TL;DR: Key Takeaways
Incontinence-associated dermatitis (IAD) is a preventable condition affecting millions of older adults, yet most conventional incontinence products may inadvertently worsen the problem.
In one large study, over 82% of residents experienced urinary incontinence, with approximately 35.4% experiencing incontinence-associated dermatitis related to prolonged moisture exposure
Urease-producing bacteria on skin can raise skin pH from a healthy 4.5–5.5 to levels above 6.8, which may trigger inflammatory responses and changes in barrier function
Traditional plastic-backed products may create a more occlusive moisture environment, where proteolytic and lipidolytic enzymes may contribute to skin irritation, particularly when moisture remains in contact with skin tissue.
Aging skin is inherently more vulnerable with reduced lipid content, elevated transepidermal water loss, and compromised barrier function, making elderly adults 3–5 times more susceptible to IAD than younger populations
Structured prevention protocols combining breathable products, pH-appropriate care, and zinc oxide barriers were associated with reduced IAD incidence from 35.9% to 17.7% in hospitalized patient populations studied.
A different approach lies in breathable, plant-based materials that help support healthy skin pH, reduce prolonged maceration risk, and support the skin's natural protective barrier.
How Incontinence Products Interact with Aging Skin
When an elderly parent, grandparent, or patient begins experiencing bladder leaks, the instinct is to reach for whatever incontinence product sits on drugstore shelves. It seems straightforward: more absorbency equals better protection. Yet within weeks or months, many caregivers notice something concerning—persistent redness, uncomfortable irritation, skin that appears altered, and in some cases, visible skin changes.
The person you're caring for may become increasingly uncomfortable or reluctant to discuss what's happening.
This isn't a failure of caregiving. Rather, it reflects how the design features of many traditional incontinence products—plastic backing, synthetic topsheets, and super-absorbent cores—create a microenvironment where moisture can accumulate and remain in contact with skin. According to research published in BMC Geriatrics examining nursing home residents, incontinence-associated dermatitis affects a substantial proportion of elderly individuals with incontinence, making it one of the common complications of aging that deserves attention.
What follows is evidence-based guidance rooted in recent clinical research, designed to help caregivers, family members, and healthcare providers understand the mechanisms of incontinence-associated skin irritation, how product design influences these mechanisms, and what alternative approaches exist. This is about giving you the knowledge to make informed choices that support the comfort and dignity of those you care for.
Understanding Incontinence-Associated Dermatitis: Beyond Surface Irritation
The Scale of the Problem
Incontinence-associated dermatitis (IAD)—often mistakenly called "adult diaper rash"—represents a significant form of skin irritation affecting many older individuals. A nationwide survey of Japanese nursing homes found that 82.9% of residents experienced urinary incontinence, 68.9% had fecal incontinence, and 64.9% dealt with both simultaneously. Research across European and North American facilities consistently shows that over half of nursing home residents experience some form of incontinence, placing them at continuous risk for skin irritation.
The incidence of IAD itself varies depending on care setting and prevention practices, but studies examining nursing home populations report rates ranging from 17% to 42% among newly incontinent residents within the first month. When prevention protocols are implemented systematically, studies indicate that IAD rates can be reduced compared to standard care approaches.
What Happens Beneath the Surface
What makes incontinence-related skin irritation noteworthy is that changes can occur beneath the skin's surface before visible signs appear. Experimental studies using models that mimic aged human skin reveal that when skin is exposed to prolonged maceration (from extended wetness), proteases may begin affecting the prickle cell layer of the epidermis—observable changes occurring before visible redness appears to the naked eye.
Research examining lipidolytic enzyme effects demonstrates that lipases and phospholipases present in fecal matter may contribute to barrier changes by affecting sebum and intercellular lipids, potentially accelerating changes before the visible inflammatory response. By the time caregivers notice redness, sub-surface changes may have been developing for days or weeks.
How Incontinence-Related Skin Irritation Develops: A Four-Stage Process
Stage 1: pH Changes Through Bacterial Activity
The pathway to IAD-related irritation begins with a specific chemical process that occurs when urine contacts skin colonized by urease-producing bacteria. These bacteria—including common species like Staphylococcus, Proteus, and certain Corynebacterium strains—produce the enzyme urease, which breaks down urea (abundant in urine) into carbon dioxide and ammonia.
This process, detailed in a 2024 mechanistic review published in Skin Health and Disease, can raise pH levels significantly. Healthy skin maintains a mildly acidic pH between 4.5 and 5.5. When urease activity raises pH above 6.8, research on community-dwelling incontinent women found that elevated skin pH was associated with both increased urease-producing bacterial colonization and higher IAD prevalence. The alkaline environment may activate fecal enzymes that remain less active at normal skin pH.
Stage 2: Maceration and Moisture-Related Changes
While pH elevation sets conditions for irritation, prolonged moisture contact amplifies effects. The stratum corneum—the outermost layer of skin—is designed to regulate water movement. When chronically overhydrated through prolonged contact with urine or stool, analysis of skin characteristics in nursing home residents shows that transepidermal water loss increases, skin surface pH may rise, and protective barrier changes can occur at the molecular level.
Aging compounds this vulnerability. Research on skin changes in older adults reveals that elderly skin naturally exhibits reduced lipid content, compromised permeability homeostasis, decreased stratum corneum hydration, and elevated baseline pH—all factors that may predispose to more rapid barrier changes when challenged with incontinence. This explains why irritation may develop faster and more severely in older populations compared to younger adults.
Stage 3: Enzymatic Activity and Inflammation
Once moisture has affected the stratum corneum's integrity, digestive enzymes present in fecal matter gain access to skin layers. Histopathological examination of incontinence-affected skin demonstrates that proteases may cause changes in the prickle cell layer of the epidermis and inflammation around hair follicles—observable changes occurring before visible erosion becomes apparent. When researchers introduced bacteria into enzyme-affected skin, they observed bacterial clusters deep within skin tissue with associated inflammatory cells.
Complementary research on lipidolytic enzymes found that lipases and phospholipases may accelerate skin changes by affecting the lipid components that hold skin cells together, potentially compromising barrier function and increasing vulnerability to further irritation.
Stage 4: The Self-Perpetuating Cycle
Once established, incontinence-related irritation can create conditions that perpetuate the process. Irritated skin has impaired barrier function, which may allow deeper enzyme penetration. Alkaline pH may promote further bacterial activity. Inflammation causes discomfort that may reduce mobility, leading to longer intervals between product changes. Caregivers, observing worsening symptoms, may switch to "more absorbent" products—typically those with thicker plastic backing and higher SAP (super absorbent polymer) content—which may paradoxically maintain the high-moisture microenvironment.
Breaking this cycle requires understanding that the challenge isn't insufficient absorbency—it's the overall microenvironment created by product design.
Why Product Design Matters: The Moisture Microenvironment
How Plastic Backing Affects Skin Conditions
Most conventional incontinence products sold in drugstores and facilities share a common construction: a plastic or polyethylene backing layer designed to prevent leakage. While this achieves its stated goal, it creates a design consequence that dermatologists and wound care specialists have documented.
Clinical trials examining incontinence brief design and skin characteristics found that standard plastic-backed briefs maintain skin pH in the range of 6.0–7.0, significantly above the healthy 4.5–5.5 range. When researchers tested briefs engineered with acid-promoting fiber technology, skin pH returned to the optimal range, and IAD risk indicators decreased measurably. The study's conclusion was clear: product design directly influences skin pH and associated irritation risk.
The mechanism is straightforward. Plastic backing prevents moisture vapor from escaping the product. Even when the absorbent core has "locked away" liquid urine through superabsorbent polymers, the high-humidity microenvironment persists against the skin surface. This sustained moisture, combined with body heat, creates conditions for:
Prolonged maceration (skin overhydration)
Reduced evaporative cooling
Sustained contact with ammonia vapor from bacterial activity
Accelerated enzyme activity
Moisture-related pH elevation
Material Selection and Skin Contact
Beyond plastic backing, the materials directly contacting skin have significant effects. Traditional incontinence products often use cotton topsheets, sometimes marketed as "soft" or "natural." While cotton is a natural fiber, its performance characteristics in an incontinence application present challenges.
Cotton absorbs moisture but retains it against the skin rather than wicking it away. Its structure, while comfortable when dry, can become problematic when saturated, potentially causing friction on vulnerable elderly skin. More importantly, cotton doesn't actively manage pH or the bacterial microenvironment—it holds whatever conditions accumulate against the skin surface.
Synthetic fibers like standard polypropylene topsheets marketed as "stay-dry" can present their own considerations. While they do move moisture away from immediate skin contact better than cotton, they're typically paired with the same occlusive plastic backing. Experimental research on absorbent pads containing artificial urine showed that the combination of occlusive materials and chemical additives influenced skin irritation markers in controlled studies.
Breathable Design: A Different Approach to Product Engineering
How Material Selection Changes Skin Outcomes
Emerging evidence points toward a fundamental design principle: matching product engineering to skin's physiological needs. This means selecting materials that allow moisture vapor transmission while still containing liquid, using fiber structures that move fluid rapidly away from skin contact, and eliminating petroleum-based plastics that create sustained moisture environments.
Dermatological safety studies comparing plant-based and synthetic fiber incontinence pads found that plant-based topsheet materials demonstrated superior skin biocompatibility, lower inflammatory response in vulnerable populations, and better moisture vapor transmission compared to petroleum-based polymers. The researchers specifically noted that plant-based design proved beneficial for elderly patients at risk for irritation.
Plant-based fibers—such as those derived from wood pulp, bamboo, or corn—can be engineered to achieve multiple goals simultaneously:
Rapid wicking: Drawing moisture away from skin contact within seconds
Breathability: Allowing vapor transmission while containing liquid
pH neutrality: Not contributing to alkaline pH elevation
Reduced chemical load: Minimizing synthetic dyes, fragrances, and petroleum derivatives
Plant-Based Product Design in Practice
Products designed with these principles—such as Attn: Grace incontinence pads—represent this design philosophy. Rather than starting with conventional materials and attempting to mitigate their limitations, the design process begins with materials selected for compatibility with aging skin.
The construction includes:
Plant-based, micro-perforated topsheet: The layer touching skin is composed of plant-based fibers engineered to allow both liquid penetration and vapor release, maintaining a less humid skin microclimate
Rapid-wicking core: Fluid is moved away from skin contact quickly and distributed throughout the absorbent core to minimize localized moisture accumulation
Breathable design: Unlike plastic-backed products, the construction allows moisture vapor to escape, reducing the humidity buildup that may contribute to prolonged maceration and enzyme activation
The approach addresses each stage of the irritation process:
pH management: By maintaining airflow and rapid moisture removal, breathable design helps preserve skin's natural acidic pH, which may help inhibit certain bacterial colonization patterns
Maceration prevention: Vapor transmission and wicking minimize the prolonged wetness that causes stratum corneum overhydration
Reduced enzyme exposure: Faster fluid movement away from skin contact limits duration of enzyme contact
Chemical elimination: Removing petroleum-based plastics, chlorine bleach, synthetic fragrances, and dyes removes additional potential irritation sources
Notably, products like Attn: Grace carry Dermatest® "Excellent" certification, indicating third-party validation of skin compatibility, and B Corp™ certification, reflecting commitment to EU standards that address ingredient restrictions.
Read our piece on The Absolutely NotsTM, where we have put together a comprehensive list of more than two thousand ingredients that we will never use in our designs or product formulas.
Building a Comprehensive Skin Care Framework
The Four-Step Approach to Managing Incontinence-Related Skin Health
Clinical evidence supports a systematic approach to IAD management that goes beyond product selection. A structured skin care protocol tested in ICU patients was associated with reduced IAD incidence by incorporating consistent cleansing, protection, and monitoring routines. While this study focused on hospitalized patients, evidence suggests these principles apply across care settings.
Step 1: Gentle, pH-Appropriate Cleansing
Soap and water—the traditional cleansing method—can influence IAD risk through pH effects. Most conventional soaps are alkaline (pH 9–10), which may disrupt skin's acid mantle and remove protective lipids. Guidelines from prevention and care research specifically recommend using skin cleansers with pH between 4.0 and 6.8, ideally in no-rinse formulations that minimize friction and moisture exposure.
For elderly adults with incontinence-related skin concerns:
Use pH-balanced, fragrance-free cleansers or plain water for routine cleaning
Pat skin dry gently rather than rubbing
Consider gentle flushable wipes formulated with purified water and botanical extracts for between-change freshening without full washing
Minimize harsh scrubbing or excessive washing frequency, which may increase transepidermal water loss
Step 2: Apply Protective Barriers
Zinc oxide-based barrier creams have strong clinical evidence for IAD management. A nursing program pilot study in elderly patients found that structured skin care including zinc oxide-based protection was associated with reduced IAD severity, improved skin pH toward the mildly acidic range, and enhanced skin hydration compared to standard care.
Zinc oxide works through multiple mechanisms:
Creates a physical barrier against urine, stool, and enzyme contact
Possesses mild antimicrobial properties that may reduce bacterial overgrowth
May help maintain skin pH in the optimal range
Is well-tolerated even on irritated or inflamed skin
Products like Attn: Grace All Natural Barrier Cream use zinc oxide as the active ingredient, combined with botanical oils, and are notably petroleum-free—distinct from conventional options like petroleum jelly, which may trap moisture rather than allowing skin to maintain proper hydration balance.
Application protocol: After cleansing and drying, apply a thin, even layer of barrier cream to areas at risk. Reapply after each product change.
Step 3: Change Products at Appropriate Intervals
Even the most breathable, well-designed product must be changed at appropriate intervals. Research on IAD risk factors in nursing homes identified prolonged exposure to incontinence as one of the strongest predictors of skin changes. The balance lies between changing too frequently (increasing friction) and too infrequently (allowing moisture accumulation).
Evidence-based guidelines suggest:
Check for wetness every 2–4 hours during waking hours
Change immediately after any bowel movement
Change overnight products upon waking
Increase change frequency during IAD flares or for individuals with double incontinence
Step 4: Monitor and Adjust Care
Caregivers should conduct brief skin assessments at each change, observing for:
Category 1 irritation (early): Redness without broken skin, which may feel warm or appear shiny
Category 2 irritation (moderate): Visible skin changes or moisture damage
Maceration signs: Skin appearance changes
If early signs appear, intensify prevention measures: increase change frequency, ensure thorough but gentle cleansing, reapply barrier cream, consider breathable product options, and track whether interventions are effective.
Supporting Whole-Body Skin Health in Aging
Why Elderly Skin Requires Specialized Attention
Incontinence-related skin irritation doesn't occur in isolation—it emerges from age-related skin changes and environmental factors. Comprehensive reviews of aging-associated skin changes document that elderly skin exhibits multiple characteristics:
Reduced lipid synthesis: Ceramides and fatty acids in the stratum corneum decline, affecting skin structure
Elevated transepidermal water loss: Aging skin loses water more readily, affecting barrier function
Decreased stratum corneum hydration: Despite higher water loss, elderly skin retains less moisture - Increased baseline pH: Skin pH naturally drifts toward neutral with age, reducing the protective acid mantle
Slower repair processes: When barrier changes occur, elderly skin requires more time to normalize
These changes mean that elderly adults benefit from proactive, whole-body skin support, not just focused management of incontinence areas.
Supporting Skin Beyond the Incontinence Zone
Clinical studies examining moisturizer interventions in nursing homes found that regular application of appropriate moisturizers was associated with reduced skin tear incidence. While these studies focused on extremities, the principle applies to all skin surfaces: maintaining barrier integrity through consistent moisturization helps support skin resilience against various challenges.
Products designed for aging skin can support these needs:
Body oils: Formulated with plant-derived oils, these post-shower treatments help support skin elasticity and provide relief from irritation related to frequent cleansing
Antimicrobial support: Hypochlorous acid-based products offer gentle bacterial management without requiring rinsing—ideal for quick refreshes that maintain barrier function
The philosophy recognizes that skin health is an integral component of overall health in elderly populations, deserving of comprehensive attention.
When Professional Evaluation is Appropriate
Situations Requiring Healthcare Provider Assessment
While structured prevention and well-designed products can address many incontinence-related skin concerns, certain situations warrant professional evaluation:
Skin irritation that doesn't improve within 72 hours of implementing prevention protocol changes
Signs suggesting secondary infection: Increasing pain, warmth, drainage, or spreading beyond the affected area
Suspected fungal involvement: Satellite lesions or intense itching
Underlying conditions requiring evaluation: Symptoms appearing alongside new urinary symptoms or changes in bowel patterns
Severe erosion or significant skin changes: Wounds that aren't responding to standard care
Healthcare providers can:
Perform cultures to identify specific concerns
Prescribe specialized barrier products when indicated
Evaluate for treatable causes of incontinence
Coordinate care with specialists for complex situations
Having Compassionate Conversations About Incontinence
One of the biggest barriers to effective skin management is reluctance to discuss the issue. Elderly adults may feel embarrassed or resigned. Caregivers may feel uncomfortable broaching intimate topics.
Framing the conversation around normalcy and dignity helps:
"Incontinence affects a large proportion of older adults; this is very common"
"The discomfort you're experiencing doesn't have to be tolerated. There are products and approaches designed to support skin comfort"
"We're going to focus on keeping your skin healthy and comfortable while managing leaks"
Many healthcare providers have training in incontinence management and can provide medical perspectives on underlying causes and management options.
Conclusion: Product Design and Skin Compatibility
Incontinence is a medical condition affecting tens of millions of adults and the products we choose to manage have significant consequences for skin health and comfort. For too long, the incontinence product industry has prioritized leakage containment, sometimes with limited consideration for skin compatibility, leaving elderly adults to manage uncomfortable skin changes that arise not from the incontinence itself but from product design choices.
The science suggests that supporting skin health requires breathability, pH balance, minimal chemical exposure, and rapid moisture management; requirements that can be more difficult to achieve with occlusive, plastic-backed designs. Plant-based, breathable alternatives designed with skin physiology as the primary concern represent a different approach, one that respects the biological realities of aging skin.
By combining well-designed product selection with structured care protocols—pH-appropriate cleansing, protective barriers, appropriate change intervals, and whole-body skin support—caregivers and healthcare providers can support skin comfort and reduce incontinence-related irritation. This isn't about perfect outcomes in every situation; it's about giving those we care for the best possible chance at comfort and dignity.
Attn: Grace exists because traditional solutions failed to meet comprehensive skin care standards, and our approach—breathable plant-based materials, chemical elimination, rapid-wicking engineering, and complementary care products—offers a research-grounded alternative for those prioritizing skin health alongside leakage protection.
Your elderly parent, patient, or loved one deserves products designed with their skin biology in mind. The evidence supports this approach. Now it's about encouraging broader adoption of a different level of care.
Frequently Asked Questions
How quickly can incontinence-related skin irritation develop in elderly adults?
Incontinence-associated dermatitis can develop within weeks in elderly individuals with compromised skin barriers. Research tracking nursing home residents found that among newly incontinent elderly adults, IAD incidence ranged from 17% to 42% within the first month. In some high-risk care settings, visible signs have been observed within 48–72 hours of exposure. This timeline emphasizes why management must begin promptly rather than waiting to see if problems develop.
Can incontinence-related skin irritation be managed or reversed?
With appropriate intervention, many cases of incontinence-related skin irritation can be managed effectively, particularly when addressed early. Clinical trials suggest that early-stage irritation may begin to improve within days, though timelines vary widely depending on skin condition, care setting, and individual health factors.
When exposure is minimized and protective measures applied. More significant changes may require 1–3 weeks for improvement. The key is addressing the root causes—selecting breathable products, maintaining proper pH, protecting skin with barriers—while the skin regenerates. Elderly skin does require more time to normalize than younger tissue, but with consistent care, meaningful improvement is often achievable with consistent care.
Can I use baby diaper rash cream for my elderly parent?
While baby diaper rash creams containing zinc oxide share some protective mechanisms, they're not specifically formulated for elderly skin needs. Baby skin has different characteristics—higher lipid content, faster healing, and different pH characteristics. Additionally, many baby products contain fragrances or ingredients that may irritate compromised elderly skin. Products like Attn: Grace All Natural Barrier Cream are specifically formulated with elderly skin physiology in mind, including botanical ingredients chosen for mature skin compatibility.
Will breathable products work for heavy nighttime leaks?
It's a common misconception that breathable design means reduced absorbency. Modern plant-based incontinence products achieve both breathability and high capacity through engineered core structures that efficiently distribute fluid. Attn: Grace Ultimate Pads hold 760ml—equivalent to many plastic-backed overnight products—while maintaining 100% breathable construction.
What should I do if incontinence-related skin irritation keeps recurring?
Recurrent irritation typically signals one of several factors requiring systematic evaluation. First, assess whether product change frequency is appropriate. Second, evaluate cleansing routines and whether pH-balanced products are being used. Third, ensure barrier cream application is thorough and frequent. Fourth, consider whether using breathable, well-designed products makes a difference.
Finally, consult healthcare providers about underlying incontinence causes that might be addressable, reducing overall exposure. Persistent irritation often requires a comprehensive approach addressing product design, skin care protocol, change frequency, and underlying medical factors simultaneously.
Are "natural" or "organic" labels meaningful for incontinence products?
Labels like "natural" and "organic" are largely unregulated, making them potentially misleading. What matters more are specific, verifiable claims: materials used, chemical exclusions, breathability characteristics, and third-party certifications. Attn: Grace products provide transparent specifications: plant-based topsheets, elimination of many questionable chemicals, and Dermatest® Excellent certification. Look for products that specifically address incontinence-related skin risk factors—breathability, rapid wicking, pH-neutral materials—backed by transparent material disclosure.