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Incontinence Associated Incontinence Associated Dermatitis in the Person with Dermatitis in the Person with Inflammatory Bowel DiseaseInflammatory Bowel Disease

Mikel Gray, PhD, FNP, PNP, CUNP, CCCN, FAANP, FAANMikel Gray, PhD, FNP, PNP, CUNP, CCCN, FAANP, FAANProfessor & Nurse PractitionerProfessor & Nurse Practitioner

University of Virginia Department of UrologyUniversity of Virginia Department of Urology

ObjectivesObjectives

vv Define Incontinence Associated Dermatitis (IAD) Define Incontinence Associated Dermatitis (IAD) and its epidemiology and its epidemiology

vv Identify persons with Inflammatory Bowel Identify persons with Inflammatory Bowel Disease who are at risk for IADDisease who are at risk for IAD

vv Discuss the etiology and pathophysiology of IAD Discuss the etiology and pathophysiology of IAD focusing on the adverse effects of stool in contact focusing on the adverse effects of stool in contact with the skinwith the skin

vv Review the assessment of IADReview the assessment of IADvv Describe options for prevention and treatmentDescribe options for prevention and treatment

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Definition: Definition: Incontinence Associated Dermatitis Incontinence Associated Dermatitis (IAD)(IAD)

vv Irritation and inflammation Irritation and inflammation associated with exposure to stool associated with exposure to stool or urineor urine

vv Often accompanied by erosion of Often accompanied by erosion of the skinthe skin

vv Sometimes accompanied by Sometimes accompanied by secondary cutaneous infection secondary cutaneous infection (ie: candidiasis)(ie: candidiasis)

vv Etiology and pathophysiology Etiology and pathophysiology distinct from pressure ulcerationdistinct from pressure ulceration

Prevalence in Acute CarePrevalence in Acute Care

976 Total number of

patients surveyed

35% had Foley catheter

(deemed continent)

20.3% (198)prevalence of incontinenceurine or stool

• 27% had IAD• 33% had a pressure

ulcer• 18% had a probable

fungal Infection

21% had more than 1 type of injury

Junkin J, Selekof J. IAD prevalence in acute care. WOCN National Conference, June 2006 Junkin J, Selekof J. IAD prevalence in acute care. WOCN National Conference, June 2006 Minneapolis, MN. Minneapolis, MN.

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Epidemiology of IADEpidemiology of IAD

vv 95% of 44 ICU patients with incontinence 95% of 44 ICU patients with incontinence (n=44)(n=44)11

vv MDS mined data suggests at least 5.7% MDS mined data suggests at least 5.7% prevalence from 10, 217 residents in 31 statesprevalence from 10, 217 residents in 31 states22

vv 3.4% i3.4% incidence in 981 residents on IAD ncidence in 981 residents on IAD prevention program (over 14 days)prevention program (over 14 days)

vv Median (range) time to onset 13 days Median (range) time to onset 13 days vv 39% still had IAD after 2 weeks39% still had IAD after 2 weeks

1. Peterson, AACN NTI abstract, 2007. 1. Peterson, AACN NTI abstract, 2007. 2. Bliss DZ et al. Nursing Research 2006; 55(4): 243.2. Bliss DZ et al. Nursing Research 2006; 55(4): 243.

IAD Risk in Persons with IBDIAD Risk in Persons with IBD

vv Prevalence of fecal incontinence higher in parous Prevalence of fecal incontinence higher in parous women with IBD as compared to those without IBDwomen with IBD as compared to those without IBD11

vv Onset of FI associated with vaginal delivery; Onset of FI associated with vaginal delivery; caesarean section may be protective caesarean section may be protective

vv Prevalence of daytime FI Prevalence of daytime FI ­­ from 5%from 5%--11% and 11% and nighttime FI from 12%nighttime FI from 12%--21% within first 121% within first 1--2 decades 2 decades after IPAAafter IPAA22

vv MetaMeta--analysis of 43 observational studies with 9317 analysis of 43 observational studies with 9317 subjects found mild FI in 17% and severe FI in 3.7%subjects found mild FI in 17% and severe FI in 3.7%33

1. Ong JPL et al. Inflammatory Bowel Disease 2007; 13(11): 1391. 1. Ong JPL et al. Inflammatory Bowel Disease 2007; 13(11): 1391. 2. Hahnloser D et al. British Journal of Surgery 2007; 94(3): 333. 2. Hahnloser D et al. British Journal of Surgery 2007; 94(3): 333. 3. Hueting WE et al. Digestive Surgery 2005; 22(13. Hueting WE et al. Digestive Surgery 2005; 22(1--2): 69.2): 69.

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Physiology: Skin’s Moisture Barrier Physiology: Skin’s Moisture Barrier Prevents MASDPrevents MASD

vv Stratum corneum: Stratum corneum: avascularavascular, , keratinocytes or corneocytes keratinocytes or corneocytes

vv Lipid matrixLipid matrix: slows movement : slows movement of water & electrolytesof water & electrolytes

vv WaterWater: hydrates corneocytes : hydrates corneocytes vv pHpH: (range 5.0: (range 5.0--5.9) “acid 5.9) “acid

mantle”mantle”vv Bacterial floraBacterial flora: compete with : compete with

pathogens to prevent pathogens to prevent infection infection

vv TemperatureTemperature: regulates : regulates permeabilitypermeability

vv Stratum corneum: Stratum corneum: avascularavascular, , keratinocytes or corneocytes keratinocytes or corneocytes

vv Lipid matrixLipid matrix: slows movement : slows movement of water & electrolytesof water & electrolytes

vv WaterWater: hydrates corneocytes : hydrates corneocytes vv pHpH: (range 5.0: (range 5.0--5.9) “acid 5.9) “acid

mantle”mantle”vv Bacterial floraBacterial flora: compete with : compete with

pathogens to prevent pathogens to prevent infection infection

vv TemperatureTemperature: regulates : regulates permeabilitypermeability

Barrier Function: The BricksBarrier Function: The Bricks

vv Corneocytes (keratinocytes)Corneocytes (keratinocytes)–– Anucleated cells filled with keratin & Anucleated cells filled with keratin &

other molecules created by other molecules created by breakdown of filaggrin breakdown of filaggrin

–– Collectively referred to as natural Collectively referred to as natural moisturizing factor (NMF) moisturizing factor (NMF)

–– Surrounded by cornified envelope Surrounded by cornified envelope (corneodesmosomes) that degrade as (corneodesmosomes) that degrade as they move to surface of skinthey move to surface of skin

–– ~~20% content is H20% content is H2200

VerdierVerdier--Sevrain S, Bonte F. Journal of Cosmetic Dermatology 2007; Sevrain S, Bonte F. Journal of Cosmetic Dermatology 2007; 6:75.6:75.

Figure: Figure: http://www.bioskinregeneration.com/wrinkles/skin.jphttp://www.bioskinregeneration.com/wrinkles/skin.jpgg

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Moisture Barrier:Moisture Barrier:Natural Moisturizing Factor (NMF)Natural Moisturizing Factor (NMF)

vv Natural Moisturizing Factor contains various Natural Moisturizing Factor contains various hygroscopic moleculeshygroscopic molecules11::–– Amino acids Amino acids 40%40%–– pyrrolidone carboxylic acidpyrrolidone carboxylic acid 12% 12% –– LactateLactate 12%12%–– Urea Urea 7%7%

vv NMF levels ↓ by:NMF levels ↓ by:–– Repeated washing with soaps or detergentsRepeated washing with soaps or detergents22

–– Low humidity (<10%), UV exposureLow humidity (<10%), UV exposure33

–– AgeAge44

–– AtopyAtopy551. Verdier1. Verdier--Sevrain S, Bonte F. Journal of Cosmetic Dermatology Sevrain S, Bonte F. Journal of Cosmetic Dermatology 2007; 6:75. 2. Caspers PJ et al. Journal Investigative 2007; 6:75. 2. Caspers PJ et al. Journal Investigative Dermatology 2001; 116: 434. 3. Katagari C et al. Journal Dermatology 2001; 116: 434. 3. Katagari C et al. Journal of Dermatologic Sci 2003; 31: 29. 4. Horii et al. of Dermatologic Sci 2003; 31: 29. 4. Horii et al. British Journal of Dermatology 1989; 121: 587. British Journal of Dermatology 1989; 121: 587. 5. Matsumoto T et al. Journal of Dermatology 2007; 34: 447.5. Matsumoto T et al. Journal of Dermatology 2007; 34: 447.

Skin’s Moisture Barrier: Skin’s Moisture Barrier: The Mortar (Lipid Matrix)The Mortar (Lipid Matrix)

vv Primary componentsPrimary components11::–– CeramidesCeramides ~~ 50%50%–– CholesterolCholesterol ~~ 23%23%–– Free fatty acidsFree fatty acids ~~15%15%–– Organized in lamellar arrangement as biOrganized in lamellar arrangement as bi--layers with layers with

water; stores water needed for adequate hydration and water; stores water needed for adequate hydration and slows water passageslows water passage

vv Lipid Matrix ↓ by:Lipid Matrix ↓ by:–– AgeAge22

–– Seasonal effectsSeasonal effects11

–– AtopyAtopy221. Verdier1. Verdier--Sevrain S, Bonte F. Journal of Cosmetic Dermatology 2007; Sevrain S, Bonte F. Journal of Cosmetic Dermatology 2007; 6:75. 2. Rogers J et al. Archives in Dermatologic Resarch 1996; 288: 6:75. 2. Rogers J et al. Archives in Dermatologic Resarch 1996; 288: 756. 3. Chamlin SL et al. Archives in Dermatology 2001; 756. 3. Chamlin SL et al. Archives in Dermatology 2001; 137: 1110.137: 1110.

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Moisture Barrier: Moisture Barrier: Additional FactorsAdditional Factors

vv Aquaglyceroporin AQP3Aquaglyceroporin AQP311

–– Membrane protein that forms water channels across cell Membrane protein that forms water channels across cell facilitating transport of water, urea, glycerol within facilitating transport of water, urea, glycerol within epidermis but preventing excessive loss via SCepidermis but preventing excessive loss via SC

–– Expressed from the granulosum to just below the SCExpressed from the granulosum to just below the SCvv Tight Membrane JunctionsTight Membrane Junctions22

–– Water gradient steepest at junction or stratum corneum Water gradient steepest at junction or stratum corneum and stratum granulosumand stratum granulosum

–– TMJ comprises transmembrane proteins that control skin TMJ comprises transmembrane proteins that control skin permeabilitypermeability

1. Verkman AS, Mitra American J Physiology Renal Phys 2000; 1. Verkman AS, Mitra American J Physiology Renal Phys 2000; 278: F13. 2. Madara JL. Annual Review of Physiology 1998; 60: 278: F13. 2. Madara JL. Annual Review of Physiology 1998; 60: 143.143.

Adverse Effects of Adverse Effects of Stool on Skin Stool on Skin

vv Fecal enzymesFecal enzymes–– Protease & lipase potentially break down both Protease & lipase potentially break down both

principal elements of moisture barrierprincipal elements of moisture barrier1,21,2

–– In vivo evidence shows that exposure to In vivo evidence shows that exposure to digestive enzymes in human skin led todigestive enzymes in human skin led to33

uu­­ TEWL & TEWL & ­­ pHpHuuDamage exacerbated when bile salts presentDamage exacerbated when bile salts presentuuVisible damage ONLY when occlusion present Visible damage ONLY when occlusion present uuEvidence of damage present after 12 daysEvidence of damage present after 12 days

1. Atherton DJ Eur Academy Dermatology Venereology 2001; 15 (Supp1): 1. 1. Atherton DJ Eur Academy Dermatology Venereology 2001; 15 (Supp1): 1. 2. Gray M. Journal of WOC Nursing 2004; 31(1 Suppl):S22. Gray M. Journal of WOC Nursing 2004; 31(1 Suppl):S2--9. 9. 3. Anderson PH et al. Contact Dermatitis 1994; 30(3): 152. 3. Anderson PH et al. Contact Dermatitis 1994; 30(3): 152. 4. Buckingham KW, Berg RW. Pediatric Dermatology 1986; 3(2): 107.4. Buckingham KW, Berg RW. Pediatric Dermatology 1986; 3(2): 107.

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Adverse Effects of Stool on Adverse Effects of Stool on SkinSkin

vv Stool ConsistencyStool Consistency–– Overwhelming clinical experience suggests that Overwhelming clinical experience suggests that

liquid stool more damaging than solid (formed) liquid stool more damaging than solid (formed) stoolstool

–– Diarrhea emerged as risk factor in multivariate Diarrhea emerged as risk factor in multivariate analysis of 532 children managed by diapersanalysis of 532 children managed by diapers11

–– Diversion of stool in SICU unit for patients with Diversion of stool in SICU unit for patients with FI & diarrhea ↓ incidence of skin damage from FI & diarrhea ↓ incidence of skin damage from 43.0% to 12.5%43.0% to 12.5%22

1. Adalat S, Wall D, Goodyear H. Pediatric Dermatology Pediatric Dermatology 2007; 24 (5): 283. 1. Adalat S, Wall D, Goodyear H. Pediatric Dermatology Pediatric Dermatology 2007; 24 (5): 283. 2. Benoit R & Watts CA. Journal Wound, Ostomy & Continence Nursing 2007; 34(2): 163.2. Benoit R & Watts CA. Journal Wound, Ostomy & Continence Nursing 2007; 34(2): 163.

Pathogenic Factors Pathogenic Factors vvCandida albicansCandida albicans

–– Found in stool, skin and diaper in 2 groups Found in stool, skin and diaper in 2 groups of infants with incontinence associated of infants with incontinence associated (nappy) dermatitis(nappy) dermatitis1,21,2

–– Both studies reported absence in Both studies reported absence in comparison cohorts without skin damagecomparison cohorts without skin damage

–– Oral thrush emerged as risk factor for Oral thrush emerged as risk factor for incontinence associated dermatitis in incontinence associated dermatitis in multivariate analysis of 532 infants and multivariate analysis of 532 infants and children in diaperschildren in diapers33

1. Rebora A, Keyden JJ. British Journal of Dermatology 1981; 105(5): 551. 1. Rebora A, Keyden JJ. British Journal of Dermatology 1981; 105(5): 551. 2. Goklap AS et al. Tropical & Geographical Medicine 1990; 42(3): 238. 2. Goklap AS et al. Tropical & Geographical Medicine 1990; 42(3): 238. 3. Adalat S, Wall D, Goodyear H. Pediatric Dermatology Pediatric Dermatology 2007; 3. Adalat S, Wall D, Goodyear H. Pediatric Dermatology Pediatric Dermatology 2007; 24 (5): 283.24 (5): 283.

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Pathophysiology of IADPathophysiology of IAD

IAD: IAD: Diagnosis Diagnosis

vv Relies solely on Relies solely on inspection inspection –– Inflammation (bright Inflammation (bright

red) in light skinned red) in light skinned persons persons

–– IAD located in IAD located in skin foldskin foldor or underneath underneath containment devicecontainment device, , borders are poorly borders are poorly demarcated & irregulardemarcated & irregular

–– Surface of skin may Surface of skin may “glisten” owing to “glisten” owing to serous exudateserous exudate

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IAD: Diagnosis in persons with IAD: Diagnosis in persons with Darker Skin TonesDarker Skin Tones

vv Inflammation not readily Inflammation not readily apparent (ie: not bright apparent (ie: not bright red); often presents as red); often presents as area of area of hyperpigmentationhyperpigmentation or or subtlesubtle red tonered tone

vv Hypopigmented areas Hypopigmented areas with chronic with chronic inflammation inflammation

vv Pattern of skin damage Pattern of skin damage does not varydoes not vary

IAD: Diagnosis IAD: Diagnosis

vv Inspect Skin Folds Inspect Skin Folds –– Opposing skin surfaces trap Opposing skin surfaces trap

& harbor moisture& harbor moisture–– Warm moist environment Warm moist environment

encourages bacterial and encourages bacterial and fungal colonization, fungal colonization, overgrowth and infectionovergrowth and infection

–– Friction occurs as skin folds Friction occurs as skin folds rub against one anotherrub against one another

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IAD: DiagnosisIAD: Diagnosis

vvAssess for skin Assess for skin erosionerosion–– Partial thickness Partial thickness

erosion occurs with erosion occurs with IADIAD

–– Necrotic tissue: Necrotic tissue: eschar or slough, full eschar or slough, full thickness damage thickness damage indicates pressure indicates pressure ulcerationulceration

IAD: DiagnosisIAD: Diagnosis

vv Look for secondary Look for secondary cutaneous infection, cutaneous infection, especially candidiasisespecially candidiasis–– Opportunistic infection with Opportunistic infection with

candida albicanscandida albicans–– Thrives in warm, moist Thrives in warm, moist

environment & damages environment & damages stratum corneumstratum corneum

–– Seen in 18% of one group of Seen in 18% of one group of 976 acute care inpatients976 acute care inpatients11

1. Junkin J, Selekof J. IAD prevalence in acute care. WOCN National Conference, June 2006 1. Junkin J, Selekof J. IAD prevalence in acute care. WOCN National Conference, June 2006 Minneapolis, MN. Minneapolis, MN.

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Differentiate MASD from Differentiate MASD from Pressure UlcerationPressure Ulceration

Gray M et al. JWOCN 2007; 34(2).Gray M et al. JWOCN 2007; 34(2).

Clinical Evidence: Prevention Clinical Evidence: Prevention and Treatment and Treatment

vv Structured skin care Structured skin care regimen should be regimen should be defined based on defined based on available evidence available evidence and followed and followed routinelyroutinely

(Lyder, (Lyder, J ET NursJ ET Nurs 1992; Hunter et al., 1992; Hunter et al., JWOCNJWOCN 2003; Zehrer et al., OWM 2003; Zehrer et al., OWM 2004; Bale et al., J Tissue Viability 2004; Bale et al., J Tissue Viability 2004; Bliss, et al., 2004; Bliss, et al., JWOCN JWOCN 2006)2006)

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IAD: Prevention & Treatment IAD: Prevention & Treatment

IAD: CleanseIAD: Cleanse

vv When frequent bathing necessary, current When frequent bathing necessary, current evidence suggests….evidence suggests….–– Gentle cleansing: Gentle cleansing: NO scrubbing NO scrubbing 1,21,2

–– Select a cleanserSelect a cleanser with pH close to acid mantle of skinwith pH close to acid mantle of skin–– Select product that minimizes potential irritants, Select product that minimizes potential irritants,

scents, etc. scents, etc. –– Towel drying has been found to compromise Towel drying has been found to compromise

moisture barrier, consider nomoisture barrier, consider no--rinse formulation for rinse formulation for frequent bathingfrequent bathing22

1. Gray M et al. Journal of Wound, Ostomy & Continence Nursing 2007; 34(2):134.1. Gray M et al. Journal of Wound, Ostomy & Continence Nursing 2007; 34(2):134.2. Voegeli D. Journal of Wound, Ostomy & Continence Nursing 2008; 35(1).2. Voegeli D. Journal of Wound, Ostomy & Continence Nursing 2008; 35(1).

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CleanseCleanse

vv Incontinence skin cleansersIncontinence skin cleansers–– ‘pH Balanced’ designed to maintain the ‘pH Balanced’ designed to maintain the

acid mantle of perineal skinacid mantle of perineal skin–– Many are “no rinse” (avoids need to towel Many are “no rinse” (avoids need to towel

dry)dry)–– Require Require less timeless time than basin cleansing with than basin cleansing with

soap and watersoap and water–– Many contain emollients or humectants to Many contain emollients or humectants to

preserve lipid barrier, thus combining 2 preserve lipid barrier, thus combining 2 steps into a single actionsteps into a single action

MoisturizeMoisturize

vvThree categoriesThree categories–– HumectantsHumectants attract water to the skin attract water to the skin –– EmollientsEmollients replace lipids to stratum replace lipids to stratum corneumcorneum; ;

designed to smooth skin surfacedesigned to smooth skin surface–– OcclusivesOcclusives act to protect skin from exposure act to protect skin from exposure

to moisture and potential irritants; vary in to moisture and potential irritants; vary in their ability to maintain skin hydrationtheir ability to maintain skin hydration

–– Some prefer emollient based on clinical Some prefer emollient based on clinical considerations, no research available to verify considerations, no research available to verify or refuteor refute

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ProtectProtectvv Skin Protectants shouldSkin Protectants should

–– Act as a “moisture barrier”, protecting skin from Act as a “moisture barrier”, protecting skin from deleterious effects of exposure to irritants and deleterious effects of exposure to irritants and excess moistureexcess moisture

–– Maintain hydration and favorable skin’s normal Maintain hydration and favorable skin’s normal transepidermal water loss (TEWL)transepidermal water loss (TEWL)

–– Avoid maceration when left on for prolonged Avoid maceration when left on for prolonged period of timeperiod of time

–– OptionsOptionsuuOintment based skin protectantsOintment based skin protectantsuuLiquid acrylates (marketed as a skin barrier)Liquid acrylates (marketed as a skin barrier)

ProtectProtect

vvOintment based skin Ointment based skin protectantsprotectants–– PetrolatumPetrolatum: blend of : blend of

castor seed oil & castor seed oil & hydrogenated castor hydrogenated castor oiloil

–– DimethiconeDimethicone: silicone : silicone based oilbased oil

–– Zinc OxideZinc Oxide: white : white powder, mixed with powder, mixed with cream or ointment cream or ointment basebase

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ProtectProtectvv PetrolatumPetrolatum

–– Good protection against irritant Good protection against irritant –– Avoided macerationAvoided maceration–– Modest skin hydrationModest skin hydration

vv DimethiconeDimethicone–– Variable protection against irritantVariable protection against irritant–– Modest protection against macerationModest protection against maceration–– Good skin hydrationGood skin hydration

vv Zinc OxideZinc Oxide–– Good protection against irritantGood protection against irritant–– Did not avoid macerationDid not avoid maceration–– Poor skin hydrationPoor skin hydration

1. Hoggarth A et al. OWM 2005; 51(12): 30.1. Hoggarth A et al. OWM 2005; 51(12): 30.

ProtectProtect

vv Skin barriers (polymer acrylate)Skin barriers (polymer acrylate)–– NonNon--alcohol preferredalcohol preferred

uuLess painLess painuuLess dryingLess drying

vv No different when compared to ointment based No different when compared to ointment based skin protectants in one robust RCT (powered for skin protectants in one robust RCT (powered for economic rather than efficacy outcomes)economic rather than efficacy outcomes)

Bliss DZ et alBliss DZ et al. Journal of Wound, Ostomy & Continence Nursing 2009; 35 (2).. Journal of Wound, Ostomy & Continence Nursing 2009; 35 (2).

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Cleanse, Moisturize & Protect:Cleanse, Moisturize & Protect:Single Step ApproachSingle Step Approach

vv Disposable Bathing Disposable Bathing ClothCloth: Cleanses & : Cleanses & moisturizesmoisturizes

vv Shield ClothsShield Cloths: Tailored : Tailored cloths, cleanse cloths, cleanse (chlorhexidine (chlorhexidine gluconate), moisturize gluconate), moisturize (glycerine, aloe), (glycerine, aloe), protect (3% protect (3% dimethicone)dimethicone)

IAD: TreatmentIAD: Treatment

vv Establish or continue structured Establish or continue structured program based on “cleanse, program based on “cleanse, moisturize & protect”moisturize & protect”

vv Minimize exposure to irritants Minimize exposure to irritants (Aggressively manage UI or FI)(Aggressively manage UI or FI)

vv Treat secondary cutaneous Treat secondary cutaneous infectionsinfections

vv Allow skin to heal or apply Allow skin to heal or apply protectant with active ingredients protectant with active ingredients designed to promote healingdesigned to promote healing

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IAD TreatmentIAD Treatment

vvAluminum sulphate or acetate (Burow’s Aluminum sulphate or acetate (Burow’s Solution) with Stomahesive powder: Solution) with Stomahesive powder: –– Applied as compress; causes protein Applied as compress; causes protein

precipitation & has antimicrobial propertiesprecipitation & has antimicrobial properties–– Exerts drying & soothing effect; followed by Exerts drying & soothing effect; followed by

application of moisture barrierapplication of moisture barrier–– Often used when dermatitis complicated by Often used when dermatitis complicated by

extensive erosion and serous exudateextensive erosion and serous exudate

IAD Treatment:IAD Treatment:CandidiasisCandidiasis

vvCandidiasisCandidiasis–– Topical antifungals are effective for the Topical antifungals are effective for the

treatment of cutaneous infectionstreatment of cutaneous infections–– Effective agents include the polyene Effective agents include the polyene

antibiotics, azoles and the allylaminesantibiotics, azoles and the allylamines11

–– Resistance to antifungals is emerging, careful Resistance to antifungals is emerging, careful monitoring of research literature is essentialmonitoring of research literature is essential

1. Evans E & Gray M, Journal of Wound, 1. Evans E & Gray M, Journal of Wound, OstomyOstomy & Continence Nursing 2003; ,30(1).& Continence Nursing 2003; ,30(1).

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Conclusion Conclusion

vv IAD is an increasingly recognized and IAD is an increasingly recognized and clinically relevant condition associated with clinically relevant condition associated with FI and urinary incontinenceFI and urinary incontinence

vv Patients with IBD are at increased risk for FI Patients with IBD are at increased risk for FI and associated sequelae, including IADand associated sequelae, including IAD

vv Prevention and treatment of IAD is based on Prevention and treatment of IAD is based on a structured skin care regimen that employs a structured skin care regimen that employs principles of cleanse, moisturize and protectprinciples of cleanse, moisturize and protect

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