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Peristomal Skin Complications
Peristomal Skin Complications Søren Meisner, MD, and Lis Balleby, RN ET Peristomal skin complications are very common and are seen in 80% of persons operated on with an ostomy. Our article gives, in addition to general principles of skin care, detailed recommendations for erythema and leakage, irritant contact dermatitis, allergic contact eczema, folliculitis, infections, pseudoverrucous epidermal hyperplasia, dermatologic diseases and special wounds. All topics with information on etiology, patient history, diagnosis, treatment, follow-up and referral. The summary of recommendations can be used as a quick guide to peristomal skin complications in the care of ostomy patients. Semin Colon Rectal Surg 19:146-150 © 2008 Elsevier Inc. All rights reserved.
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stomies are surgically created openings connecting the gastrointestinal tract or the urinary tract and the skin. An ostomy operation leads to incontinence and it is necessary to wear a bag/appliance for collection of bowel content or urine. Peristomal skin complications are very common and are seen in 80% of persons operated on with an ostomy.
General Principles of the Skin Care Around an Ostomy The adhesive, keeping the appliance in place, should completely cover the peristomal skin to protect against urine, feces, or bowel secretion. It is important that the opening in the adhesive plate is carefully fitted to match the exact size of the stoma without covering any mucosa. Gentle removal of adhesives is recommended to avoid skin stripping. Skin cleansing is performed with a soft tissue or cotton balls and water, no use of chemical substances. Hair may be cut or trimmed close to the skin or very carefully shaved. The skin has to be absolutely dry before dressing. The skin around the ostomy is partly or completely occluded, resulting in some changes in the skin. Visible changes in the skin are very often seen, although this does not mean that a skin problem exists. These changes are chronic and can be seen as hypo- or hyperpigmentation and atrophy. Skin lesions and wounds may be caused by mechanical trauma, chemical trauma, Candida, or bacteria. Very often lesions are caused by a combination of several factors. Urine, feces, or bowel secretion, coming in contact
Department of Surgery K, Bispebjerg University Hospital, Copenhagen, Denmark. Address reprint requests to: Søren Meisner, MD, Chief Surgeon, Dept. of Surgery K, Bispebjerg University Hospital, Copenhagen, Denmark. E-mail: [email protected].
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1043-1489/08/$-see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1053/j.scrs.2008.07.003
with the skin, causes most peristomal skin complications. The reason is generally poor technique using/placing the appliance, maybe in combination with a difficult ostomy: mal positioning (eg, ostomy in a fold, close to scars, or too close to the groin), improper construction or bad surgical technique (eg, ostomy at skin level, retraction of the surrounding skin, irregular mucocutaneous border), or complications (prolapse, retracted ostomy, peristomal hernia). In the diagnostic workup of peristomal skin complications, it is mandatory that the ostomy operated perform a complete change of the appliance, to control the technique. The peristomal surroundings are inspected with the patient in different positions (sitting, supine, and standing) to evaluate possible mal positioning. Uniform description of peristomal skin changes is very important: Atrophy: loss of substance with sustained structure Blister: fluid collection in the skin ⬎0.5 cm Crusta: crust, formed by dried vesicle or pustule Excoriation: traumatic loss of skin substance Erosion: superficial wound with loss of epidermis Erythema: redness of the skin caused by dilation and congestion of the capillaries Hyper granulation: granulation tissue at the mucocutaneous border Pustule: small inflamed skin swelling filled with pus Ulcer: ulceration of all skin layers Vesicle: small circumscribed elevation of the epidermis containing a serous fluid ⬍0.5 cm Skin changes are typically seen within an area of 10 ⫻ 10 cm corresponding to the size of the adhesive. The adhesive is the part of the appliance keeping the appliance in place and protecting the skin against irritation from urine, feces, or
Peristomal skin complications bowel secretion. The distribution of the skin changes can give a hint of the etiology/cause of the changes: Close to the ostomy: irritation/damage by urine, feces, or bowel secretion due to leakage. In the periphery: too violent removal of the appliance (stripping) or too strong adhesion. The adhesive area: reaction to the content in the adhesive (irritant contact dermatitis or allergy). Be aware that the appliance can consist of more types of adhesive, one closest to the ostomy (more absorptive) and one in the periphery (more adhesive).
Follow-Up and Referral As soon as the ostomy operated discovers skin problems, he or she should be referred to the ostomy care nurse. This strategy helps to shorten treatment time and allows registration of complications and follow-up. A skin damage, which might seem harmless in a different part of the body, can quickly develop into a serious condition (vicious circle): the adhesive cannot adhere sufficiently—feces or urine comes in contact with the skin and accelerates the skin damage—the adhesive cannot adhere sufficiently . . . . The stoma care nurse will, if relevant in the particular case, cooperate with both dermatologist and surgeon.
Erythema/Erosion and Leakage
147 dissolved adhesive might give a hint of possible causes. The peristomal surroundings are inspected with the patient in different positions (sitting, supine, and standing) to evaluate possible mal positioning. Several factors may cause the erythema/erosion: mal positioned ostomy, very short ostomy, retracted ostomy, folds and excavations close to the ostomy, or other complications related to the surgical technique. Change in BMI create changes in the structure of the abdominal wall or development of a peristomal bulge or hernia.
Treatment The cause has to be established and if possible removed. Poor technique in change of the appliance should be corrected. When the skin is damaged, it can be moist or secreting, making it difficult for the adhesive to adhere. It is recommended to use Gentian violet (maximum, 0.5%), a siliconebased film or hydrocolloid powder. Dealing with complications, such as hernia, skin retractions, folds, and retracted ostomy, the stoma care nurse tries initially to compensate using special appliance techniques (paste, convex adhesive, and belt). Surgical correction might be an option if leakage with skin problems continues despite the special care.
Follow-Up and Referral Stoma care nurse, if relevant in the particular case, cooperates with the surgeon.
Etiology
Irritant Contact Dermatitis
Erythema/erosion is most often caused by episodes of leakage. During leakage, feces or urine comes in contact with peristomal skin. The skin is eroded by proteolytic enzymes, alkaline environment, and ammonia. Urine, feces, or bowel secretion makes its way underneath the adhesive and dissolves the adhesive. The skin becomes macerated and the occlusion makes the damaging agents even more potent. Leakage is seen due to poor technique using the appliance, mal placement, or mal construction of the ostomy.
Etiology
Patient History The daily routine is checked thoroughly. A number of questions are relevant: removal of the adhesive, substance used for cleaning the skin, how the cleaning is performed, how often and of which indication a change of appliance is made, use of template, manual cutting of the adhesive, does the size of the opening fit the ostomy, use of skin care substances, episodes of diarrhea.
Morphology The damaged area will start at the mucocutaneous border and correspond to the leakage. The lesions will vary from dry to wet erythema and erosion.
Skin changes can be caused by irritations from the compounds in the adhesive or from compounds in other substances used in the ostomy care. It is often seen after longtime use of adhesives containing acrylate. Irritant contact dermatitis is a nonallergic form of contact eczema, provoked by irritating compounds, damaging the skin chemically or mechanical. Irritant contact dermatitis can be seen in an acute and a chronic form. The peristomal skin condition can also be disturbed by chemical compounds such as soap or other detergents (gasoline, ether, alcohol, and perfume), bacteria, or Candida and due to leakage (see erythema/erosion). Mechanical destruction of the skin is seen due to forceful removal of the adhesive (stripping), friction from a belt, and heavy skin cleaning (eg, with foam). Many compounds are detergents, which, besides the toxic effect, also removes the protective fatty layer between the keratinocytes. The skin barrier is destroyed. The mechanically and chemically damaged skin is very vulnerable to biochemical compounds, bacteria, and Candida. Be aware that a severe untreated eczema somewhere else on the body increases the risk of peristomal skin problems.
Patient History Diagnosis In addition to the history, the ostomy operated should perform a complete change of the appliance, to control the technique. The appliance is checked and the degree and area of
The patient should be queried as to erythema/erosion and leakage, any change in type of appliance, use of new detergent, changes in social life, work, new sport activity, etc., which might have lead to change in ostomy care routine.
S. Meisner and L. Balleby
148
Morphology
Diagnosis
Changes can vary from slight erythema to corrosion of the skin with ulcerations. The most seen changes are erythema, infiltration of the skin, crusted and vesicles, or bulla. If the changes are due to reaction to compounds in the adhesive, the damaged area fits/corresponds to the area of the adhesive. If stripping is the cause, the eczema is seen where the adhesive “force” is maximum, that is, in the periphery.
Test the product under suspicion somewhere else on the abdomen for 24 to 48 hours. If the reaction is negative, begin further workup by patch testing, prick testing, and usage test.
Diagnosis It is not possible visually to differentiate between allergy and irritant dermatitis. The diagnosis is made as an exclusion diagnosis or based on patient history, and possible supplement to a usage test.
Treatment The cause has to be established and if possible removed. If the damaged area is very moist, treatment with Gentian violet (maximum, 0.5%), silicone-based film, or hydro-colloid powder is recommended. If the recovery is slow (not resolved within 1 to 2 weeks), group 1 hydrocortisone liniment is added. If the problem is not resolved after an additional 3 to 4 weeks, referral to a dermatologist is indicated. After complete healing, it is recommended to use a special skin-protecting base plate to avoid relapse. Make sure that the patient is correctly instructed in ostomy care technique and that the technique is maintained. If stripping occurs, despite correct technique, change to an adhesive with less adhesive capabilities. In a situation with missing or slow healing or quick relapse, consult with the surgeon, discussing possible surgical correction of surgical-related etiology.
Treatment The allergen must be identified and avoided. It is necessary to search for additional information concerning products, to make sure that a product without the allergen can be found. Treatment with group 1 hydrocortisone liniment is recommended. If the problem is not resolved after an additional 3 to 4 weeks, referral to a dermatologist is indicated. After complete healing, it is recommended to use a special skin protecting base plate to avoid relapse.
Follow-Up and Referral The stoma care nurse will, if relevant in the particular case, cooperate with both dermatologist and surgeon.
Folliculitis Etiology Folliculitis is infected hair follicles and is seen when the single hair escapes the adhesive and draws bacteria backwards into the hair follicle. It can also be seen after traumatic removal of hair where bacteria contaminate the empty follicle. The infection is most often caused by Staphylococcus.
Patient History
Follow-Up and Referral
See section on erythema/erosion. The daily routine should be mapped.
The stoma care nurse will, if relevant in the particular case, cooperate with both dermatologist and surgeon.
Morphology
Allergic Contact Eczema Etiology Allergic contact eczema is an allergic reaction caused by an allergen. The allergy is lifelong. The allergen might be a substance in the appliance, the adhesive, additional aids, or skin care products. Sensitization time with powerful allergens can be a few weeks, but it often take years to develop the allergy. Allergy due to ostomy care products is rare.
Punctuate redness of affected hair follicles. They progress from eythematous vesicles or pustules to encrusted areas as they resolve. The lesions are very often itchy and a burning pain.
Diagnosis Diagnosis is based on patient history and having the patient demonstrate change of appliance.
Treatment
Questions to ask include: How does the allergy present? Previous experienced allergic reactions to specific products? Any history of atopic disease among relatives or patient? Any coincidence with changes in skin care technique or changes in the type of skin care products?
Instruction in the correct technique when changing the appliance is the correct treatment. Cut or carefully shave (hair trimmer) the hairy area. If the condition of the skin does not resolve, bacteria culture and antibiotic resistance is performed. Consultation with dermatologist for selection of antibiotic.
Morphology
Follow-Up and Referral
Allergic contact eczema often has limited damage: erythema, congestion, secreting skin, vesicles, ulceration, and bleeding.
The stoma care nurse will, if relevant in the particular case, cooperate with the dermatologist.
Patient History
Peristomal skin complications
Infections Etiology Infections with bacteria and Candida in the peristomal skin are relative rare. If infections occur, it is most often seen in an area with skin damage. The moist, warm, and slight alkaline environment is an excellent growth condition. It is always seen in patients with suboptimal technique in ostomy selfcare. When the skin barrier is breached, infection with Candida is seen. Increased tendency to infections is seen with poor general condition, diabetes mellitus, and during systemic treatment with antibiotics, steroids, and chemotherapy.
Patient History A patient history is taken with a focus on general health/ medical condition and on medical treatments (diabetes mellitus), especially conditions where systemic steroids are used. (See also section on erythema/erosion.) Daily routines should be mapped and the patient should demonstrate ease in changing of the appliance.
Morphology Great variations in clinical picture can be seen. In daily praxis it is most often infections with Candida, typically presenting with severe redness, secretion, satellite pustules outside the infected area, and white to gray color of the affected area. Infection with bacteria is often caused by Staphylococcus (see section on folliculitis).
Diagnosis Diagnosis is based on collaboration with a dermatologist (patient history, swab for bacteria culture and antibiotic resistance, skin swab for direct microscopy for Candida).
Treatment The cause has to be established and if possible removed. Infections are often secondary. The damaged skin area can be treated with Gentian violet (maximum, 0.5%) two to three times a week. If the problem does not resolve within 2 weeks, testing for bacteria culture and antibiotic resistance and skin swab for direct microscopy for Candida should be performed. Further workup and treatment is done in collaboration with a dermatologist.
149 mainly from triple phosphate (calcium, magnesium, and ammonium phosphate) but can also be developed from urea.
Patient History (See section on erythema/erosion.) The daily routines should be mapped and patient should demonstrate ease in the change of appliance.
Morphology Thickened epidermis with white, gray, brown, or dark wartlike papules or nodules (2 to 5 mm above skin level, some times up to 10 mm), they can be single or more confluent. The tissue is fragile and bleeds easily. The damage always starts at the mucocutaneous junction and spreads over small to larger areas corresponding to the leakage. The lesions can be painful and hypersensitive. Encrustations are seen as gray to white deposits on the skin or in the collection bag. The deposits (crystals) can damage the skin and cause bleeding.
Diagnosis Diagnosis is based on the patient history and having the patient demonstrate change of appliance. The clinical features are quite typical.
Treatment The cause has to be established and if possible removed. Teaching the correct technique for changing the appliance is mandatory. Due to pain, bleeding, and the elevated lesions, correct ostomy care can be difficult. A vicious circle is soon seen and the lesions can grow rapidly. Most important is careful fitting of the pouch opening, maybe assisted by paste. Small lesions are treated with silver nitrate twice a week. Large lesions can be removed with Argon Plasma Coagulation; sometimes local anesthesia is needed. In cases with encrustations, the pH of the urine should be checked and acidification of the urine might be helpful (vitamin C), preventing urea-producing microorganisms seen in urostasis or urinary infections. Use of a leg bag and a special night drainage bag can also be used.
Follow-Up and Referral The stoma care nurse will, if relevant in the particular case, cooperate with a surgeon.
Follow-Up and Referral The stoma care nurse will, if relevant in the particular case, cooperate with the dermatologist.
Pseudoverrucous Epidermal Hyperplasia
Dermatologic Diseases The peristomal skin, in patients with known dermatologic diseases (psoriasis, atopic dermatitis), is generally less resistant. Since the skin is constantly in a stress condition due to the appliance, recurrence of the dermatologic disease can be seen in the area around the ostomy.
Etiology Pseudoverrucous epidermal hyperplasia is seen when the skin is in contact with a chronic irritant factor, typically when leakage occurs frequently. In urostomy patients, encrustations are also seen. These are crystal deposits on the skin,
Patient History (See section on erythema/erosion and allergic contact eczema.) It is important to check the technique used in changing the appliance.
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Morphology Morphology depends on the dermatologic disease.
Diagnosis
P. gangrenosum is treated locally with group 1 hydrocortisone (liniment). If no effect of the treatment or quick relapse, consult the surgeon (operative correction of surgical-related ostomy complications).
Diagnosis is made in collaboration with a dermatologist.
Treatment Treatment is always in collaboration with a dermatologist. Local treatment of the peristomal skin is difficult and demanding. When the active drug is delivered in ointments and lotions, the skin gets fatty, making the adhesive difficult or impossible to adhere to the skin. As an alternative, liniment designed for treatment of nail and hair can be used. These compounds often irritate due to the content of spirits or alcohol. Allow the spirits or alcohol to evaporate (in a cup) before applying it to the skin. If the skin damage is confined to a smaller area, lotion covered with a film (Tegaderm™) can be used before applying the adhesive. If the lesion presents as an ulcer not located very close to the ostomy, lotion on alginate is put directly in the ulcer cavity and covered with a film.
Follow-Up and Referral The stoma care nurse will, if relevant in the particular case, cooperate with a surgeon.
Special Wounds Pressure wounds are seen after the use of very stiff or hard appliance base plates, compression with a belt, or the use of base plate with convexity. Pyoderma gangrenosum ulcers are painful, often full thickness, and excavate under typically purple-colored skin edges. Etiology is unknown, 50% incidence occurs with underlying systemic disease (inflammatory bowel disease, polyarthritis, hematological disorders). P. gangrenosum can develop in all patients. Compression or convexity probably contributes to the development and it is important not to misdiagnose pyoderma as a pressure wound.
Patient History (See section on erythema/erosion.) It is important to check the technique used in changing the appliance.
Final Remarks Peristomal skin changes are the most common complication in patients after ostomy surgery. A Danish epidemiological study revealed that more than 50% of patients with an ostomy had a peristomal skin disorder at the time of the investigation.1 There are reasons to believe, based on experience from stoma care nurses and from the literature, that two main causes exist. The first one is poor management of the ostomy appliance. The second one is insufficient surgical technique and consequently nuisance to the patients, resulting in poorer quality of life. It is recommended that stoma care nurses and surgeons carry out a lifelong follow-up to the ostomy patients.
Summary of Recommendations for Peristomal Skin Complications Take a patient history. Map daily routines including technique used in changing the appliance (adhesive, detergents, fitting of pouch opening, change in social life, change in underlying disease, ostomy output, etc.). Diagnose, based on the following: 1. Patient history 2. Clinical examination with focus on the ostomy, peristomal area, folds, scars, bulging, hernia, etc. 3. Eventual test for allergy, culture, antibiotic resistance, and skin scrape microscopy Treat, determine, and remove the causative factors. Check and/or change appliance technique. Treat dermatologic diseases. Follow-up: by ostomy care nurse. Referral: In any case of peristomal skin problems, refer to ostomy care nurse. The stoma care nurse will, if relevant in the particular case, cooperate with the surgeon and/or dermatologist.
Diagnosis Diagnosis is based on the clinical features together with the patient history and patient demonstrating a change of the appliance.
Treatment Pressure decompression can be difficult, since the special appliance technique responsible for the complication has been chosen due to episodes of leakage (mal placement, retracted ostomy).
Bibliography Intestinal Stomas—Principles, Techniques and Management. MacKeigan JM, Cataldo PA (eds). St. Louis, MO, Quality Medical Publishing, Inc., 1993 Abdominal Stomas and Their Skin Disorders—An Atlas of Diagnosis and Management. CC Lyon, AJ Smith (eds). Martin Dunitz, 2001
References 1. Herlufsen P, Olsen AG, Carlsen R, et al: Ostomy Skin Study—a study of peristomal skin disorders in patients with permanent stomas. Br J Surg 15(16):854-867, 2006
O
stomies are surgically created openings connecting the gastrointestinal tract or the urinary tract and the skin. An ostomy operation leads to incontinence and it is necessary to wear a bag/appliance for collection of bowel content or urine. Peristomal skin complications are very common and are seen in 80% of persons operated on with an ostomy.
General Principles of the Skin Care Around an Ostomy The adhesive, keeping the appliance in place, should completely cover the peristomal skin to protect against urine, feces, or bowel secretion. It is important that the opening in the adhesive plate is carefully fitted to match the exact size of the stoma without covering any mucosa. Gentle removal of adhesives is recommended to avoid skin stripping. Skin cleansing is performed with a soft tissue or cotton balls and water, no use of chemical substances. Hair may be cut or trimmed close to the skin or very carefully shaved. The skin has to be absolutely dry before dressing. The skin around the ostomy is partly or completely occluded, resulting in some changes in the skin. Visible changes in the skin are very often seen, although this does not mean that a skin problem exists. These changes are chronic and can be seen as hypo- or hyperpigmentation and atrophy. Skin lesions and wounds may be caused by mechanical trauma, chemical trauma, Candida, or bacteria. Very often lesions are caused by a combination of several factors. Urine, feces, or bowel secretion, coming in contact
Department of Surgery K, Bispebjerg University Hospital, Copenhagen, Denmark. Address reprint requests to: Søren Meisner, MD, Chief Surgeon, Dept. of Surgery K, Bispebjerg University Hospital, Copenhagen, Denmark. E-mail: [email protected].
146
1043-1489/08/$-see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1053/j.scrs.2008.07.003
with the skin, causes most peristomal skin complications. The reason is generally poor technique using/placing the appliance, maybe in combination with a difficult ostomy: mal positioning (eg, ostomy in a fold, close to scars, or too close to the groin), improper construction or bad surgical technique (eg, ostomy at skin level, retraction of the surrounding skin, irregular mucocutaneous border), or complications (prolapse, retracted ostomy, peristomal hernia). In the diagnostic workup of peristomal skin complications, it is mandatory that the ostomy operated perform a complete change of the appliance, to control the technique. The peristomal surroundings are inspected with the patient in different positions (sitting, supine, and standing) to evaluate possible mal positioning. Uniform description of peristomal skin changes is very important: Atrophy: loss of substance with sustained structure Blister: fluid collection in the skin ⬎0.5 cm Crusta: crust, formed by dried vesicle or pustule Excoriation: traumatic loss of skin substance Erosion: superficial wound with loss of epidermis Erythema: redness of the skin caused by dilation and congestion of the capillaries Hyper granulation: granulation tissue at the mucocutaneous border Pustule: small inflamed skin swelling filled with pus Ulcer: ulceration of all skin layers Vesicle: small circumscribed elevation of the epidermis containing a serous fluid ⬍0.5 cm Skin changes are typically seen within an area of 10 ⫻ 10 cm corresponding to the size of the adhesive. The adhesive is the part of the appliance keeping the appliance in place and protecting the skin against irritation from urine, feces, or
Peristomal skin complications bowel secretion. The distribution of the skin changes can give a hint of the etiology/cause of the changes: Close to the ostomy: irritation/damage by urine, feces, or bowel secretion due to leakage. In the periphery: too violent removal of the appliance (stripping) or too strong adhesion. The adhesive area: reaction to the content in the adhesive (irritant contact dermatitis or allergy). Be aware that the appliance can consist of more types of adhesive, one closest to the ostomy (more absorptive) and one in the periphery (more adhesive).
Follow-Up and Referral As soon as the ostomy operated discovers skin problems, he or she should be referred to the ostomy care nurse. This strategy helps to shorten treatment time and allows registration of complications and follow-up. A skin damage, which might seem harmless in a different part of the body, can quickly develop into a serious condition (vicious circle): the adhesive cannot adhere sufficiently—feces or urine comes in contact with the skin and accelerates the skin damage—the adhesive cannot adhere sufficiently . . . . The stoma care nurse will, if relevant in the particular case, cooperate with both dermatologist and surgeon.
Erythema/Erosion and Leakage
147 dissolved adhesive might give a hint of possible causes. The peristomal surroundings are inspected with the patient in different positions (sitting, supine, and standing) to evaluate possible mal positioning. Several factors may cause the erythema/erosion: mal positioned ostomy, very short ostomy, retracted ostomy, folds and excavations close to the ostomy, or other complications related to the surgical technique. Change in BMI create changes in the structure of the abdominal wall or development of a peristomal bulge or hernia.
Treatment The cause has to be established and if possible removed. Poor technique in change of the appliance should be corrected. When the skin is damaged, it can be moist or secreting, making it difficult for the adhesive to adhere. It is recommended to use Gentian violet (maximum, 0.5%), a siliconebased film or hydrocolloid powder. Dealing with complications, such as hernia, skin retractions, folds, and retracted ostomy, the stoma care nurse tries initially to compensate using special appliance techniques (paste, convex adhesive, and belt). Surgical correction might be an option if leakage with skin problems continues despite the special care.
Follow-Up and Referral Stoma care nurse, if relevant in the particular case, cooperates with the surgeon.
Etiology
Irritant Contact Dermatitis
Erythema/erosion is most often caused by episodes of leakage. During leakage, feces or urine comes in contact with peristomal skin. The skin is eroded by proteolytic enzymes, alkaline environment, and ammonia. Urine, feces, or bowel secretion makes its way underneath the adhesive and dissolves the adhesive. The skin becomes macerated and the occlusion makes the damaging agents even more potent. Leakage is seen due to poor technique using the appliance, mal placement, or mal construction of the ostomy.
Etiology
Patient History The daily routine is checked thoroughly. A number of questions are relevant: removal of the adhesive, substance used for cleaning the skin, how the cleaning is performed, how often and of which indication a change of appliance is made, use of template, manual cutting of the adhesive, does the size of the opening fit the ostomy, use of skin care substances, episodes of diarrhea.
Morphology The damaged area will start at the mucocutaneous border and correspond to the leakage. The lesions will vary from dry to wet erythema and erosion.
Skin changes can be caused by irritations from the compounds in the adhesive or from compounds in other substances used in the ostomy care. It is often seen after longtime use of adhesives containing acrylate. Irritant contact dermatitis is a nonallergic form of contact eczema, provoked by irritating compounds, damaging the skin chemically or mechanical. Irritant contact dermatitis can be seen in an acute and a chronic form. The peristomal skin condition can also be disturbed by chemical compounds such as soap or other detergents (gasoline, ether, alcohol, and perfume), bacteria, or Candida and due to leakage (see erythema/erosion). Mechanical destruction of the skin is seen due to forceful removal of the adhesive (stripping), friction from a belt, and heavy skin cleaning (eg, with foam). Many compounds are detergents, which, besides the toxic effect, also removes the protective fatty layer between the keratinocytes. The skin barrier is destroyed. The mechanically and chemically damaged skin is very vulnerable to biochemical compounds, bacteria, and Candida. Be aware that a severe untreated eczema somewhere else on the body increases the risk of peristomal skin problems.
Patient History Diagnosis In addition to the history, the ostomy operated should perform a complete change of the appliance, to control the technique. The appliance is checked and the degree and area of
The patient should be queried as to erythema/erosion and leakage, any change in type of appliance, use of new detergent, changes in social life, work, new sport activity, etc., which might have lead to change in ostomy care routine.
S. Meisner and L. Balleby
148
Morphology
Diagnosis
Changes can vary from slight erythema to corrosion of the skin with ulcerations. The most seen changes are erythema, infiltration of the skin, crusted and vesicles, or bulla. If the changes are due to reaction to compounds in the adhesive, the damaged area fits/corresponds to the area of the adhesive. If stripping is the cause, the eczema is seen where the adhesive “force” is maximum, that is, in the periphery.
Test the product under suspicion somewhere else on the abdomen for 24 to 48 hours. If the reaction is negative, begin further workup by patch testing, prick testing, and usage test.
Diagnosis It is not possible visually to differentiate between allergy and irritant dermatitis. The diagnosis is made as an exclusion diagnosis or based on patient history, and possible supplement to a usage test.
Treatment The cause has to be established and if possible removed. If the damaged area is very moist, treatment with Gentian violet (maximum, 0.5%), silicone-based film, or hydro-colloid powder is recommended. If the recovery is slow (not resolved within 1 to 2 weeks), group 1 hydrocortisone liniment is added. If the problem is not resolved after an additional 3 to 4 weeks, referral to a dermatologist is indicated. After complete healing, it is recommended to use a special skin-protecting base plate to avoid relapse. Make sure that the patient is correctly instructed in ostomy care technique and that the technique is maintained. If stripping occurs, despite correct technique, change to an adhesive with less adhesive capabilities. In a situation with missing or slow healing or quick relapse, consult with the surgeon, discussing possible surgical correction of surgical-related etiology.
Treatment The allergen must be identified and avoided. It is necessary to search for additional information concerning products, to make sure that a product without the allergen can be found. Treatment with group 1 hydrocortisone liniment is recommended. If the problem is not resolved after an additional 3 to 4 weeks, referral to a dermatologist is indicated. After complete healing, it is recommended to use a special skin protecting base plate to avoid relapse.
Follow-Up and Referral The stoma care nurse will, if relevant in the particular case, cooperate with both dermatologist and surgeon.
Folliculitis Etiology Folliculitis is infected hair follicles and is seen when the single hair escapes the adhesive and draws bacteria backwards into the hair follicle. It can also be seen after traumatic removal of hair where bacteria contaminate the empty follicle. The infection is most often caused by Staphylococcus.
Patient History
Follow-Up and Referral
See section on erythema/erosion. The daily routine should be mapped.
The stoma care nurse will, if relevant in the particular case, cooperate with both dermatologist and surgeon.
Morphology
Allergic Contact Eczema Etiology Allergic contact eczema is an allergic reaction caused by an allergen. The allergy is lifelong. The allergen might be a substance in the appliance, the adhesive, additional aids, or skin care products. Sensitization time with powerful allergens can be a few weeks, but it often take years to develop the allergy. Allergy due to ostomy care products is rare.
Punctuate redness of affected hair follicles. They progress from eythematous vesicles or pustules to encrusted areas as they resolve. The lesions are very often itchy and a burning pain.
Diagnosis Diagnosis is based on patient history and having the patient demonstrate change of appliance.
Treatment
Questions to ask include: How does the allergy present? Previous experienced allergic reactions to specific products? Any history of atopic disease among relatives or patient? Any coincidence with changes in skin care technique or changes in the type of skin care products?
Instruction in the correct technique when changing the appliance is the correct treatment. Cut or carefully shave (hair trimmer) the hairy area. If the condition of the skin does not resolve, bacteria culture and antibiotic resistance is performed. Consultation with dermatologist for selection of antibiotic.
Morphology
Follow-Up and Referral
Allergic contact eczema often has limited damage: erythema, congestion, secreting skin, vesicles, ulceration, and bleeding.
The stoma care nurse will, if relevant in the particular case, cooperate with the dermatologist.
Patient History
Peristomal skin complications
Infections Etiology Infections with bacteria and Candida in the peristomal skin are relative rare. If infections occur, it is most often seen in an area with skin damage. The moist, warm, and slight alkaline environment is an excellent growth condition. It is always seen in patients with suboptimal technique in ostomy selfcare. When the skin barrier is breached, infection with Candida is seen. Increased tendency to infections is seen with poor general condition, diabetes mellitus, and during systemic treatment with antibiotics, steroids, and chemotherapy.
Patient History A patient history is taken with a focus on general health/ medical condition and on medical treatments (diabetes mellitus), especially conditions where systemic steroids are used. (See also section on erythema/erosion.) Daily routines should be mapped and the patient should demonstrate ease in changing of the appliance.
Morphology Great variations in clinical picture can be seen. In daily praxis it is most often infections with Candida, typically presenting with severe redness, secretion, satellite pustules outside the infected area, and white to gray color of the affected area. Infection with bacteria is often caused by Staphylococcus (see section on folliculitis).
Diagnosis Diagnosis is based on collaboration with a dermatologist (patient history, swab for bacteria culture and antibiotic resistance, skin swab for direct microscopy for Candida).
Treatment The cause has to be established and if possible removed. Infections are often secondary. The damaged skin area can be treated with Gentian violet (maximum, 0.5%) two to three times a week. If the problem does not resolve within 2 weeks, testing for bacteria culture and antibiotic resistance and skin swab for direct microscopy for Candida should be performed. Further workup and treatment is done in collaboration with a dermatologist.
149 mainly from triple phosphate (calcium, magnesium, and ammonium phosphate) but can also be developed from urea.
Patient History (See section on erythema/erosion.) The daily routines should be mapped and patient should demonstrate ease in the change of appliance.
Morphology Thickened epidermis with white, gray, brown, or dark wartlike papules or nodules (2 to 5 mm above skin level, some times up to 10 mm), they can be single or more confluent. The tissue is fragile and bleeds easily. The damage always starts at the mucocutaneous junction and spreads over small to larger areas corresponding to the leakage. The lesions can be painful and hypersensitive. Encrustations are seen as gray to white deposits on the skin or in the collection bag. The deposits (crystals) can damage the skin and cause bleeding.
Diagnosis Diagnosis is based on the patient history and having the patient demonstrate change of appliance. The clinical features are quite typical.
Treatment The cause has to be established and if possible removed. Teaching the correct technique for changing the appliance is mandatory. Due to pain, bleeding, and the elevated lesions, correct ostomy care can be difficult. A vicious circle is soon seen and the lesions can grow rapidly. Most important is careful fitting of the pouch opening, maybe assisted by paste. Small lesions are treated with silver nitrate twice a week. Large lesions can be removed with Argon Plasma Coagulation; sometimes local anesthesia is needed. In cases with encrustations, the pH of the urine should be checked and acidification of the urine might be helpful (vitamin C), preventing urea-producing microorganisms seen in urostasis or urinary infections. Use of a leg bag and a special night drainage bag can also be used.
Follow-Up and Referral The stoma care nurse will, if relevant in the particular case, cooperate with a surgeon.
Follow-Up and Referral The stoma care nurse will, if relevant in the particular case, cooperate with the dermatologist.
Pseudoverrucous Epidermal Hyperplasia
Dermatologic Diseases The peristomal skin, in patients with known dermatologic diseases (psoriasis, atopic dermatitis), is generally less resistant. Since the skin is constantly in a stress condition due to the appliance, recurrence of the dermatologic disease can be seen in the area around the ostomy.
Etiology Pseudoverrucous epidermal hyperplasia is seen when the skin is in contact with a chronic irritant factor, typically when leakage occurs frequently. In urostomy patients, encrustations are also seen. These are crystal deposits on the skin,
Patient History (See section on erythema/erosion and allergic contact eczema.) It is important to check the technique used in changing the appliance.
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Morphology Morphology depends on the dermatologic disease.
Diagnosis
P. gangrenosum is treated locally with group 1 hydrocortisone (liniment). If no effect of the treatment or quick relapse, consult the surgeon (operative correction of surgical-related ostomy complications).
Diagnosis is made in collaboration with a dermatologist.
Treatment Treatment is always in collaboration with a dermatologist. Local treatment of the peristomal skin is difficult and demanding. When the active drug is delivered in ointments and lotions, the skin gets fatty, making the adhesive difficult or impossible to adhere to the skin. As an alternative, liniment designed for treatment of nail and hair can be used. These compounds often irritate due to the content of spirits or alcohol. Allow the spirits or alcohol to evaporate (in a cup) before applying it to the skin. If the skin damage is confined to a smaller area, lotion covered with a film (Tegaderm™) can be used before applying the adhesive. If the lesion presents as an ulcer not located very close to the ostomy, lotion on alginate is put directly in the ulcer cavity and covered with a film.
Follow-Up and Referral The stoma care nurse will, if relevant in the particular case, cooperate with a surgeon.
Special Wounds Pressure wounds are seen after the use of very stiff or hard appliance base plates, compression with a belt, or the use of base plate with convexity. Pyoderma gangrenosum ulcers are painful, often full thickness, and excavate under typically purple-colored skin edges. Etiology is unknown, 50% incidence occurs with underlying systemic disease (inflammatory bowel disease, polyarthritis, hematological disorders). P. gangrenosum can develop in all patients. Compression or convexity probably contributes to the development and it is important not to misdiagnose pyoderma as a pressure wound.
Patient History (See section on erythema/erosion.) It is important to check the technique used in changing the appliance.
Final Remarks Peristomal skin changes are the most common complication in patients after ostomy surgery. A Danish epidemiological study revealed that more than 50% of patients with an ostomy had a peristomal skin disorder at the time of the investigation.1 There are reasons to believe, based on experience from stoma care nurses and from the literature, that two main causes exist. The first one is poor management of the ostomy appliance. The second one is insufficient surgical technique and consequently nuisance to the patients, resulting in poorer quality of life. It is recommended that stoma care nurses and surgeons carry out a lifelong follow-up to the ostomy patients.
Summary of Recommendations for Peristomal Skin Complications Take a patient history. Map daily routines including technique used in changing the appliance (adhesive, detergents, fitting of pouch opening, change in social life, change in underlying disease, ostomy output, etc.). Diagnose, based on the following: 1. Patient history 2. Clinical examination with focus on the ostomy, peristomal area, folds, scars, bulging, hernia, etc. 3. Eventual test for allergy, culture, antibiotic resistance, and skin scrape microscopy Treat, determine, and remove the causative factors. Check and/or change appliance technique. Treat dermatologic diseases. Follow-up: by ostomy care nurse. Referral: In any case of peristomal skin problems, refer to ostomy care nurse. The stoma care nurse will, if relevant in the particular case, cooperate with the surgeon and/or dermatologist.
Diagnosis Diagnosis is based on the clinical features together with the patient history and patient demonstrating a change of the appliance.
Treatment Pressure decompression can be difficult, since the special appliance technique responsible for the complication has been chosen due to episodes of leakage (mal placement, retracted ostomy).
Bibliography Intestinal Stomas—Principles, Techniques and Management. MacKeigan JM, Cataldo PA (eds). St. Louis, MO, Quality Medical Publishing, Inc., 1993 Abdominal Stomas and Their Skin Disorders—An Atlas of Diagnosis and Management. CC Lyon, AJ Smith (eds). Martin Dunitz, 2001
References 1. Herlufsen P, Olsen AG, Carlsen R, et al: Ostomy Skin Study—a study of peristomal skin disorders in patients with permanent stomas. Br J Surg 15(16):854-867, 2006