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Management of peristomal skin: an update

Maureen Benbow
MSc BA RGN HERC
Senior Lecturer University of Chester

Individuals who find themselves having to cope with the diagnosis of a serious, sometimes life-threatening condition, subsequent major surgery, and in some cases chemotherapy and/or radiotherapy, have very little warning of their condition. They have to come to terms with the diagnosis, recover from surgery and some need to adjust to the additional burden of coping with a stoma. Each year 70,000-100,000 people in the UK have colorectal or urological surgery resulting in stomas.(1) The most common reasons for stoma surgery are for the treatment of colorectal cancer, bladder cancer, ulcerative colitis and Crohn's disease.(2) Most of these patients will be aged 60 years or over and the most common stoma is a colostomy.(3) Colostomies account for approximately 49% of all permanent stomas in the UK with ileostomies and urostomies accounting for 39% and 12% respectively.(4) Some stomas will be formed for short periods, but others will be placed for decades or life, as in Crohn's disease. The number of permanent stomas is reducing due to improved surgical techniques and earlier diagnosis and treatment; it is estimated that 50% of stomas are permanent.(5)

Life changes
A stoma operation causes extreme changes in a patient's life due to physical damage, loss of bodily function, changes in personal hygiene and disfigurement.(6) Stomas inevitably cause problems that can lead to anxiety, distress and even depression for the patient.(7) The formation of a stoma causes an altered body image for the patient, resulting in psychological morbidity.(8,9) Brown and Randle suggest that this may be exacerbated for individuals living in industrialised countries, where the consumer culture provides a wide range of stylised images of the body.(10) However, Jenks et al found that people with cancer undergoing stoma formation adapted positively to their stoma.(11)

Ostomies
An ostomy is a surgically created artificial opening in which a portion of diseased tissue is removed and a false exit is made to allow waste to be expelled. This may happen in parts of the urinary tract or gastrointestinal tract due to birth defects, disease, injury or other disorders. Colostomies may be formed when a portion of large bowel is brought to the abdominal wall; ileostomy refers to the connection of a portion of small bowel to the abdominal wall. Urostomies divert the flow of urine from the diseased or injured bladder. Although many colostomies are permanent following, for example, abdominoperineal resection for colorectal cancer, some are formed temporarily to allow healing of a diseased or injured portion of bowel. Tracheostomies, either temporary or permanent, may also be formed to bypass diseased or injured tissue or for assisted ventilation in intensive care settings.
Along with tracheostomies for patients suffering from head and neck cancer and other conditions, support is frequently needed with feeding. This may be provided by the insertion of a percutaneous endoscopic gastrostomy (PEG) tube which provides an artificial connection between the stomach and the abdominal wall via a tube through which patients are fed a liquid diet. Leakage of caustic gastric contents may cause skin problems due to poor placing of the tube, tube migration or improper positioning while feeding.(12)

The consistency of the output
The consistency of the output from a colostomy depends on the level of bowel from which it originates and may vary from properly formed stool to liquid output. Ileostomy usually involves removal of the entire colon and rectum and the waste has a liquid consistency. Ileal conduit is the most common type of urostomy where a small segment of the ileum is separated from the small intestine to form a pouch to which the ureters are connected. The small intestine is reconnected so that bowel movements pass normally and one end of the excised bowel is closed.
A tracheostomy is a surgically created opening in the neck into the trachea into which a tube is placed to provide an airway and to facilitate removal of secretions from the lungs.(13) Fistulae are common complications of head and neck cancer surgery because of infection, radiation or poor surgical technique.(14) The combination of oral saliva contamination, fistula output, lymph gland erosion and wound exudate contributes to the potential for infection and skin complications and there is often a large volume of fluid found around the tracheostomy. This makes head and neck surgery wound care intensive.(14)

Preoperative considerations
Psychosocial preparation, education and support are essential to avoid the risk of postoperative complications associated with alterations in peristomal skin and tissue integrity. This will include clinician assessment of the physical characteristics and psychological needs of the patient, their capacity for learning about and coping with their new situation, and selecting the best anatomical stoma site.(15) Special consideration with regard to siting, access, visibility and the ability to self-care must be afforded to those patients who are overweight or wheelchair users. A properly fitting pouch system will be comfortable, maintain a secure seal and move well with the patient.(16) Patients must be taught to regularly inspect the peristomal skin for signs of breakdown.(16)

Incidence of peristomal skin problems
Many patients with stomas have no associated skin problems, but for those who do, it adds to the stress of adapting to the stoma.(17) Peristomal skin problems are the most common reason for ostomy patients to access nursing services.(16) At least one stoma-related complication was found in 47% of patients, usually occurring within the first five years of stoma formation.(18,19) Arumugan et al found that 50% of patients developed complications within one year.(20) The overall rate of peristomal skin complications ranges from 18% to 55%, but there is no standardised classification system or details of the types of skin complications.(21) There is also little published on the frequency, type or management of stoma-related skin disorders.(22) The limited data that are available are largely unreliable and unrepresentative of general populations. Ratliff and Donovan found an incidence of 1-13% of peristomal skin problems in patients with colostomies; 9-21% in those with ileostomies.(23,24) Other studies found an incidence of skin
problems in 15-65% of patients with urostomies.(23-25)

Identifying risk factors
Integrity of the skin surrounding any stoma is essential for normal use of stoma appliances.(22) The situation can be aggravated by the presence of a dermatological condition such as eczema or psoriasis. Anxiety about skin disorders in the peristomal area was recently identified as one of 37 factors affecting quality of life in individuals with stomas.(26) The aim of a study conducted by Lyon et al was to identify and document the range of stoma-related skin disorders in abdominal stoma patients.(22) Skin problems were reported in 73% of a sample of 525 patients with stomas that affected stoma appliance use.
Identification of risk factors for peristomal skin problems is essential to treating the underlying cause and optimising management; otherwise the relief may be temporary and recurring. Risk factors may include chemical injury (irritant contact dermatitis,
encrustations), mechanical injury (pressure/shear, friction, stripping, mucocutaneous separation), infection (candidiasis, folliculitis), immunologic (allergic contact dermatitis) or disease-related (varices, pyoderma gangrenosum, malignancy).(16)
Prevention is better and less costly in both financial terms and patient discomfort. Valuable NHS resources are required to fund extra nursing and sometimes medical care and equipment may be wasted due to the inability to achieve adherence due to the skin condition, for an often avoidable problem. For the patient, the main practical problems will be leakage and odour leading to embarrassment plus time lost from work or interference with normal social activities. Other risk factors include poorly sited or poorly constructed stoma, obesity, associated wound complications and recurring disease. These may, in time, alter the geography of the area needing a review of the type of pouching system to avoid recurrence of the problem. This is where the skills, knowledge and services of the stoma nurse are invaluable.

Prevention and management
The visible tissue of a stoma should be shiny, moist and a pinkish/red colour; dark discolouration may indicate ischaemia or necrosis and requires immediate medical attention.(3) The peristomal skin must be cared for meticulously.(27) If the skin is burning, itching, painful or eroded, advice must be sought from a stoma nurse. Careful infilling of irregular skin surfaces with pastes, strips or other forms of barrier combined with careful nontraumatic changing of stoma bags when about half full should minimise the risk of skin damage. The type of system used will dictate the frequency with which the whole system is removed and the area cleansed. Unexpected soiling must be investigated as a matter of urgency, not only to reassure the patient but also to prevent peristomal skin complications.

Peristomal skin problems
Prevention and/or early identification of peristomal skin complications are essential components of successful, cost-effective stoma patient management.(15) A well-fitting ostomy system should preclude damage to the surrounding skin from effluent and skin stripping. However, an awareness of the properties of the output will inform skin care regimes, for example:

  • Gastric juices contain proteolytic enzymes and hydrochloric acid, which are particularly irritant to the point of digesting the skin surrounding the ostomy.(18)
  • Urine may leak from a urostomy causing the build-up of crystal deposits on the skin requiring gentle removal with half-strength diluted acetic acid at each appliance change.(27)
  • The output from a tracheostomy may contain enzyme-rich saliva or large amounts of lymph, which, in time, will cause maceration of the skin.
  • Excessive leakage from tracheostomy fistulae or lymph nodes is particularly difficult to manage due to the contours of the face and neck and the size of reservoir needed to catch the leakage.

Maceration and excoriation
Skin becomes macerated when it has become over-hydrated due to long-term exposure to wound exudate, wet dressings or direct leakage from a stoma or wound. Peristomal hyperplasia may occur at the mucocutaneous junction as a result of persistent exposure to effluent over time. Changing the appliance to a better fitting one combined with appropriate skin care should resolve this problem.(28)
The main skin problem experienced by stoma patients is excoriation of the skin due to leaking urine, saliva or faeces, which may be due to an ill-fitting appliance or weight changes.(27) Excoriated skin is defined as that which has been traumatised, worn away or abraded, often in the presence of maceration due to incontinence.(29) Other problems may be associated with poor technique when changing the appliance, causing trauma to the epidermis on removal, radiotherapy in cancer patients, changes in the skin integrity due to aging, stress, illness or dietary problems. Excoriation may present as sore, red and inflamed broken skin around the stoma while maceration will show as white, soft and soggy skin. Both conditions will weaken the integrity of the skin predisposing it to further trauma and problems with dressing/appliance adherence.

Skin irritation
Skin irritation is a common problem in patients with ileostomies (34%), which may be secondary to contact dermatitis, mechanical trauma or infections.(20,30) An allergic reaction or irritation may also progress to irritant contact dermatitis. In all of these cases it is necessary to examine the patient's skin and skin contours and their stoma practises (what they use to cleanse the stoma, pastes, powders and appliances) until a likely causative agent is found and dealt with. Skin protection can be provided by the use of hydrocolloid wafers, powders or barrier films to conserve moisture and promote healing. In severe cases, nonadhesive pouching may be a necessary temporary measure. 

Infection    
Lyon and Smith found that 7% of peristomal skin problems were caused by infection possibly due to the warm, dark, moist environment under hydrocolloid wafers, intermittently contaminated by urine or faeces.(18) The most common infection is folliculitis.(31) Candidiasis may occur around the stoma causing pain and irritation, particularly in diabetic and immunocompromised patients. This is more likely where there has been persistent leakage or following a course of antibiotics.(31) Antifungal powder may be indicated to help control leakage and moisture build-up.(30)
Any existing breach in the integrity of the skin will predispose to infection, for example psoriasis, eczema and allergic dermatitis. Patients should be assessed for their risk of infection so that proactive management may prevent skin infections. The patient should be educated to identify any peristomal redness, rashes or leakage, which should be reported to and dealt with immediately by the clinician or through referral to stoma care specialist nurses.

Cleaning the stoma and surrounding area
Cleanliness and a positive self-image are important to the wellbeing of the person with a stoma, but over-exuberant cleaning with antiseptics of the stoma and surrounding skin is contraindicated. Skin produces its own protective moisturisers, oils and waterproofing and by removing these, the skin becomes exposed to drying out, cracking and the easy entry of bacteria. The general guidance on washing the peristomal skin is to use only warm water, but a mild, pH-balanced, unfragranced soap used in moderation should not upset the pH or chemical balance of the skin.(32) The pouching system should be removed by supporting the skin and using a soft moist tissue and the skin cleansed gently with plain water to avoid abrasion. Chemicals should be avoided unless used for good reason and the skin should be patted dry before a new system is applied.  

Conclusion
In every healthcare setting, healthcare professionals have a duty of care to all patients to ensure that problems are detected, appropriate treatments are instigated and referrals to specialist nurses made at an early stage. Prevention and good management are critical components of ostomy care with regard to quality of life. Documenting the individual's skin problems and the solutions found will help to inform future care.

References:

  1. Department of Health. Consultation document on the arrangements for paying appliance contractors. London: DH; 2005.
  2. Salter M. Altered body image: the nurse's role. 2nd edition. London: Baillière Tindall; 1997.
  3. Plant C, Brierley R. Coping with a colostomy. Nurs Resident Care 2001;3:260-4.
  4. Herlufsen P, Olsen AG, Carlsen B, et al. Study of peristomal skin disorders in patients with permanent stomas. Br J Nurs 2006;15:854-62.
  5. Vujnovich A. The management of stoma related skin complications. Wounds UK 2006;2;36-47.
  6. Persson E, Hellström AL. Experiences of Swedish men and women 6-12 weeks after ostomy surgery. J Wound Ostomy Continence Nurs 2002;29:103-8.
  7. Black P. Common problems following stoma surgery. Br J Nursing 1994;3:413-7.
  8. Persson E, Severinsson E, Hellström A. Spouses' perceptions of and reactions to living with a partner who has undergone surgery for rectal cancer resulting in a stoma. Cancer Nurs 2004;27:85-90.
  9. Nugent KP, Daniels P, Stewart B, Patankar R, Johnson CD. Quality of life in stoma patients. Dis Colon Rectum 1999;42:1569-74.
  10. Brown H, Randle J. Living with a stoma: a review of the literature. J Clin Nurs 2005;14:74-81.
  11. Jenks JM, Morin KH, Tomaselli N. The influence of ostomy surgery on body image in patients with cancer. Appl Nurs Res 1997;10:174-80.
  12. Johnson D. Common complications of tube feeding. 2000. Available from: http://depts.washington.edu/growing/Nourish/Tubecomp.htm#Tube% 20feeding%20syndrome
  13. Fung K. Tracheostomy. 2005. Available from: http://www.nlm.nih.gov/medlineplus/ency/article/ 002955.htm
  14. Newlands SD. Head and neck lecture for junior medical students. 2001. Available from: http://www.utmb.edu/oto/MedicalStudent.dir/Head-Neck/Head-Neck.htm
  15. Erwin-Toth P. Prevention and management of peristomal skin complications. Adv Skin Wound Care 2000;13:175-80.
  16. Rolstad BS, Erwin-Toth PL. Peristomal skin complications: prevention and management. Ostomy Wound Manag 2004;50:68-77.
  17. Black P. Holistic stoma care. London: Ballière Tindall; 2000.
  18. Lyon C, Smith A. Abdominal stomas and their skin disorders: an atlas of diagnosis and management. London: Martin Dunitz; 2001.
  19. Shellito P. Complications of abdominal stoma surgery. Dis Colon Rectum 1998;41:1562-72.
  20. Arumugam PJ, Bevan L, Macdonald L, et al. A prospective audit of stomas, analysis of risk factors and complications and their management. Colorectal Dis 2003;5:49-52.
  21. Colwell J, Goldberg M, Carmel J. The state of the standard diversion. J Wound Ostomy Continence Nurs 2001;28:6-17.
  22. Lyon CC, Smith AJ, Griffiths CEM, Beck MH. The spectrum of skin disorders in abdominal stoma patients. Br J Dermatol 2000;143:1248-60.
  23. Ratliff CR, Donovan AM. Frequency of peristomal skin complications. Ostomy Wound Manag 2001;47:26-9.
  24. Nordström G, Borglund E, Nyman CR. Local status of the urinary stoma - the relationship to peristomal skin complications. Scand J Urol Nephrol 1990;24:117-22.
  25. Ratliff CR, Scarano KA, Donovan AM. Descriptive study of peristomal complications. J Wound Ostomy Continence Nurs 2005;32:33-7.
  26. Prieto L, Thorsen H, Juul K. Development of a quality of life questionnaire for patients with colostomy or ileostomy. Health Quality Life Outcomes 2005;3:62.
  27. Black P. Practical stoma care: a community approach. Br J Community Nurs 1997;2:249-53.
  28. Leong AP, Londono-Schimmer EE, Philips RK. Life-table analysis of stomal complications following ileostomy. Br J Surg 1994;81:727-9.
  29. Collins F, Hampton S, White R. A-Z dictionary of wound care. Dinton: Quay Books; 2002.
  30. Efron JE. Ostomies and stomal therapy. 2004. Available from: http://www.fascrs.org/displaycommon.cfm?an=1&subarticlenbr=107
  31. Turnbull GB. The ostomy files: infections of the peristomal skin. Ostomy Wound Manag 2005;51:14-6. Available from: http://www.o-wm.com/owm/displayArticle.cfm?articleID=article4221#
  32. Black P. Treating peristomal skin problems in the community. BrJ Community Nurs 2002;7:212-7.