Peristomal Skin Conditions: Pyoderma Gangrenosum

Holly Hovan MSN, GERO-BC, APRN, CWOCN-AP

Introduction

Peristomal pyoderma gangrenosum (PPG) is a somewhat uncommon and challenging condition to diagnose and treat, as no evidence-based guidelines or standard treatments exist.¹ PPG can occur after the surgical placement of an ostomy, impacting approximately 0.5 to 1.5 people per million annually, and accounts for 15% of pyoderma gangrenosum cases.¹ Effective management of PPG requires local and often systemic immunosuppression and topical wound care, which is compatible with being applied beneath an ostomy pouch.

What is Peristomal Pyoderma Gangrenosum (PPG)?

PPG is a neutrophilic dermatosis characterized by painful ulcers which can be recurrent and is often associated with systemic diseases such as inflammatory bowel disease (IBD), arthritis, or hematologic disorders. PPG initially presents as pustules or blisters and often quickly enlarges into partial- or full-thickness wounds, sometimes with erythematous or purple, irregular borders, and purulent exudate. These ulcers are typically painful, fail to heal with usual treatment, and are often associated with pouching difficulties, usually related to wound drainage and open ulcers beneath the ostomy pouch. It is important to note that convex pouching systems may also be a precipitating factor to PPG ulcerations, as they can sometimes be a source of pressure or friction.²

How to Identify Peristomal Pyoderma Gangrenosum (PPG)

PPG is a diagnosis of exclusion, which means all other causes of the ulcer should first be ruled out. A tissue biopsy may assist with ruling out other conditions along with clinical presentation and assessment findings. An interprofessional approach is essential and a critical piece of the management plan for PPG. A medical work-up should be completed with evaluation for underlying pathology, along with lab work, ruling out or treating other autoimmune processes, drug-induced vasculitis, coagulopathies, and malignances.²

Treatment and Management of PPG: Advanced Wound Care

Medical management of PPG involves advanced wound care to manage drainage, reduce the inflammatory process with topical steroids, and possibly intralesional injections to reduce inflammation as well.² Intralesional injections with triamcinolone acetonide, a steroid, may help to reduce inflammation and pain. Literature has also shown that oral prednisone therapy at a dose of 0.5 to 1mg/kg/day has been effective in controlling PPG.²

Topical management of PPG includes removing sources of pressure and friction from the area, including removal of convex pouching systems and use of a soft, flat skin barrier. Absorptive products such as alginates or foam secured with hydrocolloid dressings beneath the pouching system can be helpful.² Products made specifically for wound care around a stoma are also useful for management of PPG ulcers, and are intended to be extended wear beneath the pouching system.

Conclusion

Medical and topical management along with an interprofessional approach (involving multiple disciplines) are key pieces to a successful treatment plan for PPG. Looking at the entire patient picture is important. Additionally, managing quality of life (QoL) in terms of assisting with a technique for pouching to manage drainage and prevent leaks is essential. The management of exudate and pain with pouch changes is critical, especially while the PPG lesion is healing. When treating PPG, clinicians often manage a patient with systemic inflammation which is best done by a holistic, interdisciplinary team.

References

1. Afifi, L., Sanchez, I., Wallace, M., Braswell, S., Ortega-Loayza, A., & Shinkai, K. (2018). Diagnosis and management of peristomal pyoderma gangrenosum: A systematic review. Journal of the American Academy of Dermatology, 78:6, 1195-1204. https://doi.org/10.1016/j.jaad.2017.12.049.
2. Salvadalena, G.D, & Hanchett, V. Peristomal skin complications. In: Wound, Ostomy, and Continence Nurses Society Core Curriculum Ostomy Management. Philadelphia, PA: Wolters Kluwer; 2022:250-269.

About the Author

Holly is a board certified gerontological nurse and advanced practice wound, ostomy, and continence nurse specialist at VA Northeast Ohio Healthcare System in Cleveland, Ohio. She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately ten 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, HMP Global, its affiliates, or subsidiary companies.