Common Peristomal Skin Conditions Conditions

Characteristics

Treatment

Folliculitis

Traumatic removal of hair during pouch change results in inflammation and infection of hair follicles. Lesions are painful and moist.

Topical antimicrobial powder, cover large lesions with nonadherent dressing. Once healed, carefully shave area. Use of adhesive remover and sealant is advised after lesions healed.

Candidiasis

Warm, moist environment creates an environment for growth of candida albicans. Generally diffuse red patches with characteristic advancing border and satellite lesions. Severe itching common.

Topical antifungal powder. Assess system for leakage or undermining of seal. Refit pouching system as appropriate.

Irritant Dermatitis

Chemical destruction of the skin caused by topical products or leakage. Area appears red, moist and painful. May be localized to a specific area of pouch undermining or leakage. Overgrowth of tissue caused by over exposure of moisture. Appears as raised, moist lesions with a wart-like appearance. Lesions are painful.

Review product usage and techniques To determine cause. Correct/revise pouching system.

Mechanical Trauma

External item or force causing damage to the stoma and/or skin from pressure, laceration, friction or shear.

Assess equipment and technique. Modify to prevent re-injury.

Allergic Contact Dermatitis

Allergic response generated by patient sensitivity to a particular product. Skin appears red, swollen, eroded, weepy or bleeding. Generally corresponds to the exposed area.

Remove the allergen, avoid other irritants and protect the skin. Patch test with other products as needed. Refer to dermatology for multiple allergies.

Pseudoverrucous Lesions (formerly called PEH)

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Assess equipment for proper aperture and fit. Resize as needed in severe cases, sharp debridement of the tissue may be required.

Conditions

Characteristics

Treatment

Peristomal Abscess

One or more open, painful lesions surrounded by a halo of redness. Not uncommon in patients with active Crohn’s disease in the distal bowel.

Unroofing of ulcer by surgeon. Management depends on size. Review options, including nonadherent dressings, hydrogel, astringent solution, calcium alginate, hydrofiber or hydrocolloid wafer. A Non-adherent pouching system can be fashioned with a one-piece pouch with belt tabs, an extra gasket and a solid skin barrier wafer.

Pyoderma Gangrenousum

Associated with IBD, arthritis, leukemia, polycythemia vera and multiple myeloma. Red open lesions become raised with irregular purplish margins.

Systemic treatment of underlying disease, local ulcer treatment by unroofing the area is generally not advised. Intralesional and systemic steroid therapy may be prescribed. Topical therapy and pouching same as with abscess.

Radiation Injury

Red, thinned skin. Gently cleanse skin with cool Easily traumatized by removal of water. skin adhesives. Use a skin barrier that is easy to remove. Be cautious in use of solvents or skin sealants due to frequent sensitivities and risk of chemical trauma.

Caput Medusa (Peristomal Varies)

In patients with portal (liver) hypertension, the pressure at the portal systemic shunt in the mucocutaneous junction increases, creating venous engorgement. With trauma, profuse bleeding can occur.

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Apply pressure and/or use hemostatic agents, e.g. silver nitrate. Cautery or surgical ligation may be necessary. Remove pouch carefully. Avoid aggressive skin barriers and skin sealants. If stoma is relocated varices will eventually recur around the new stoma unless underlying liver disease is treated (e.g. liver transplant).

D

Common Stoma Complications

Conditions

Characteristics

Treatment

Necrosis/ ischemia

Dark red to black mucosa may appear dry, mottled. Stoma may be firm or flaccid Ischemia usually noticeable within 12-24 hours; can be evident up to 3-5 days post-op Results froma. Excessive tension on the mesentery with resultant compromise to arterial Inflow, venous outflow, or both. Can be a result of abdominal distension, obesity, excessive edema

Distal necrosis: if superficial, conservative management: tissue allowed to demarcate, slough * Stoma will then be flush or slightly retracted; stenosis may occur Necrosis extending below fascial level

b. Interruption of blood supply to the stoma e.g. embolus, clot

* Mucocutaneous separation develops

c. Excessive devascularization d. Narrowly spaced sutures; sutures tied snugly around stoma, or continuous constricting sutures

* Run risk of perforation and subsequent peritonitis * Notify surgeon immediately

* Usually requires re-operation with construction of new stoma Intervention * Ongoing mucosal assessment * Prompt notification of surgeon of mucocosal changes * Utilization of clear pouches in post operative period, proper sizing of equipment, frequent pouch changes * Odor control as tissue sloughs * Psychological support to patient and family

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Conditions

Characteristics

Treatment

Mucocutaneous Separation

Separation of the suture line at the junction of the stomal mucosa and skin. Maybe superficial or deep; may be partial or circumferential

Interventions

Bleeding

a. Gently probe with swab to determine depth, undermining b. Irrigate with normal saline/ to clean c. If deep: use rope packing e.g. hypertonic saline rope. A 2 piece system may be beneficial d. Shallow wounds: use powder or granules to fill defect, then cover and pouch e. If separation is draining large amount of fluid, it may need to be included in pouch opening f. If peritoneal contamination is a concern, the surgeon may resuture stoma to skin, either locally or under anesthesia

Portal hypertension (caput medusa) Due to underlying liver disease. A-V shunt formation can lead to profuse bleeding a mucocutaneous junction

Avoid trauma to area. Gentle technique when applying and removing products. If bleeding occurs apply pressure and seek medical attention. Cautery or ligation may be needed

Trauma Results from improperly sized or applied pouching systems; incorrect shaving techniques, forceful irrigation; sports related injuries

Revise equipment and technique. Avoid re-injury If bleeding continues seek medical assistance

Disease process/medication Underlying blood dyscrasias; anticoagulant therapy

Avoid trauma to area. Gentle technique when applying and removing products. If bleeding occurs apply pressure and seek medical attention

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Conditions

Characteristics

Treatment

Prolapse

Telescoping of bowel through the stoma

Interventions * Surgery * Conservative management Reduce prolapse Use of binder or prolapse belt to keep reduced * Modify pouching system as needed to avoid trauma to bowel mucosa

Retraction

Stoma resting at or below skin level. Can be due to weight changes recession may be indicative of recurrent Crohn’s Disease due to scarring and contracting of bowel

Modify pouching system; maintain seal between pouch and skin without undermining a. Use of convexity b. Accessory products Surgery as needed

Parastomal Hernia

Most common with colostomies Appears as a bulge around the stoma; the bulge represents loops of the intestine that protrude through the fascial defect around the stoma and into the subcutaneous tissue Results from: * Stoma placed outside of rectus muscle * Increased intra-abdominal pressure with lifting and straining * Defect in abdominal musculature-loss of muscle tone (as with weight gain or aging) * excessively large fascial defect * Placement of stoma in midline incision * Wound infection

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Avoid colostomy irrigations. If hernia can be reduced apply hernia belt/binder If obstructed or incarcerated seek immediate medical care

Conditions

Characteristics

Treatment

Food Bolus Obstruction

Most common with ileostomies

Home-relief measures

Results from ingestion of highfiber foods such as nuts, popcorn, string vegetables, oranges, or fruit peels (insoluble fibers)

a. Warm bath

Symptoms: severe cramping, abdominal pain, nausea, vomiting, cessation of stomal output or watery, odorous output, high-pitched tinkling bowel sounds, stomal edema

c. If stoma is swollen, remove pouch and replace with one that has larger aperture

b. Peristomal massage and knee-chest position to attempt to dislodge mass

Occur usually just proximal to stoma

d. If able to tolerate fluids and is passing stool, avoid solid foods and increase intake of fluids to help replace electrolytes

Teach prevention: limited intake of high fiber food, especially insoluble fibers, chew food well, adequate fluid intake

e. If vomiting or not passing stool, or both, take nothing by mouth. Physician should be notified f. Physician is notified: 1. Stool output stops 2. Symptoms persist with use of conservative measures for 24 hours 3. Cannot tolerate fluids Ileal lavage may be necessary to relieve food bolus obstruction

H:Common Peristomal Skin Conditions

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