Peristomal Skin Complications: Prevention and Management
Ostomy surgery results in a dramatic alteration in elimination processes and body image - changes that impact both the patient and family. Peristomal skin complications further magnify this alteration, negatively affecting patient adjustment.1,2
For the healthcare system, peristomal skin complications usually mean resource utilization - increased patient care needs and the struggle to attain an optimal functional status or comfortable state of well-being are expensive. When addressing prevention and treatment, an outcomes measurement plan that tracks and documents 1) clinical effectiveness of the intervention; 2) impact on functional status and well being, 3) satisfaction with care provided, and 4) cost3 should be considered. Measuring outcomes documents intervention effectiveness and demonstrates the value of services.4,5
As in most situations, treatment is more expensive than prevention. Additional patient visits, equipment expenses, embarrassment about leakage and odor problems, plus lost work days and altered social activities, are costs that could be avoided or significantly decreased with routine surveillance.
The skin plays an important role in ostomy care, providing the surface on which the pouching system is adhered. Intact, dry epidermis and a well-fitted pouching system enable a sustained, predictable wear time. When skin integrity is compromised or when drains or an open incision infringe on adhesives, potential for pouch leakage exists. The cyclical pattern of pouch leakage/skin erosion/pouch leakage must be broken to enable epidermal resurfacing and restoration of an intact seal. Peristomal skin protection is the cornerstone of ostomy management; treatment of the skin relies on methods to create dry surfaces, fill irregular contours, and treat infections, while an adhesive seal is maintained.6
Incidence and Risk Factors
The incidence of peristomal skin complications is difficult to determine. In a review of the literature, Colwell et al7 report that the overall rate of peristomal skin complications ranges from 18% to 55%. However, these studies did not provide a standardized classification system nor was detailed information available on the type of peristomal skin complication.8 A survey conducted by the United Ostomy Association in 2000 recognized peristomal skin problems as the most common reason patients visited an outpatient wound ostomy continence (WOC) nursing service. Empiric evidence from the authors' 50 years of combined experience working with ostomy patients suggests that most patients living with a stoma will experience peristomal skin compromise and require treatment.
Risk factors that predispose patients to peristomal skin complications include a poorly located and/or poorly constructed stoma, obesity, wound complications adjacent to or in the peristomal field, and recurrent disease.9,10 Additionally, the presence of stoma complications (eg, retraction, prolapse, or hernia) increases the risk for concurrent peristomal skin complications because they change the abdomen and, subsequently, the pouching system may need alteration. Without adequate follow-up, leakage and peristomal skin complications result.
Ironically, the most common causes of peristomal skin complications occur because of lack of access to qualified healthcare professionals (WOC/ET nurses) who specialize in ostomy care and can manage these problems efficiently and effectively. Results of a longitudinal study of 4,739 stoma patients in Europe showed that the Quality of Life index is higher for patients who have access to a stoma care nurse for up to 6 months postoperatively as compared to those who do not.11 However, fewer than 4,000 WOC/ET nurses practice in the US and most are located in acute care settings. As hospital stays decrease, patients are moved into alternative care settings, accessing care as outpatients.12 Outpatient clinics offer access to WOC/ET nursing; however, reimbursement for the service is limited or not provided. As a result, ostomy-related problems may go untreated until they require definitive treatment and the patient is hospitalized.4 Of course, now the patient is in the most expensive care setting in the healthcare system, accumulating physician fees for problems that easily could have been managed in the outpatient setting. Insufficient resources and lack of reimbursement for specialized care represent barriers to access - a significant risk factor for complications because prevention and intervention strategies are not available to all patients with a stoma.13
Prevention across the Lifespan
Stoma siting. A comprehensive plan to prevent peristomal skin complications begins preoperatively because successful stoma management is predicated on the creation of a well-sited stoma. Site selection is performed by a qualified professional (WOC/ET nurse) who assesses and marks the abdomen. The site selected is located within the rectus muscle and at the apex of the infraumbilical bulge. Areas proximal to bony prominences, creases, and the umbilicus are avoided. The potential stoma site is evaluated in supine, sitting, and standing positions and must be visible to the patient. These guidelines result in a site that facilitates a secure pouch seal and enhances self-care postoperatively. It also reduces the potential for short-term and long-term stoma and peristomal skin complications.14,15
Surgical technique. Surgical technique (ie, stoma protrusion, suturing) plays a critical role in preventing peristomal skin complications. Stoma protrusion has been identified as a risk factor for compromised skin because flush and retracted stomas discharge effluent at or below skin level. This increases the risk of effluent eroding the skin barrier adhesive. A stoma with adequate protrusion (ie, 2.5 cm) and a lumen pointed upward rather than bowing downward provides a spout to discharge effluent directly into the pouching system (see Figure 1).6
Post-op care. Postoperatively, most peristomal skin complications can be minimized or avoided when patients understand the optimal environment for healthy skin and utilize that information during care. Not all peristomal skin complications are preventable; some are disease-related, immunologic, or infectious. However, knowledge and application of basic skin care approaches are key to keeping the skin clean, dry, and protecting it from exposure to effluent, trauma, chemical injury.16
Routine peristomal skin care. Understanding what is normal. Routine peristomal skin care is not complex, yet must be methodically taught, observed, and reinforced by healthcare providers so patients (or their caregivers) are able to demonstrate skill acquisition. Basic skin care begins with defining and demonstrating "normal" skin condition for the patient. Despite education to the contrary, many patients (and some clinicians) consider a chronic state of peristomal skin irritation as normal. However, peristomal skin should be intact and healthy even though covered with an adhesive skin barrier. It should appear similar to skin on the other side of the abdomen. This concept should be reinforced during routine teaching and assessment sessions to help patients recognize what is normal and what is not.16
Pouching system fit. Because irritant contact dermatitis is the most common skin complication, all efforts are made to maintain a pouching system that is properly sized and contoured.15,17 This is the most critical prevention and treatment strategy as it protects peristomal skin from exposure the stool, urine, and mucus (the irritants). All too often patients and inexperienced healthcare providers assume that the initial pouching system is the type a patient uses throughout their lifetime. The pouching system fitted immediately after surgery will meet the needs at that time. However, within the first 3 months of surgery, stomal edema resolves and the stoma size changes, requiring several pouch refittings during this time. Additionally, abdominal distension and firmness will diminish, necessitating refitting to accommodate the contouring, rigidity, and depth of the skin barrier of the pouching system.18 Without reassessment of the pouching system, leakage results, exposing the peristomal skin to effluent.
Patient instruction should include use of a disposable measuring guide to measure the stoma at each pouch change and verify that the size of the opening to the pouch is correct. The pouching system must fit so the skin at the base of the stoma is covered. If the size of the stoma is significantly smaller than the size of the opening in the skin barrier, a pouch refitting with a knowledgeable expert is recommended. The need for assessment and refitting is a lifelong reality for the patient.
Wear time/leakage. Establishing a pouch change schedule and taking action if pouch leakage occurs are important tactics to protect peristomal skin. A routine pouch-changing schedule of once every 4 to 7 days provides consistency that usually avoids surprise leakage problems. Extending pouch wear time beyond what is recommended by the ostomy care nurse or manufacturer should be avoided to prevent both "silent leakage" and frank leakage. Silent leakage occurs when the skin barrier erodes and the skin is exposed to effluent, even though there are no visible signs of leakage. Usually, silent leakage is signaled by patient complaints of burning and excessive itching without signs of detached skin barrier adhesive. Skin barrier erosion is evident when the pouching system is removed. Frank leakage is evident when effluent leaks through the skin barrier. Odor also may be noted as this point. With either form of leakage, the pouch should be changed and a clean system applied as soon as the problem is detected.
Adhesives and cleansing. Protecting skin also includes nontraumatic adhesive use and skin cleansing. Gentle removal of adhesives is recommended to avoid skin stripping. The pouching system is removed by supporting the skin and using a soft tissue with water. For patients with sensitive or friable skin, a skin sealant may be used to prevent trauma during adhesive removal. Cleansing is performed with soft tissues or cotton balls to avoid abrasion. Chemicals may cause irritant contact dermatitis; therefore, the rule of thumb is "avoid use of all skin care products for the skin unless there is a specific indication for that patient".6,14,16 Indiscriminate use of products exposes the skin to risk for irritant contact dermatitis and unnecessarily increases the cost of care. Peristomal skin is cleansed with a pH-balanced soap that does not have a lotion or oil base.6,11 In some situations, the cleansing agent of choice is water alone. The skin must be dry before applying the pouching system.
Drying the skin. Maintaining dry skin reduces the risk of developing candidiasis and is critical to obtaining a good adhesive seal. Patients may shower with the pouch off on the day they are due for a pouch change and apply the clean system once the skin is patted dry. When bathing with the pouch on, the skin barrier and pouching system should be dried before dressing. Patients may use a hair dryer on a cool setting or simply air dry the outside adhesive and any pouch cover material.
Surveillance. Following hospitalization, surveillance in the outpatient setting includes inspection of the skin, stoma, and pouching system as well as evaluation of patient adjustment and an educational update. Initial postoperative visits with the WOC/ET nurse should take place 2 to 4 weeks following hospitalization, with subsequent visits at 3 months and 6 months. Annual visits are part of a standard surveillance for patients with abdominal stomas.18
Abdominal changes. Changes in the abdomen over a lifetime impact pouch fittings and the condition of the peristomal skin. Pregnancy, a new exercise program, a change in weight, lifestyle changes, and some disease states change the contours of the abdomen. Although the size of the stoma and pouch opening are essential characteristics in fitting pouches, the contour, rigidity, and depth of the skin barrier on the pouching system are equally important. These characteristics, rather than stoma size, are the most common long term reasons for for refitting pouching systems.
Treating Peristomal Skin Complications
Patients are usually the first to know that the skin has changed and has become irritated. The pouch is leaking; the peristomal skin is itching, burning, or painful. Something has changed. If the skin is eroded and moist, patients generally are instructed on how to use skin barrier powder to manage these areas. The powder is dusted over the moist area and excess removed to avoid interference with the pouch adhesive. If the pouch is routinely worn for 6 days, the patient may change the pouch after a shorter weartime interval in order to check the skin. If a pouching system is regularly leaking in one location, using skin barrier paste, strips, or other forms of skin barriers to fill irregular skin surfaces may alleviate the problem. When first-line defenses fail, a visit with a knowledgeable ostomy care provider (WOC/ET nurse) is scheduled.
Peristomal skin complications and management approaches can be categorized by etiology: chemical (see Table 1), mechanical (see Table 2), infectious (see Table 3), immunologic (see Table 4) and disease-related (see Table 5). Crohn's Disease ulceration of the peristomal skin is also a disease-related condition resembling pyoderma gangrenosum; however, the lesions are not violaceous nor do they exhibit extensive undermining. Treating the underlying disease is indicated in Crohn's ulcerations; topical management is similar to pyoderma gangrenosum. Categorizing complications helps organize and manage outcome measurement databases.
Frequently, peristomal skin complications are classified by early or late presentations. The peristomal skin complication seen in the early postoperative period is mucocutaneous separation. Allergic contact dermatitis is a rare occurrence in stoma patients, particularly in the early postoperative period20 because allergies usually occur following repeated contact with the allergen. Pseudoverrucous lesions, encrustations, pressure/shear injuries, mucosal transplantation, folliculitis, varices, pyoderma gangrenosum, and malignancy generally occur over the longer term. Candidiasis, irritant contact dermatitis, and stripping injuries can occur any time.
Assessment, treatment, and follow-up are key to successful management of peristomal skin complications (see Table 6). Assessment and documentation should always incorporate parameters specific to the care setting.
Prevention and management of peristomal skin complications is an important aspect of ostomy care. It is also a component to be tracked in quality management plans in the hope of recommending quality measurement. The peristomal skin classification system demonstrated in the tables is a useful way to classify complications in databases in order to begin a standardized approach to reporting outcomes.5 By consistently providing basic care, assessment, documentation, and treatment approaches, the quality management principles of "doing the right thing at the right time, in the right way, for the right person and getting the best possible results"21 is demonstrated.
Research is needed related to peristomal skin complications because much of what is used in practice today is based on expert opinion. Additionally, much of the current research related to abdominal stomas may be performed to justify the need for continent diversion surgery, rather than to discover more effective approaches to caring for stoma patients. Although such research is important, in the US, an estimated 450,000 people are currently living with and may continue to require stomas.4
Providing quality care for the person with an abdominal stoma requires attention to clinical care, qualify of life issues, and cost. The condition of peristomal skin in this matrix is significant because compromised tissue leads to increased care, health-seeking activities, problems with adjustment, and increased costs. A comprehensive approach to the prevention and management of peristomal skin complications begins preoperatively and continues until the stoma can be closed or for the rest of a persons life. Access to knowledgeable care providers is key to decreasing complications and minimizing their effect.