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Under the umbrella of MASD

16 March 2023 is Moisture Associated Skin Damage (MASD) Awareness Day which was first hosted in 2022 following an initiative to increase awareness of MASD risk factors. The guiding principle for the day is to get everyone to #ThinkMASD and have a plan, in your workplace, to minimise moisture for those patients most at risk.

So, what is MASD and why all the fuss?

Moisture Associated Skin Damage (MASD) is an umbrella term for skin inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, sweat, faeces, wound exudate, saliva, or mucus (LeBlanc, 2019).

There are 4 main types of MASD which are:

  • Intertriginous Dermatitis (ITD) which is where moisture gets trapped within folds of skin causing inflammation.
  • Peristomal MASD – inflammation and erosion, caused by moisture, around and extending outwards from the stoma/skin junction.
  • Peri-wound MASD – skin maceration and erosion from wound exudate.
  • Incontinence Associated Dermatitis (IAD) – chemical irritation caused by prolonged contact between the skin and urine and/or faeces.

(Fletcher, J. 2020. Yates, A, 2020)

For the purposes of this clinical blog, I am going to discuss Incontinence Associated Dermatitis (IAD) in more detail. You may be familiar with it or know it through some other descriptions such as perianal dermatitis, nappy rash, moisture lesions amongst others. It represents a significant health challenge with an estimated incidence of MASD being 3.4-25% in health care settings (Gray et al, 2015). The challenge of really understanding how much of a problem it is stems from the difficulties in recognising the condition and distinguishing it from Category 2 pressure ulcers or other conditions such as contact dermatitis, which can lead to inappropriate management (Beeckham et al. 2015).

Although IAD is not a direct cause of pressure ulcer development, prolonged exposure to moisture weakens the epidermal layer in several ways: over-hydration (maceration) of the top layer of skin (Stratum corneum) can make it easier for irritants to penetrate the skin and makes it more susceptible to shear forces. Constant exposure to urine can alter the local pH from mildly acidic to alkaline allowing microbes to multiply increasing the risk of localised infection, while liquid faeces contain protein digesting enzymes which can breakdown the surface of the skin (Yates, A. 2020).  Other factors which create a build-up of moisture, alongside incontinence or wound exudate in the perianal area, are long periods of sitting or lying on non-breathable materials, severe sweating due to increased temperature or leaking tissue oedema associated with cardiac failure (Dissemond et al. 2021).

IAD can lead to negative patient outcomes especially in the older patient. It can cause physical and mental suffering with patient’s symptom severity ranging from uncomfortable to the development of very painful ulceration with secondary infection. This can then increase a patient’s susceptibility to spreading infection or pressure ulceration and result in increased care needs and costs (Banharak, S. et al. 2021).

Preventing and managing IAD is a team effort and when incontinence is anticipated then a structured skin care regime, to promote optimal skin health and prevent skin breakdown, needs to be put in place. These include:

  • Patients at risk of developing IAD should have a daily skin inspection, or more frequently if they are at high risk of IAD. This can easily be incorporated into the routine skin inspection for pressure ulcer risk and patients’ hygiene needs (Voegeli, 2017).
  • Any site identified to be at risk of prolonged exposure to moisture should be cleansed with a simple neutral pH skin cleanser (avoiding using soaps and perfumed products which strip natural oils from the skin) and using soft non-woven clothes rather than rough washcloths.
  • Patting the skin dry avoiding additional friction damage from the act of rubbing the skin dry.
  • For patients with occasional incontinence the use of simple moisturisers, after toileting, should be sufficient to replace the natural skin lipids and promote the natural skin barrier.
  • For patient with more persistent incontinence, where the skin is showing signs of stress, then the use of skin barrier products is recommended. These can be in the form of creams or film products and should be applied sparingly and allowed to dry well before replacing pads or clothing. Application should follow the manufacturer’s instructions.
  • The appropriate use of absorbent products is important, following an appropriate continence assessment, as they limit exposure to moisture and avoid overhydration of the skin. However, these need to be of highly breathable material with super absorbency which can control the pH level. If not, they may contribute to the worsening IAD by creating occlusive conditions alongside the possibility of prolonged exposure to urine and/or faeces due to infrequent pad changes or limited cleansing (Mugita, Y. et al. 2021).
  • Consider the presence of fungal infection, especially in the folds of the groin area. This is characterised by a dry, pale-pink, or white area that causes an itchy or burning sensation. This can be treated with a topical anti-fungal cream, applied after washing and drying and before the application of moisturisers or barrier products. This should be applied regularly and until the symptoms subside.  (Fletcher, J. 2020. Yates, A. 2020. Mehaffey, K. 2021)

Taking a person-centred approach and understanding the elements of prevention, treatment and management of incontinence or any other factor which contribute to prolonged exposure to moisture, in the perianal area, should be the primary focus for preventing IAD. These include good skin assessment, regular skin inspection, use of gentle cleansers, ensuring skin is dried well by patting, the regular use of emollients or barrier products (where appropriate) and the use of effective absorbent products following a comprehensive continence assessment.  The outcome will be a reduction in the occurrence of IAD, reduced pain and suffering for the patients alongside a lowering the risk of developing infection or contributing to their risk of developing pressure ulcers.

Watch OSKA Peers Under Pressure Clinical Webinar – Under the Umbrella of MASD


Banharak, S. et al., (2021). Prevention and care for incontinence-associated dermatitis among older adults: A systematic review. Journal of multidisciplinary healthcare. 14. Pg. 2983-3004.

Beeckman D et al. (2015) Proceedings of the Global IAD Expert Panel. Incontinence associated dermatitis: moving prevention forward. Wounds International. Available to download from www.

Dissemond, j. et al, (2021). Moisture-associated skin damage (MASD): A best practice recommendation from Wund-D.A.CH. JDDG. 19(6). Pg 815-825

Fletcher, J. (2020) Pressure ulcer education 6: incontinence assessment and care. Nursing Times. Vol 116: 3, 42-44

Gray, M. Et al, (2012). Incontinence-associated dermatitis: a comprehensive review and update. Journal of Wound, Ostomy and Continence Nursing. Vol 39:1, 61-74.

LeBlanc, K. (2019). Moisture-Associated Skin Damage (MASD). (Available at) [Accessed 17.02.23].

Mehaffey, K. (2021). Managing Incontinence-Associated Dermatitis: It’s a team effort! Medsurg Nursing. (30);2. 149-150.

Mugita, Y. et al. (2021). Assessing absorbent products’ effectiveness for the prevention and management of incontinence-associated dermatitis caused by urinary, faecal or double adult incontinence: A systematic review. Journal of Tissue Viability. 30(4). Pg. 599-607.

Voegeli D. (2017). Incontinence-associated dermatitis: new insights into an old problem. Practice Nursing. 28(2):73–79 Yates, A. (2020). Incontinence-associated dermatitis 1: risk factors for skin damage. Nursing Times [online] Vol 116: 3. Pg 46–50.