by Keval Parikh and James McGuire DPM, PT, CPed, FAPWHc
by Holly Hovan MSN, RN-BC, APRN, ACNS-BC, CWOCN-AP
As discussed in a prior blog, stoma location is certainly one of the key factors in successful ostomy management and independence with care at home. However, even with proper stoma siting, peristomal skin complications may occur for a variety of reasons. In this blog I discuss a few of the more common peristomal skin complications and tips for management.
Common Peristomal Skin Complications
Peristomal skin complications definitely impact ostomy management because the peristomal skin is our pouch anchor. Without healthy peristomal skin, it is very difficult to get a good seal. Some examples of peristomal skin complications follow, with management suggestions:
Moisture-associated skin damage (MASD): denuded skin that is usually related to cutting the pouch too large or a leaking pouch
- Tips for management: Ensure that the pouch is cut 1/8” larger than the stoma and that there is a flat pouching surface (fill any divots/areas of scarring with paste or strip paste); use skin barrier powder to treat denuded skin, and dust off excess powder.
Fungal MASD: similar to MASD, but skin irritation has the appearance of a fungal rash – red, sometimes with small pustules, itchy satellite lesions
- Tips for management: Ensure that the pouch is cut 1/8” larger than the stoma and that there is a flat pouching surface (fill any divots/areas of scarring with paste or strip paste); use an antifungal powder to treat denuded skin, and dust off excess powder.
Folliculitis: could be related to diaphoresis, warm weather, ultimately trauma to hair follicles (shaving, pouch removal, etc.)
- Tips for management: Consider adhesive remover when removing the pouch to avoid further damage to hair follicles; skin barrier powder is helpful to treat denuded skin before applying a new pouch.
Mechanical trauma: skin tearing, damage, or stripping from friction, pressure, or medical adhesive–related skin injury (MARSI)
- Tips for management: Remove the pouch gently, and use adhesive remover to loosen the seal when removing; use skin barrier powder to treat the skin injury, and dust off excess powder; be sure the pouch fits appropriately.
Pyoderma gangrenosum (PG) lesions: painful, with an irregular shape and borders, usually seen in patients with an immune system disorder, Crohn’s disease, or colitis
- Tips for management: Use topical treatment of the lesion based on appearance; control pain; take a multidisciplinary approach to provide holistic management according to the underlying cause.
Skin reaction or allergy to barrier: itching, painful, usually rash-like in appearance
- Tips for management: Try testing different barriers on small areas of the skin and determining whether the cause of the allergy is the tape border, a product that was used (skin barriers, pouching accessories), or the pouch itself.
Suture granuloma: related to granulation tissue that forms from suture material around the stoma-mucocutaneous junction
- Tips for management: You may use skin barrier powder to treat the area if it is interfering with pouching; the powder may also need to include the pouched area versus pouching over top because this may cause a leak; consult with the surgeon for additional options to treat.
Treating the Cause of the Peristomal Skin Complication
With all of the peristomal skin complications discussed here, there is a theme: we need to treat the underlying cause. If we do not treat the underlying cause, the problem will remain, and we will never achieve full resolution of symptoms. The first step to be taken when managing a peristomal skin issue is to determine the underlying cause of the issue. Then, treat the cause and take an interprofessional approach, involving other services as necessary (dermatology, general surgery, nutrition, etc.). Your dietitians are especially helpful resources when there’s a leaky pouch that may be related to diet—foods that bulk stools should be recommended as needed. Additional causes of increased or loose output should also be investigated or ruled out.
Some additional causes of difficulty with pouching are parastomal hernia, weight loss, and weight gain. Anytime there is weight loss or gain, the stoma should be measured to ensure a proper fit and to avoid complications such as peristomal MASD resulting from an appliance that is cut too small or too large. Support belts and/or surgical consultations may be helpful with management of parastomal hernia. Again, what is the cause of the skin issue or pouching difficulty? Identify that, and then treat. Also, remember to keep it simple. Sometimes less is more with ostomy management!
About the Author
Holly is a board certified gerontological nurse and advanced practice wound, ostomy, and continence nurse coordinator at The Department of Veterans Affairs Medical Center in Cleveland, Ohio. She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately six years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention. She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation. She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible. She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.