The Ostomy Files: Choosing a Skin Barrier
There are many options to consider when selecting the appropriate ostomy appliance for your patient, including pouch features (eg, the type of outlet, preference for a filter, opacity, cloth backing) and adhesives. A skin barrier should be selected that will provide a secure, protective seal around the stoma while maintaining optimal skin condition. With guidance from the WOCN, the patient has the ultimate decision over what works best for his/her lifestyle.
Consider the skin: epithelial cells are bonded by a matrix of lipids and enzymes to create an acid mantle, providing protection from bacterial and fungal invasion. Metabolic processes produce perspiration. The natural process of cell death leads to the shedding of epithelial cells. The ideal ostomy skin barrier must manage skin function and process without breaking down or loosening and maintain an optimal skin pH to prevent fungal or bacterial invasion. Most importantly, it must adhere securely yet remove gently to avoid skin stripping or cause mechanical injury. Ostomy skin barriers are made up of a polymeric matrix (see Figure 1) and compounds (hydrocolloids) that provide absorption (eg, of perspiration), tack/stickiness (ie, the property relating to instantaneous bonding to the skin), and moldability to fit against the skin for long-term adhesion. Ostomy adhesives are pressure-sensitive. The long-term bond between skin and appliance depends on the adhesive making full contact with the skin surface and is achieved by applying gentle pressure upon application. This allows the polymers to flow into the skin, increasing the contact area (see Figure 2).
Stomas with aggressive output often break down the adhesive; contact with stoma effluent is the most common cause of skin irritation, leading to skin problems and discomfort. Peristomal skin health is critical, because it can have a direct impact on the way the patient deals with a stoma, which directly affects his/her quality of life.1 Research has demonstrated the most common reason for peristomal skin breakdown is chemical irritation of the skin — specifically, by stool or urine. This can be caused by an improper ostomy appliance fit, skin barrier erosion, or a combination of both. The OstomySkinStudy2 revealed frequency of skin disorders was highest among participants living with an ileostomy (57%), followed by urostomy (48%). Of the peristomal skin disorders observed, 77% were due to skin exposed to stool or urine. Contact with stoma effluent is the most common cause (up to 48%)3 of skin irritation leading to skin problems and discomfort.
Keeping the skin dry and healthy involves a combination of different compounds (hydrocolloids) with different moisture-absorbing capabilities. Different hydrocolloid combinations create a balance between initial absorption and absorption during use. Standard wear barriers absorb moisture quickly and may be considered in humid environments and for people who perspire heavily. Extended wear barriers absorb moisture at a slower rate and are indicated for use with liquid output. The polymeric matrix (adhesive framework) and the hydrocolloids work together to maintain the adhesive structure and resist erosion from stoma effluent (see Figure 3). As moisture is absorbed, the inside edge of adhesive swells around the stoma, creating a protective seal.
Ease of removal is judged by the force required to remove the adhesive from the skin. The adhesive should be able to be removed without stressing or irritating the skin and without leaving residue (see Figure 4). This is determined by the cohesiveness of the barrier as it wears. If the barrier absorbs moisture and still maintains integrity, it should be easier to remove with less discomfort.
Coloplast has developed a skin-friendly, double-layer adhesive that optimizes five key components. The lower layer is absorptive, contributing to the pH balance of the skin. The upper layer is erosion-resistant and protects the lower layer. Both layers work together to provide initial tack, adhesion and flexibility. In addition, the SenSura® adhesive has an oval shape, which combined with flex patterns around the perimeter of the barrier, provides ultra flexibility. This allows the adhesive to move with the body and maintain a secure seal. Coloplast offers a full line of SenSura barriers including Xpro, an excellent option when extra protection is needed from aggressive output.
Understanding how the ostomy skin barrier adhesive affects your patient’s skin will aid you in choosing an optimal skin barrier and avoiding skin issues.
The Ostomy Files is made possible through the support of Coloplast, Minneapolis, MN (www.us.coloplast.com). The opinions and statements of the clinicians providing The Ostomy Files is specific to the respective authors and the ideas presented are not necessarily those of Coloplast, OWM, or HMP Communications. This article was not subject to the Ostomy Wound Management peer-review process.
1. Stoia Davis J, Svavarsdóttir M, Pudło M, et al. Factors impairing quality of life for people with an ostomy. Gastrointestinal Nurs. 2011;9(2 suppl):14-23.
2. Herlufsen P, Olsen AG, Carlsen B, et al. OstomySkinStudy: a study of peristomal skin disorders in patients with permanent stomas. Br J Nurs. 2006;15(16):854–862.
3. Martins L, Samai O, Fernández A, Urquhart M, Hansen AS. Maintaining healthy skin around an ostomy: peristomal skin disorders and self-assessment. Gastrointestinal Nurs. 2011;9 (2 suppl):9-13.