Peristomal Skin Complications: Management
Recommendations
| Identify and Treat the Cause | ||
|---|---|---|
| 1 | Take a careful history and assess each patient’s risk factors for skin barrier disruption. | Level of Evidence Not Assessed |
| Address Patient-centered Concerns | ||
|---|---|---|
| 2 | Provide information and advice on prevention and treatment options. | Level of Evidence Not Assessed |
| Provide Local Care | ||
|---|---|---|
| 3 | Determine and implement appropriate management technique for the specific peristomal skin complication detected. | Level of Evidence Not Assessed |
| 4 | Identify and implement appropriate strategies to prevent future complications, including patient education, reinforcement and follow-up. | Level of Evidence Not Assessed |
| 5 | Reassess skin barrier function regularly and modify the clinical approach as necessary. | Level of Evidence Not Assessed |
| Provide Organizational Support | ||
|---|---|---|
| 6 | Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information | Level of Evidence Not Assessed |
Background
Management of peristomal skin complications depends on the type of complication and the cause.• Chemical injury:
o Irritant contact dermatitis may result from skin contact with stoma effluent or skin care products. One or more of the following may be required: a smaller opening for the pouching system or a refitting with a convex adhesive surface; filling of irregularities in the peristomal skin with a skin barrier product; or reinforcement of correct ostomy care techniques. Dusting irritated peristomal skin with hydrocolloid powder prepares it for forming a secure seal with the pouch adhesive.
o Pseudoverrucous lesions may develop with chronic exposure of the skin to effluent. The management approach is similar to that followed for irritant contact dermatitis. In addition, pouch changes may need to be more frequent during initial treatment.
o Encrustations are crystal deposits seen on skin exposed to alkaline, concentrated or infected urine. If pseudoverrucous lesions are present, they are managed as described above. White vinegar soaks can dissolve encrustations. The skin barrier can then be applied. It is important to ensure an adequate fluid intake to achieve a dilute urine and to check urine pH at each follow-up visit. If necessary, a 1-g maintenance dose of timed-release vitamin C can acidify the urine.
• Mechanical injury:
o Pressure/shear results in erythematous or abraded skin in the area pressure is delivered. A smaller opening on the pouching device and/or a refitting maybe necessary. The belt should be loosened, or discontinued if possible.
o Stripping can be seen as erythematous and denuded patches where an adhesive was used. Skin sealants may decrease trauma during adhesive removal. It is also important to reinforce the importance of gentle adhesive removal techniques, in the direction of hair growth while providing support for the skin.
o Mucocutaneous separation, or interruption in the suture line attaching the stoma to the skin, may be seen soon after surgery. It may be necessary to irrigate the area and pack with a hydrocolloid or powder or absorbent materials for larger wounds. The pouching system is placed over the packing to cover the entire peristomal area.
o Mucosal transplantation results in mucosal tissue migrating from the base of the stoma or scattered near the stoma. Dusting the skin with hydrocolloid powder creates a dry environment and covers mucosal transplantation area before applying pouching system.
• Infectious complications:
o Candidiasis initially presents as a pustule that progresses to burning and pruritic plaques with satellite lesions. Candidiasis is treated with antifungal powder at each pouch change until the infection has resolved. Patient education about drying the pouching system after exercise or contact with water can prevent further episodes. A skin sealant may improve pouching system adhesion in hot and humid weather.
o Folliculitis appears as erythematous and possibly pustular lesions associated with hair follicles, due to infection with Staphylococcus aureus. The ostomate should use a gentle shaving technique and avoid shaving more than once weekly. Using an antibacterial soap may also be helpful. Topical or systemic antibiotics may be necessary if local care does not clear the infection.
• Immunologic complications:
o Allergic contact dermatitis appears as a skin reaction located only on skin in contact with an allergen. The cause should be identified and product use discontinued. Patch testing may be used. Antihistamine and/or corticosteroid treatment may be required.
• Disease-related complications:
o Varices (caput medusae) appear as purplish skin with dilated and tortuous veins. Treatment is based on managing the underlying liver disease; selecting atraumatic products; and teaching gentle ostomy care techniques, management of minor bleeding and when to seek medical care.
o Pyoderma gangrenosum is a painful, possibly full-thickness and excavated ulceration with purplish edges. Treatment is based on management of the underlying systemic disease, absorption of local drainage, and use of topical anesthetics if necessary. A gentle pouch adhesive should be used, as wound drainage will increase the frequency of pouch changes.
o Malignancy usually appears as a brownish or gray friable growth on the stoma or peristomal skin. The pouching system should be refitted to provide a secure seal without covering the tumour. The patient’s physician should be consulted, as biopsy and resection are generally needed.
References
| Essential Publications |
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| n/a |