The Ostomy Files: Infections of the Peristomal Skin
At a time when payors, regulators, and accreditors in every clinical setting are carefully examining the development of an infection as an example of potential failure of provider surveillance and prevention, re-examining the etiology of some of the more common peristomal skin infections takes on additional value.
Lyon and Smith1 found that 7% of peristomal skin problems are caused by infection. The environment of the skin under skin barrier wafers may enhance the incidence of peristomal skin infections because a warm, dark, moist environment that may be intermittently soiled by urine or stool provides an ideal setting for microbial growth. Additionally, many ostomy patients may be immunosuppressed due to general ill health, diabetes, adjunctive cancer therapies, or immunosuppressive agents used to treat inflammatory bowel disease. Lyon and Smith found that swabs of the peristomal skin of their patients revealed a range of viral, bacterial, and fungal infections as well as a number of colonized bacterial and fungal organisms. All wounds are at risk of infection because they are colonized. As we now know, colonization does not indicate infection until the bacterial burden exceeds the body’s ability to fight the bacterial load and clinical signs of infection become evident.2 Even so, the common types of peristomal skin infections — bacterial, viral, and fungal — need to be examined.
Superficial skin infections caused by fungus most commonly occur in moist environments, especially in intertriginous areas (areas where skin touches skin) such as the groin, between the toes, on the perineum, or under the female breasts. Therefore, it stands to reason that fungal infections are more common in tropical climates or in patients who perspire heavily than in patients who live in more temperate climates. Other patients at risk for peristomal Candidiasis are those who have experienced frequent leakage problems or recently completed a course of antibiotic therapy.3 Colonization of the peristomal skin with Candida albicans is common, although a frank Candida peristomal skin infection is less common.1 In a study of 160 patients, Ratliff and Donovan4 reported an incidence of peristomal skin infections of C. albicans to be 1%. Peristomal candidal infections respond to topical treatment with nystatin powder and correction of any pouching system leakage problems.1,5
Another common fungal infection is caused by dermatophyte (ringworm) infection. These infections are acquired by skin-to-skin contact or contact with an inanimate object that has been contaminated by an infected person. These fungal infections appear under other medical appliances that are worn constantly such as artificial limbs. If inappropriately diagnosed and treated with topical corticosteroids, these infections may spread rapidly. Scrapings of the skin should be taken and if dermatophyte infections are found, they should be treated with preparations containing tolnaftate or undecanoates.
Peristomal viral infections are less common than fungal or bacterial infections, but when they do occur, they can present treatment challenges, particularly as they relate to increased pain and interference with the skin barrier-to-skin adhesion. Perhaps the most common are herpes zoster (shingles) and herpes simplex. These lesions can become secondarily infected, often by staphylococci; therefore, the affected skin should be swabbed for bacterial examination. Effective topical and oral antiviral treatments are available.
The most common peristomal skin infections are bacterial in nature and include folliculitis (infection of the hair follicle by Staphylococcus aureus or streptococci or both). Any break in the integrity of the peristomal skin — caused by persistent leakage, psoriasis, allergic contact dermatitis, or other chronic skin conditions — increases the risk of infection. Clinicians should be vigilant for any peristomal skin rash or redness, correct stoma management problems if leakage is a contributing factor, and proactively seek additional expert evaluation and treatment regimens from ostomy specialists. As mentioned earlier, infection control is on the radar of payors and regulators. Prevention and management of peristomal skin infections should be included on clinicians’ lists of patients at higher risk of developing skin infections.
The Ostomy Files is made possible through the support of ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ.
1 . Lyon CC, Smith AJ. Abdominal Stomas and Their Skin Disorders: An Atlas of Diagnosis and Management. London, UK: Martin Dunitz;2003.
2. Bowler PG. The 105 bacterial growth guideline: reassessing its clinical relevance in wound healing. Ostomy Wound Manage. 2003;49(1):44–53.
3. Rolstad BS, Erwin-Toth PL. Peristomal skin complications: prevention and management. Ostomy Wound Manage. 2004;50(9):68–77.
4. Ratliff CR, Donovan AM. Frequency of peristomal complications. Ostomy Wound Manage. 2001;47(9):26–29.
5. Colwell JC. Stomal and peristomal complications. In: Cowell JC, Goldberg MR, Carmel JE, eds. Fecal & Urinary Diversions: Management Principles. St. Louis, Mo.: Mosby;2004:308–325.