Understanding peristomal skin complications
Unlike wounds, where the ultimate treatment goal is healing, stomas are a breach of the skin that are designed to stay open in order to drain the stoma effluents. Complications of the peristomal skin disorders are common and require specific management (1). Complications related to the stoma may be surgical or dermatological.
Dermatological complications are common, causing a wide range of symptoms and occurring in 45% of patients, and have been shown to have a significant adverse effect on the patient’s quality of life (2) . Peristomal skin problems account for more than one in three visits to ostomy nurses (2).
On the other hand, in the first few days following stoma formation a number of complications can occur. Three most common problems identified in an audit of almost 4000 newly formed stomas were retraction (40%), separation (24%) and necrosis (9%). (7)
Therefore, peristomal skin requires scrupulous care to maintain its health and avoid dermatological complications. Healthy skin around the stoma is essential to ensure good adhesion, without which the risk of leaking and further skin damage is increased and creates a vicious circle of skin damage and pouch leakage (3).
Preventative action is the most important element of care—the best way to manage peristomal skin conditions is to prevent them from complications in the first place (3). Effective preventative strategies and patient education are vital. Identifying risk factors can help to optimise care. Assessment is crucial—it is important to conduct a targeted visual inspection as well as taking both a holistic and focused patient history (3,4).
Which are the most common peristomal skin complications
Examples of common peristomal skin complications
Condition: Caused either by a reaction to any component of the appliance (hypersensitivity reaction), or by contact with the stoma effluents (moisture associated skin damage) (4,5).
Symptoms: Redness/rash, swelling, tenderness, heat, effusion, pain/itching (4,5) .
Management: Avoid substances that cause allergic reaction (3), and consider using an adhesive remover. Do not use products/chemicals unless there is a specific indication for the individual patient (3). Check the appliance fits correctly and adapt if necessary. Consider using a barrier product such as Askina® Barrier Film.
Condition: Caused by tightness or excessive pressure of belt or any appliance that is too tight/rigid (3,5).
Symptoms: Erythema that does not resolve within 1-2 minutes of removing a pouching system (5).
Management: Assess the skin rigorously for pressure/skin damage (3). Discontinue the use of a belt where possible, or loosen when in use (3). If pressure damage occurs, consider management with thin hydrocolloid dressings(3).
Condition: Usually caused by staphylococcal infection or by complications resulting from removing hair from the skin around the stoma (4,5).
Symptoms: Lesion originating from the hair follicle sometimes pustular and with erythema, tends to be superficial (4,5).
Management: Recommend a gentle shaving procedure that is not to be performed more than once a week(3). Consider antibacterial soap/products (3). Consider using a barrier product (eg. Askina® Barrier Film and/or Superfiller).
Condition: Caused by chronic exposure of the skin to urine (5).
Symptoms: When the skin is exposed to alkaline urine, crystalline crusts are often formed on the skin surface – this may lead to wart-like hypertrophy and a subsequent inflammatory response (5).
Management: Consider use of seal or similar products (3,5). Urine may be acidified by the patient ingesting cranberry juice or vitamin C (3,5). Consider a barrier product (e.g. Askina® Barrier Film and/or Superfiller) (3).
Yeast Infection (Candidiasis)
Condition: Caused by leakage, excessive sweating of the skin, antibiotic therapy, or broken skin (4,5).
Symptoms: Initially presents as a pustule, progresses to erythemic confluent plaque with satellite lesions; burning, itching (4,5).
Management: Treat with antifungal powder at each pouch change until resolved (3). Educate patient in drying technique and how to avoid a moist environment (3). Consider a skin sealant or protective skin barrier product (e.g. Askina® Barrier Film and/or Superfiller) (3).
Skin Care Tips
- Clean the skin with a pH-balanced product (or in some cases water alone may be used) (3). Do not use emollient or oil-based products, nor those that may dry the skin. Avoid chemicals that may cause irritation (6).
- Maintain dry skin in order to reduce the risk of candidiasis. Dry skin is also essential to obtain a good adhesive seal. After bathing with the bag on, dry the skin and the pouching system carefully (3).
- Protect the skin by using non-traumatic skin protectors and cleansing the skin carefully. Remove skin protectors gently in order to avoid trauma/skin stripping. Consider using a skin sealant to prevent trauma in patients with sensitive skin (3).
Quick Guide: Peristomal Skin management
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Solutions for ostomates, clinicians and caregivers
1) Herlufsen P et al (2006) Study of peristomal skin disorders in patients with permanent stomas. British Journal of Nursing 15(16):854-62
2) Jemek GBE, Nybaek H (2008) Peristomal skin problems account for more than one in three visits to ostomy nurses. British Journal of Dermatology 159:1207-14
3) Rolstad BS, Erwin-Toth P (2004) Peristomal skin complications: prevention and management. Ostomy Wound Management 50(9):68-77
4) Nybaek H, Jemec GBE (2010) Skin problems in stoma patients. JEADV 24:249-57
5) Woo KY, Sibbald RG, Ayello EA et al (2009) Peristomal skin complications and management. Adv Skin Wound Care 22:522-32
6) Gray M, Colwell JC, Doughty D et al (2013) Peristomal moisture-associated skin damage in adults with fecal ostomies. J Wound Ostomy Continence Nurs 40(4):389-99
7) Burch.J (2008) Stoma Care. 1st Edition. Wiley-Blackwell. p 233