Peristomal Skin Complications
Methods taught by an Enterostomal Therapy (ET) Nurse, as well as supplemental written information about ostomy care, should help to prevent the development of skin problems related to ostomy care. However, skin complications can occur and these need to be identified quickly and managed appropriately in order to avoid further problems. Ideally, assessment and management of peristomal skin problems should be done in conjunction with an Enterostomal Therapy Nurse so that correct determination of the problem can occur, and correct treatment can be initiated.
The most common problems that can occur with the peristomal skin are: peristomal skin excoriation or irritation; mechanical irritation; allergy/sensitivity; folliculitis; and monilia. Other causes of skin irritation may be due to the construction/shape/size of the stoma, abdominal contours (dips and creases), changes in weight, or incorrect pouching systems.
Peristomal Skin Excoriation
Stool excoriation is the most common skin complication. It can lead to redness, weepy bleeding areas, pain, itching, stinging or burning sensations. Skin excoriation is often the result of stool coming into contact with the peristomal skin. Additional factors which may lead to excoriation include chemotherapy, radiation, psoriasis, adverse reaction or side effect to certain medications such as, steroids, antibiotics, chemotherapy, or immunosuppressives. A flush or retracted stoma can lead to stool leakage and excoriation. Poor hygiene, an inappropriate pouching system as well as allergies or sensitivity can also cause skin reactions.
The most common reason for stool irritation is an appliance or flange with an opening that is too large. Too much skin becomes exposed and stool comes in contact with it, causing irritation/erosion. The opening of an appliance/flange should be no more than 1/8 inch (3 to 4 mm) larger than the base of the stoma. This allows for adequate skin protection, but also ensures some "wiggle" room for peristalsis or normal movement of the stoma.
The opening should not be snug against the stoma as this can cause a laceration or a cut to the stoma to occur. To ensure that the opening is correct, save the paper or plastic backing of the current appliance and place it over the stoma, ensuring that it is centered over the opening. Look in a mirror and check the gap between the base of the stoma and the edge of the opening. The stoma may need to be moved around (use a tissue and just gently move it from side to side, or up and down) to check all sides. If the opening is too large, then the pattern needs to be adjusted accordingly.
Once the cause of the stool irritation has been identified and corrected, then the actual treatment is quite simple. Using a pectin based powder (e.g. Stomahesive Powder™ or Premium Powder™), sprinkled lightly on the affected area, and then sealed with a skin sealant (e.g., No Sting™ or Skin Prep™) is usually sufficient. Using powder only may prevent the appliance from adhering to the skin, so a sealant is helpful. Usually, if all things are corrected, then healing or resolution should occur by the time the next appliance change is due. Ongoing difficulties emphasize the need for review by an Enterostomal Therapy Nurse.
Mechanical irritation is another common source of irritation. This tends to be related to the removal technique of ostomy appliances, or due to fragile skin. If an appliance is removed too quickly, then the first layer of skin may become damaged, leaving a patchy, red, painful area that may "weep" fluid. This tends to happen more easily under the tape border portions of flanges, and is less likely under barrier portions of appliances. Individuals who have fragile skin (e.g. people who have had long-term steroid use, or the elderly), may be more susceptible to skin loss or damage during appliance changes.
Routine removal of the appliance should be done slowly and gently by rolling or pushing the skin away from the back of the appliance.
Peeling should be avoided (do not "rip" quickly, as is commonly done with bandages), particularly with tape bordered appliances.
If technique is not at issue, then perhaps other causes such as fragile skin, may be considered. Some individuals find the use of skin sealants such as No Sting™ or Skin Prep™ under appliances help provide a sufficient "shield" between the appliance and the skin to allow for protection and avoidance of damage. Some people find that they need to switch from a tape border product to a full barrier product to avoid problems. An Enterostomal Therapy Nurse can help to determine the best course of treatment.
Once the cause has been determined and corrected, actual treatment can be done simply with the use of a pectin-based powder (e.g., Stomahesive Powder™ or Premium Powder™), sprinkled on the affected area, and then sealed in with a skin sealant (e.g., No Sting™ or Skin Prep™). Healing/resolution will usually occur by the next appliance change. Ongoing problems emphasize the need for help from an Enterostomal Therapy Nurse.
Allergies or sensitivities to products can occur over time. These reactions are not always predictable and may take months or years to develop. Sometimes, the reaction can occur quite quickly, particularly if there is known previous sensitivities to tape(s). The reactions can range from persistent itchiness without actual rash or skin breakdown, to blistering, redness and skin breakdown. Allergies or sensitivities tend to happen more easily with tape bordered products than with full barrier products.As indicated above, the range of reactions can be quite varied. For sensitivities that just involve itchiness with no rash or skin breakdown, then using a skin sealant (e.g., No Sting™ or Skin Prep™) as a "shield" between the appliance and the skin.
Sometimes, using a full barrier product between the skin and appliance (e.g., Extra Thin Duoderm™ or Coloplast™ barrier), may be needed to improve the situation.If there is actual blistering of the skin, then at an absolute minimum, the choice of appliances must be changed. Depending upon the severity of the allergy and skin blistering/breakdown, you may need to be seen by an Enterostomal Therapy Nurse to help manage the reaction. Measures such as providing an interim appliance that will allow the skin to heal by helping to cope with the "weepy" fluid from the blistered areas and by helping to select an alternate appliance may be beneficial solutions. "Patch testing" of other products on unaffected skin may be recommended to help determine the best pouching option.
Folliculitis, infected hair follicles, can cause redness and sometimes pustules at the base of the hair follicles. There is often itching, burning and pain. This can be due to damage to the hair follicles usually after the traumatic removal of an appliance or when tape is removed too quickly. To prevent damage to the hair follicles, excess hair around the stoma should be gently removed with an electric razor, always shaving in the direction of hair growth. Scissors can also be used to remove excess hair. Protective powder can be added to the skin prior to shaving to decrease trauma. Appliances should always be removed gently by pushing the skin away from the barrier rather than pulling away from the skin.
Monilia/Candida Albicans (Yeast Infection)
Yeast can occur under the appliance as a result of excessive moisture and heat (e.g. perspiration on hot, humid days; long soaks in hot tubs), after antibiotic use, or when someone is immunocompromised (e.g. chemotherapy). Patches of yeast are solid red in color with an irregular border and will have tiny little red or white points scattered out from the main rash — called "satellite lesions". It can be itchy, and in severe cases, may weep slightly. It is important to check for the presence of yeast in other areas such as under the arms, in the groin, under breasts, in abdominal folds or in the mouth. If yeast is found in these areas as well, they must also be treated topically, usually with a cream such as Canestan™ or a mouth rinse in the case of oral yeast.
For treatment under the appliance, Mycostation™ powder is most commonly used. The powder is sprinkled lightly on the affected areas and sealed in with a skin sealant (e.g. No Sting™ or Skin Prep™). This process is repeated with each appliance change, usually for about three to four changes or until the rash is resolved. If there is no resolution, then an Enterostomal Therapy Nurse should be contacted for review.