.

What are moisture-associated skin damage (MASD) and incontinence-associated dermatitis (IAD)?

Moisture Associated Skin Damage (MASD) refers to a category of skin conditions or injuries that occur because of prolonged exposure to moisture. It primarily affects the skin, especially in areas where moisture is trapped on the skin's surface. MASD encompasses several types of skin damage, including²:

• Irritant contact dermatitis: this occurs when moisture, such as urine or sweat, encounters the skin, causing redness, inflammation, and discomfort. Prolonged contact may cause damage to the skin.
• Intertrigo: This is a condition where folds of skin (eg, in the groin, under the breasts, or between the buttocks) become irritated and can develop a rash due to moisture and friction.
• Candidiasis: Moisture can create a favorable environment for the growth of fungi, especially candida. This moisture presence can lead to a yeast infection of the skin, causing itching, redness, and discomfort.
• Maceration: Maceration is the softening and breakdown of the skin due to prolonged exposure to moisture, which can weaken the skin's natural protective barrier.

To prevent MASD, you need to keep the affected areas clean and dry, use appropriate moisturizers, and address the causes of moisture exposure.²

Incontinence-associated dermatitis (IAD) is a specific form of MASD that results from contact with urine or feces, often due to incontinence.^2-4 It mainly affects the skin in the genital area, buttocks, and perineal area. IAD can manifest as redness, inflammation, and skin peeling and can be very painful and uncomfortable for those affected. Friction (mostly) and pressure can contribute to the development and worsening of IAD.^2-4

To manage IAD, it is important to practice good hygiene, clean and dry the affected areas immediately after incontinence, and use skin protectants or barrier creams to create a protective barrier against moisture and irritants.³ In addition, it may be necessary to treat the underlying causes of the incontinence and to prevent further skin damage.^2-4

In summary, both MASD and IAD are skin conditions that result from prolonged exposure to moisture, with IAD specifically referring to skin damage caused by incontinence. Proper prevention and treatment are crucial to alleviate the symptoms and prevent further skin damage in vulnerable individuals.^2-4

How does pressure and friction contribute to IAD development?

Friction occurs when the skin rubs against another surface, such as clothing or bedding. For people with incontinence, frequently changing incontinence products, shifting in bed, or slipping on a chair can cause increased friction on already damaged skin. The friction can aggravate skin irritation and break down the skin's protective barrier, making it more susceptible to the harmful effects of urine and stool.^2-4

Prolonged pressure on the skin can reduce the blood supply to the affected area, leading to tissue damage and skin breakdown. When people with incontinence sit or lie in one position for a long period, pressure can build up on certain areas of the skin, especially in areas with bony prominences. Incontinence products such as incontinence pads or briefs can sometimes cause pressure points due to their tight fit or improper use. These pressure points can contribute to skin damage and the development of IAD. Immobile or bedridden people are particularly vulnerable to pressure-related skin damage because they cannot shift their body weight to relieve pressure on the affected areas.^2-4

To prevent and treat IAD, caregivers should take steps to minimize pressure and friction on the affected skin, such as⁴:

1. Changing incontinence products regularly to keep the skin clean and dry.
2. Using protective barriers such as skin creams or ointments to form a protective layer on the skin.
3. Implementing a repositioning plan for people who are not mobile to reduce pressure on sensitive areas.
4. Selecting appropriate clothing and bedding materials to reduce friction.
5. Ensuring proper hygiene and gentle cleaning of the perineal area after each incontinence episode.

Proper care and preventive measures are essential to manage and reduce the risk of developing IAD in people with incontinence, especially those who are bedridden or have limited mobility.

What are some key differences between pressure injuries and MASD?

The main differences between pressure injuries (pressure ulcers) and certain forms of moisture-related skin damage (MASD) or incontinence-related dermatitis (IAD) are:

Pressure injury (pressure ulcer)⁵:

• Etiology: Pressure injuries are usually caused by prolonged pressure on the skin, often over bony prominences such as the heels, sacrum, elbow, or back of the head.
• Appearance: They may manifest as localized skin damage at various stages, including intact skin with non-blanchable redness (stage 1), partial skin loss (stage 2), full-thickness skin loss with visible fat (stage 3), or full-thickness skin loss with exposed bone, muscle, or tendon (stage 4).
• Margins: Pressure ulcers often have well-defined margins.
• Pain: Depending on the depth and stage of the ulcer, they may or may not be painful.
• Location: Common sites for pressure injuries are bony prominences and areas that are exposed to prolonged pressure or shear forces.

Figure 1: Stage 3 pressure injury with inflamed peri-wound skin due to excessive wound exudate.

Moisture-associated skin damage (MASD) or incontinence-associated dermatitis (IAD)^2-4:

• Etiology: MASD and IAD occur when the skin is exposed to moisture such as urine, feces, sweat, or wound exudate over a long period.
• Appearance: They typically present as erythema (redness) and maceration (softening) of the skin, often with satellite lesions or pustules.
• Margins: The margins of MASD/IAD are usually not clearly defined and gradually blend into the surrounding healthy skin.
• Pain: The affected area may be painful, especially if irritated or exposed to moisture, but it is generally less painful than pressure ulcers if not palpitated.
• Location: MASD and IAD often occur in areas exposed to moisture, such as the perineal area, buttocks, groin, and skin folds.

Figure 2:  IAD Cat. 2b (Skin loss and clinical signs of infection) + stage 3 pressure injury on sacrum.

Important points to distinguish between the 2 conditions^2-5:

• History: A thorough history can provide valuable clues, as pressure injuries are associated with persistent pressure, whereas MASD/IAD is associated with dampness.
• Location: Pay attention to the location of the skin damage. Pressure injuries often occur over bony prominences, while MASD/IAD affects moist, friction-prone areas.
• Appearance and margins: Assess the appearance and margins of the skin damage. Well-defined margins tend to indicate a pressure injury, while poorly defined margins indicate MASD/IAD.

In certain scenarios, particularly when there is suspicion of a fungal infection, such as Candida Albicans, or a bacterial infection, such as Pseudomonas Aeruginosa, it is advisable to seek an infection specialist on the multidisciplinary team. Their expertise and clinical acumen can assess the situation and may recommend wound cultures to ensure accurate diagnostic evaluation.^2-4

Prevention and Management strategies for MASD and IAD

Prevention and treatment strategies for Moisture-Associated Skin Damage (MASD) and Incontinence-Associated Dermatitis (IAD) focus primarily on maintaining skin integrity, moisture management, and protecting the skin from further damage. Below are some important strategies for prevention and treatment^4,6,7:

Prevention strategies:

• Skin assessment: Assess the skin regularly, especially in high-risk individuals, such as those with incontinence or limited mobility. Maintain a skin assessment log and document any changes in skin condition.
• Proper hygiene: Adhere to good hygiene practices, including gentle cleansing and drying of the perineum and affected areas after each incidence of incontinence. Use pH-balanced, fragrance-free cleansers and avoid vigorous rubbing.
• Barrier creams: Apply skin barrier creams or ointments as a preventive measure, especially in areas exposed to moisture. These products form a protective barrier that helps prevent skin breakdown.
• Moisture management: Keep the skin as dry as possible. Change incontinence products promptly and use moisture-wicking materials in clothing and bedding to prevent moisture build-up.
• Skin protection: Use measures such as skin protectants or dressings on vulnerable areas to minimize friction and moisture. Silicone-based dressings can be particularly effective.
• Appropriate incontinence products: Ensure proper selection and fitting of incontinence products to prevent leakage and minimize contact with the skin.

Management strategies

Perform a thorough skin assessment to determine the severity and extent of damage. Assess the margins of the wound and refer to the patient’s history to differentiate between MASD/IAD and pressure injuries to ensure appropriate treatment.^2,6,7 

Gently cleanse the affected area with mild, pH-balanced cleansers. Avoid harsh soaps or vigorous rubbing as this may further damage the skin. Depending on the severity of the condition, topical treatments may include barrier creams, zinc oxide ointments, or specific products for treating MASD/IAD. Ensure adequate nutrition and hydration as these factors can affect the health of the skin and the body's ability to heal. Manage pain and discomfort with pain medication or other interventions. Educate patients, caregivers, and health care providers about prevention, early detection, and proper management of MASD/IAD. Continually monitor the progress of treatment and adjust as needed. Consult with wound care specialists as needed. Identify and treat any underlying medical conditions that contribute to MASD/IAD, such as urinary or fecal incontinence, to prevent recurrence. Schedule follow-up examinations to ensure that the healing process is progressing and to avoid complications.^2,6,7

The effective prevention and treatment of Moisture-Associated Skin Damage (MASD) and Incontinence-Associated Dermatitis (IAD) necessitate a comprehensive, multidisciplinary approach. This approach should encompass various health care professionals, including nurses, clinical nurse specialists, and physicians. It is imperative to customize strategies according to the unique needs and conditions of each patient and to actively seek guidance from wound care specialists whenever necessary.

1. Holroyd S. Moisture-associated skin damage caused by incontinence. Urology & Continence Care Today. Published September 2023. Accessed September 20, 2023. https://www.ucc-today.com/journals/issue/launch-edition/article/moistur…
2. Woo KY, Beeckman D, Chakravarthy D. Management of Moisture-Associated Skin Damage: A Scoping Review. Adv Skin Wound Care. 2017;30(11):494-501. doi:10.1097/01.ASW.0000525627.54569.da
3. Surber C, Dragicevic N, Kottner J. Skin Care Products for Healthy and Diseased Skin. Curr Probl Dermatol. 2018;54:183-200.
4. Beeckman D, Van Damme N, Schoonhoven L, et al. Interventions for preventing and treating incontinence-associated dermatitis in adults. Cochrane Database Syst Rev. 2016;11(11):CD011627.
5. Gray M, Giuliano KK. Incontinence-Associated Dermatitis, Characteristics and Relationship to Pressure Injury: A Multisite Epidemiologic Analysis. J Wound Ostomy Continence Nurs. 2018;45(1):63-67. doi:10.1097/WON.0000000000000390
6. Lichterfeld A, Hauss A, Surber C, et al. Evidence-based skin care: a systematic literature review and the development of a basic skin care algorithm. J Wound Ostomy Continence Nurs. 2015;42(5):501-524.
7. Kottner J, Surber C. Skin care in nursing: A critical discussion of nursing practice and research. Int J Nurs Stud. 2016 Sep;61:20-28.

Further Reading

Beeckman D, Van den Bussche K, Alves P, 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):1331-1340. 

Kottner J. Nurses as skin care experts: Do we have the evidence to support practice? Int J Nurs Stud. 2023 Sep;145:104534. 

About the Author

Dr. Dimitri Beeckman is Professor of Nursing Science at Ghent University (Belgium) and Örebro University (Sweden). He is Deputy Head of the School of Health Sciences at Örebro University and responsible for research development and internationalisation. He is a visiting professor at the Royal College of Surgeons in Ireland, Monash University (Australia) and the University of Southern Denmark. He is a past president of the European Pressure Ulcer Advisory Panel (EPUAP) and the International Skin Tear Advisory Panel (ISTAP) and an Executive Board Member (honorary treasurer) of the European Wound Management Association (EWMA). He is programme director of the Master of Nursing and Midwifery programme at Ghent University. He leads the Skin Integrity Research Group (SKINT) at Ghent University and the Swedish Centre for Skin and Wound Research (SCENTR) at Örebro University. 

He specialises in skin integrity research, clinical trials, education, implementation, instrument development and psychometrics. He is the author of more than 200 scientific publications and has presented his research in more than 80 countries. He serves on the editorial boards of the Journal of Wound, Ostomy and Continence Nursing (JWOCN), the Journal of Tissue Viability (JTV), and the International Journal of Nursing Studies Advances (IJNSA). He is Associate Editor of the International Journal of Nursing Studies (IJNS), the journal with the highest impact factor in nursing worldwide. He has received international fellowships, including from the Sigma Theta Tau International Honour Society of Nursing, the European Academy of Nursing Science (EANS) and the American Academy of Nursing (FAAN).