Peristomal Skin Complications: Assessment
Recommendations
| Identify and Treat the Cause | ||
|---|---|---|
| 1 | Take a careful history and assess. | 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 | Ensure that appropriate strategies are in place to prevent the development of peristomal skin complications. These include pre- and postoperative patient education and regular follow up by a clinician with expertise in ostomy management. | Level of Evidence Not Assessed |
| 4 | Assess peristomal skin at each follow-up visit to detect breaches of skin integrity and identify clinical features to determine potential etiology. | 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
Prevention and management of peristomal skin complications is an important element of ostomy care. The majority of ostomates require treatment for skin compromise at some point. Risk factors for skin complications include a poorly located or constructed stoma, obesity, wound complications in or near the peristomal area, and stoma complications, such as retraction, prolapse and hernia. Peristomal skin complications may be related to lack of access to qualified healthcare professionals with expertise in ostomy care. Many complications can be prevented with optimal pre-and postoperative education and care. Skin complications can be grouped into the following categories:• Chemical injury:
o Irritant contact dermatitis may result from skin contact with stoma effluent or skin care products. In the area of contact, skin is erythematous, moist and painful. Shallow erosions may be present. Assessment may reveal a poorly fitting or leaking pouch, incorrect ostomy care techniques, or overuse of skin products.
o Pseudoverrucous lesions may develop with chronic skin exposure to effluent. The epidermis is thickened with white, grey, dark red or brown papules, which may be accompanied by pain or bleeding. Assessment may identify a poorly fitting pouching system and a history revealing lack of follow-up or pouch refitting.
o Encrustations are crystal deposits seen on skin exposed to alkaline, concentrated or infected urine. Pseudoverrucous lesions may also be present. Assessment reveals skin exposure to urine, which may be accompanied by an inadequate fluid intake, high urine pH, or history of kidney stones.
• Mechanical injury:
o Pressure/shear results in erythematous or abraded skin in the area pressure is delivered. Assessment reveals erythema that does not resolve after removal of the pouching system. The skin barrier may not be seated comfortably or a tight ostomy or support belt may be used.
o Stripping can be seen as erythematous and denuded patches where an adhesive was used. The adhesive itself or improper adhesive removal techniques may be responsible. Assessment may determine whether the type of tape or technique is responsible. Leakage prompting frequent pouch changes may also be found.
o Mucocutaneous separation, or interruption in the suture line attaching the stoma to the skin, may be seen soon after surgery and result from surgical technique, excessive suture tension, poor healing and/or infection. Assessment should include verification of the integrity of the suture line or measurement of the extent of separation at each visit and a search for effluent at the base and walls of the wound to rule out a fistula.
o Mucosal transplantation results in mucosal tissue migrating from the base of the stoma or scattered near the stoma. This tissue may bleed when adhesive is removed. Transplantation results from seeding of mucosa onto the skin during stoma construction.
• Infectious complications:
o Candidiasis initially presents as a pustule that progresses to burning and pruritic plaques with satellite lesions, due to overgrowth of Candida albicans. Assessment may reveal a history of antibiotic therapy, increased perspiration or recent episodes of leakage with increased moisture under the adhesive seal.
o Folliculitis appears as erythematous and possibly pustular lesions associated with hair follicles, due to infection with Staphylococcus aureus. Assessment may reveal frequent shaving or insufficiently gentle shaving technique.
• Immunologic complications:
o Allergic contact dermatitis may appear as an erythemic and pruritic skin reaction located only on skin in contact with an allergen. Vesicles, papules or bullae may be seen, and the skin may be swollen, eroded or weeping. Sensitivity to chemicals or other ingredients in skin or ostomy care products, such as dyes, perfumes or adhesives, is usually responsible. A history of sensitivity reactions may be present.
• Disease-related complications:
o Varices (caput medusae) appear as purplish skin with dilated and tortuous veins in patients with portal hypertension due to liver disease. Assessment may reveal a source of skin trauma and sites of bleeding or erosion.
o Pyoderma gangrenosum is a painful, possibly full-thickness and excavated ulceration with purplish edges. Approximately 50% of cases are related to underlying systemic diseases, such as inflammatory bowel disease, polyarthritis or hematologic disorders. Assessment and biopsy may reveal an underlying systemic disease.
o Malignancy usually appears as a brownish or gray friable growth on the stoma or peristomal skin, which may result from inadequate surgical resection, implantation during suturing, or recurrence. It is important to assess for pain, disease history and pouch leakage.
References
| Essential Publications |
|---|
| 1 | Peristomal complications |
Quality Indicator
|
Type: Prospective Correlation study |
| Ratliff CR, Scarano KA, Donovan JM. Descriptive Study of Peristomal Complications J WOCN 2005;32(1):33-37. | |||
| In this prospective study, peristomal complications of patients with ostomies were assessed at 2-months post-op. Of the sample of 220 subjects, 13% developed complications, including mechanical damage, chemical damage and infection. The peristomal complication form that was developed from WOCN guidelines and used by the authors is provided in the article. | |||
| 2 | Stomal and peristomal complications |
Quality Indicator
|
Type: Validation study |
| Colwell JC, Beitz J. Survey of wound, ostomy and continence (WOC) nurse clinicians on stomal and peristomal complications: A content validation study. JWOCN 2007;34(1):57-69. | |||
| The purpose of this study was to validate definitions of stomal and peristomal complications and their associated interventions. A survey was sent to expert wound, ostomy and continence nurses in the United States asking them to rate the definitions. The researchers found that the definitions were considered valid (mean score 3.64 on a scale of 1 to 4, SD = 0.30, content validity index = 0.91). | |||