The Duquesne University School of Nursing assistant professor and assistant dean shares guidance on stoma complication in patients with ostomy.
Yvonne Weideman, DNP, MBA, RN
Approximately 1 million people living in the United States have an ostomy,1 a surgically created opening (stoma) to divert fecal or urinary waste from outside the body. The waste is collected via an external appliance or pouching system that consists of a pouch (also known as a bag) and a wafer (also known as a skin barrier or flange). The pouch collects the waste products, and the wafer adheres the pouching system to the skin around the stoma known as the peristomal skin.
More than 80% of ostomy patients will experience a complication with their stoma or peristomal skin within two years of their surgery.2 Therefore, it is important that healthcare providers are knowledgeable about ostomies and peristomal complications.
One complication, moisture-associated skin damage (MASD), is caused by moisture under the wafer, typically from an ill-fitting pouching system. MASD presents as erythema and denuding of the peristomal skin where leaking fluid contacted the skin.3 Continual weeping of the denuding skin can lead to additional problems with the adherence of the pouching system. In turn, this can lead to further skin damage and difficulties with pouch adherence.
In a fungal MASD, the skin irritation presents as a fungal rash characterized by erythema, small pustules, and an irregular border with satellite lesions.2 Resolution for peristomal MASD begins with correcting the pouching problem(s) that led to the ostomy leaking, including changing the type or size of the pouching system and stoma opening. Application of a stoma powder or an antifungal powder followed by application of a skin barrier spray will promote healing of the peristomal skin while absorbing any weeping from denuded skin to promote adherence of the pouching system.
Another complication, mechanical dermatitis, can result from the pouching system being removed too vigorously or from changing the pouching system too frequently. This dermatitis presents as red, painful lesions or skin tears in the peristomal area4. If the skin is denuded and/or moist and weeping, a stoma powder with a barrier spray should be applied.3 To prevent future skin damage, the patient should be taught to remove the pouching system gently, to use adhesive removals if needed, and to follow an appropriate pouching system changing schedule.
Folliculitis can result from trauma to the hair follicles from vigorous pouch removal or shaving the peristomal skin in the opposite direction of hair growth.4 It presents as painful, pruritic erythema and pustules at the base of the hair follicle and may lead to moist, weeping peristomal skin. Treatment of mild cases consists of topical antimicrobial powder to the area; more severe cases may also require an antibiotic. To prevent recurrence, patients should be taught to use an electric razor, to shave the peristomal skin in the direction of hair growth,3 and to use an adhesive removal as needed to facilitate gentle removal of the pouching system.
Two less common complications are pyoderma gangrenosum and pseudoverrucous lesions. Pyoderma gangrenosum, occurring in some patients with inflammatory bowel disease (IBD) presents as painful ulcerated lesions with a dusky red or purple border and purulent exudate. It is treated by topical steroids and management of the underlying IBD. Draining lesions can be covered with an absorptive dressing covered by a hydrocolloid dressing upon which the wafer can be applied.4 Pseudoverrucous lesions, specific to urostomy patients, present as painful lesions that appear gray, white, brown, or dark red. They stem from urine being in prolonged contact with the skin. Treatment includes preventing urine from pooling on the skin through the use of pouches that contain an antireflux valve and correction of any pouching system problems.3
In summary, peristomal skin complications can be painful, cause problems with wafer adherence, and negatively impact the patient’s quality of life. While not all peristomal complications are preventable, the risk can be decreased by ensuring patients5:
When a peristomal issue occurs, treatment should be specific to the type of complication and include the correction of any underlying pouching issues to correct and prevent future peristomal skin complications.
1Kimberly, L., Whitely, I., McNichole, L., Salvadalena, G., & Gray, M. (2019). Peristomal medical adhesive-related skin injury. Journal of Wound Ostomy and Continence Nursing, Vol. 46 (2), pp.125-136.
2Hovan, H. (2019). Peristomal skin complications and tips for management. Wound Source. Retrieved from https://www.woundsource.com/blog/peristomal-skin-complications-and-tips-management.
3Emory University Wound, Ostomy, and Continence Nursing Education Center. (2014). Ostomy care quick reference guide. Atlanta, GA: Author.
4Salvadalena, G. (2016). Peristomal skin conditions. In J. E. Carmel, J. C. Colwell, & M. T. Goldberg (Eds.), Wound, Ostomy and Continence Nurses Society core curriculum: Ostomy management (pp. 176-190). Philadelphia, PA: Wolters Kluwer.
5American Cancer Society. (2019). Protecting the skin around the stoma. Retrieved from https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/surgery/ostomies/colostomy/management.html