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Words on Wounds

A forum to discuss the latest news and ideas in skin and wound care.

Monday, October 22, 2018

Peristomal Skin Complications: An Evolving Case

CSI photo 10-22-18.jpg

A 72-year-old woman with a history of colon cancer underwent a surgical procedure to remove part of her bowel. The remaining portion of the functioning intestine was brought through her abdominal wall, creating an ileostomy. She was managing her ostomy care without any problem, but she has gained a significant amount of weight in the last 6 months, and she presents to your clinic complaining about increased pouch leakage and pain in the peristomal skin. What could be causing the patient's pain?

Peristomal skin complications are common; the incidence is estimated to be as high as 72%. Even after a year or more living with a stoma, many patients continue to experience an array of skin complications, highest among people with ileostomy (57%), followed by urostomy (48%), and colostomy (35%). 

On examination, you notice an erythematous area and skin erosion (partial-thickness skin loss) in the immediate skin surrounding the stoma consistent with irritant dermatitis. You know that the exposure of skin to effluent from an ileostomy that contains a high concentration of digestive enzymes causes skin erosion. The severity and extent of dermatitis is more noticeable in the lower inferior aspect of the stoma, suggesting fecal pooling. This would explain why the patient experienced intense burning and pain. Skin erosion and weeping lesions in the peristomal area create a challenge for the appliance to stick to the skin, creating a vicious cycle of skin irritation, appliance failure, leakage, and more skin irritation. So what precipitated the leakage?

You also notice a change in the abdominal contour, including an out-pouching protuberance around the stoma suggesting peristomal herniation. You know older adults are at risk for herniation, because the rectus abdominus muscle becomes thinner and weaker with age, affecting stoma support. Now, the patient's appliance does not conform to the contour of the herniation. Stretching and relaxing of the peristomal skin with changes in position make it challenging to maintain a good pouching seal. Another possible other reason for increased leakage is related to stoma retraction, because the stoma sits below skin level. 

What can be done to reduce leakage? You ask yourself. Several interventions should considered: 

  • Use soft-convex flange to enable the stoma to protrude more.
  • Consider abdominal support belts or girdles to keep the appliance in place.
  • Avoid heavy lifting and heavy work to prevent further herniation.
  • Recommend exercise to strengthen abdominal muscles.
  • Educate the patient about weight reduction to achieve a body mass index of 20–25.
  • Evaluate the pouching system for the size and fit of the barrier to the stoma to minimize skin exposure to effluent and irritant dermatitis.
  • Trial a two-piece system so the pouch can be changed without removing the skin barrier.
  • Use skin barrier paste or strips to fill or level skin creases/folds or at the areas that are concave under the pouching system.
  • Consider skin barrier paste to caulk the edge of the skin barrier to slow the process of erosion.
  • Consider a cyanoacrylate-based liquid skin protectant to form a protective layer over the damaged skin. Sprinkle skin barrier powder onto the denuded area and apply a liquid polymer acrylate to seal the powder.