Physicians of the Zane Cohen Centre

Peristomal Skin Complications

Methods taught by an Enterostomal Therapy (ET) Nurse, as well as supplemental written information about ostomy care, should help to prevent the development of skin problems related to ostomy care. However, skin complications can occur and these need to be identified quickly and managed appropriately in order to avoid further problems. Ideally, assessment and management of peristomal skin problems should be done in conjunction with an Enterostomal Therapy Nurse so that correct determination of the problem can occur, and correct treatment can be initiated.

The most common problems that can occur with the peristomal skin are: peristomal skin excoriation or irritation; mechanical irritation; allergy/sensitivity; folliculitis; and monilia. Other causes of skin irritation may be due to the construction/shape/size of the stoma, abdominal contours (dips and creases), changes in weight, or incorrect pouching systems.

Peristomal Skin Excoriation

Stool excoriation is the most common skin complication. It can lead to redness, weepy bleeding areas, pain, itching, stinging or burning sensations. Skin excoriation is often the result of stool coming into contact with the peristomal skin. Additional factors which may lead to excoriation include chemotherapy, radiation, psoriasis, adverse reaction or side effect to certain medications such as, steroids, antibiotics, chemotherapy, or immunosuppressives. A flush or retracted stoma can lead to stool leakage and excoriation. Poor hygiene, an inappropriate pouching system as well as allergies or sensitivity can also cause skin reactions.

The most common reason for stool irritation is an appliance or flange with an opening that is too large. Too much skin becomes exposed and stool comes in contact with it, causing irritation/erosion. The opening of an appliance/flange should be no more than 1/8 inch (3 to 4 mm) larger than the base of the stoma. This allows for adequate skin protection, but also ensures some "wiggle" room for peristalsis or normal movement of the stoma.

The opening should not be snug against the stoma as this can cause a laceration or a cut to the stoma to occur. To ensure that the opening is correct, save the paper or plastic backing of the current appliance and place it over the stoma, ensuring that it is centered over the opening. Look in a mirror and check the gap between the base of the stoma and the edge of the opening. The stoma may need to be moved around (use a tissue and just gently move it from side to side, or up and down) to check all sides. If the opening is too large, then the pattern needs to be adjusted accordingly.

Once the cause of the stool irritation has been identified and corrected, then the actual treatment is quite simple. Using a pectin based powder (e.g. Stomahesive Powder™ or Premium Powder™), sprinkled lightly on the affected area, and then sealed with a skin sealant (e.g., No Sting™ or Skin Prep™) is usually sufficient. Using powder only may prevent the appliance from adhering to the skin, so a sealant is helpful. Usually, if all things are corrected, then healing or resolution should occur by the time the next appliance change is due. Ongoing difficulties emphasize the need for review by an Enterostomal Therapy Nurse.

Mechanical Irritation

Mechanical irritation is another common source of irritation. This tends to be related to the removal technique of ostomy appliances, or due to fragile skin. If an appliance is removed too quickly, then the first layer of skin may become damaged, leaving a patchy, red, painful area that may "weep" fluid. This tends to happen more easily under the tape border portions of flanges, and is less likely under barrier portions of appliances. Individuals who have fragile skin (e.g. people who have had long-term steroid use, or the elderly), may be more susceptible to skin loss or damage during appliance changes.

Routine removal of the appliance should be done slowly and gently by rolling or pushing the skin away from the back of the appliance.

Peeling should be avoided (do not "rip" quickly, as is commonly done with bandages), particularly with tape bordered appliances.

If technique is not at issue, then perhaps other causes such as fragile skin, may be considered. Some individuals find the use of skin sealants such as No Sting™ or Skin Prep™ under appliances help provide a sufficient "shield" between the appliance and the skin to allow for protection and avoidance of damage. Some people find that they need to switch from a tape border product to a full barrier product to avoid problems. An Enterostomal Therapy Nurse can help to determine the best course of treatment.

Once the cause has been determined and corrected, actual treatment can be done simply with the use of a pectin-based powder (e.g., Stomahesive Powder™ or Premium Powder™), sprinkled on the affected area, and then sealed in with a skin sealant (e.g., No Sting™ or Skin Prep™). Healing/resolution will usually occur by the next appliance change. Ongoing problems emphasize the need for help from an Enterostomal Therapy Nurse.

Allergy/Sensitivity

Allergies or sensitivities to products can occur over time. These reactions are not always predictable and may take months or years to develop. Sometimes, the reaction can occur quite quickly, particularly if there is known previous sensitivities to tape(s). The reactions can range from persistent itchiness without actual rash or skin breakdown, to blistering, redness and skin breakdown. Allergies or sensitivities tend to happen more easily with tape bordered products than with full barrier products.As indicated above, the range of reactions can be quite varied. For sensitivities that just involve itchiness with no rash or skin breakdown, then using a skin sealant (e.g., No Sting™ or Skin Prep™) as a "shield" between the appliance and the skin.

Sometimes, using a full barrier product between the skin and appliance (e.g., Extra Thin Duoderm™ or Coloplast™ barrier), may be needed to improve the situation.If there is actual blistering of the skin, then at an absolute minimum, the choice of appliances must be changed. Depending upon the severity of the allergy and skin blistering/breakdown, you may need to be seen by an Enterostomal Therapy Nurse to help manage the reaction. Measures such as providing an interim appliance that will allow the skin to heal by helping to cope with the "weepy" fluid from the blistered areas and by helping to select an alternate appliance may be beneficial solutions. "Patch testing" of other products on unaffected skin may be recommended to help determine the best pouching option.

Folliculitis

Folliculitis, infected hair follicles, can cause redness and sometimes pustules at the base of the hair follicles. There is often itching, burning and pain. This can be due to damage to the hair follicles usually after the traumatic removal of an appliance or when tape is removed too quickly. To prevent damage to the hair follicles, excess hair around the stoma should be gently removed with an electric razor, always shaving in the direction of hair growth. Scissors can also be used to remove excess hair. Protective powder can be added to the skin prior to shaving to decrease trauma. Appliances should always be removed gently by pushing the skin away from the barrier rather than pulling away from the skin.

Monilia/Candida Albicans (Yeast Infection)

Yeast can occur under the appliance as a result of excessive moisture and heat (e.g. perspiration on hot, humid days; long soaks in hot tubs), after antibiotic use, or when someone is immunocompromised (e.g. chemotherapy). Patches of yeast are solid red in color with an irregular border and will have tiny little red or white points scattered out from the main rash — called "satellite lesions". It can be itchy, and in severe cases, may weep slightly. It is important to check for the presence of yeast in other areas such as under the arms, in the groin, under breasts, in abdominal folds or in the mouth. If yeast is found in these areas as well, they must also be treated topically, usually with a cream such as Canestan™ or a mouth rinse in the case of oral yeast.

For treatment under the appliance, Mycostation™ powder is most commonly used. The powder is sprinkled lightly on the affected areas and sealed in with a skin sealant (e.g. No Sting™ or Skin Prep™). This process is repeated with each appliance change, usually for about three to four changes or until the rash is resolved. If there is no resolution, then an Enterostomal Therapy Nurse should be contacted for review.

Ostomy Care - Selecting an Appliance

The selection of appliances for ostomy care is based on a few basic principles:

• odour-proof
• leak-proof
• protects the peristomal skin from stool and trauma, irritation
• protects the stoma from damage
• promotes independence and comfort

Selection must also take into consideration how the stoma is constructed, what the surrounding skin and abdominal contours look like, the consistency of the stool, and the cost and availability of the product.

Ostomy appliances can either be a one-piece or two-piece system. In a one-piece system, the barrier, "sticky" portion, and the collection pouch are attached to each other and cannot be separated. In a two-piece system, the barrier portion (flange) and the collection pouch are two separate pieces and are connected by some sort of a locking mechanism. The flange and pouch can be separated. There are "pros and cons" to each system, and these can be discussed with an Enterostomal Therapy Nurse.

Stoma type and construction, body contours, personal capabilities (hand strength, eyesight, etc) and preferences will all contribute to the choice of appliance. Certain aspects such as stomal type and construction may dictate and limit product choices, but usually there is some degree of choice for an individual with an ostomy. After surgery, the selection process should be done with an Enterostomal Therapy (ET) Nurse. Subsequent changes should be done in consultation with an ET to ensure that unnecessary problems and expense are avoided.

Considerations

There are several considerations to make when selecting appliances.

Barrier Type

Two types of barriers exist: regular and extended wear. The barrier is fundamental to appliances since this is the substance that protects the skin from the stool.

• Regular Wear
  Regular wear barriers are ideal for colostomies where the stool is semi-formed to formed in consistency, and tends to not "melt" or "wash away" the barrier during use. Typically, those with a colostomy can wear a regular barrier product for five to seven days before requiring a change. While it is not wrong for individuals with ileostomies to use a regular barrier, the stool will wash away the barrier more quickly and more frequent changes are suggested so that peristomal skin will remain protected.

• Extended Wear
  Extended wear barriers are more resistant to "melt-out" and are ideal for ileostomies and urostomies (urinary stomas). Some of the extended wear barriers will actually form a thick "cuff" around the stoma (in about 24 hours after application) which enhances the seal and helps to extend the wear-time. Typically, those with an ileostomy or urostomy can wear an extended wear product for five to seven days. These products tend to be more "sticky", so slow, careful removal is suggested with each appliance change.

Full-Barrier versus Tape-Border

Appliances can either be full barrier with no tape at the edges or have the barrier in the Group with a tape border.

• Full Barrier
  Full barrier products are good options for those with known tape sensitivities or allergies. As tape is not used or required to secure these appliances, reactions can be avoided. Originally, full barrier products tended to be thicker and bulkier, but there are now significant improvements and these are now lighter and thinner.

• Tape Border
  Tape border products have a border of tape extending from the Group barrier which is intended to make the appliance lighter and more flexible. The tape border also has a slightly different adhesive than the barrier, so "tack" is often immediate. Sensitivities tend to happen more readily with tape borders, and sometimes with tape borders that are flesh coloured (due to dyes used).

One-Piece System

Advantages:

• Low profile: since there is no "locking" mechanism to connect separate pieces, these appliances lay flat against the body
• Increased security: there is no concern about incorrectly attaching the pouch to the flange, so unexpected leaks from the connection will not occur
• Increased flexibility: these appliances tend to be very flexible, so will curve/mold with gentle body contours

Disadvantages:

• Inability to change pouch type: one-piece appliances are generally meant to be worn for a period of time (four to five days), and so switching a short pouch to a long pouch to suit personal needs during the course of a day are not possible.
• Inability to use a belt as some one-piece appliances do not incorporate belt tabs, so if extra security is desired or required, this may not be possible.

Two-Piece System

Advantages:

• Ability to switch pouch type: if a short pouch is desired for day-time, a longer pouch for night time, and a stoma cap for swimming, then this can be done with a two-piece system. The flange remains in place for the pre-determined time, and the 'locking' mechanism allows for the pouch type to be changed.
• Ease of application: for some, being able to apply the flange first, then the pouch during routine appliance changes, makes care easier.
• Ability to use a belt: most two-piece systems have belt tabs which allow for the use of a belt.

Disadvantages:

• Increased profile: because of the locking mechanism. The profile of the appliance is raised; the degree of profile varies between product lines.
• Decreased flexibility: most locking mechanisms tend to be quite rigid, so conforming to body contours may be problematic.
• Decreased security: incorrectly attaching the pouch to the flange may result in leakage.

Flat versus Convex

Depending upon stomal construction and surrounding body contours, a flat appliance or one with convexity may be the optimal choice.

Flat
Flat appliances are literally flat. They work best with an abdominal surface that has sufficient flat area to allow for the appliance to adhere and a protruding stoma of some degree.

Convex
Convex appliances protrude at the adhesive surface (it looks like a curve or bulge), and are designed to help flatten some body contours and to assist with accentuating stomal protrusion. This is usually required when a stoma is flush or retracted, or perhaps "tips" down and rests against the skin. Sometimes, body contours (dips and creases of varying degrees) will also interfere with an adequate seal. A convex appliance will help to compensate for this. There are several degrees of convexity — from shallow to deep — and the best type can be determined in conjunction with an Enterostomal Therapy Nurse.

Pouch Length

Pouches can be of varying sizes, either mini (with virtually no capacity to hold stool), short (about 9 to 10 inches in length), or long (about 12 inches in length). Obviously the volume of stool held in the pouch is dependent upon the size. The choice can be made according to the volume of stool produced in a day, and the frequency by which the pouch must be emptied (remembering that pouches should be emptied when 1/3 full). Some people prefer shorter pouches during the day, as concealment under clothes is easier, and longer pouches at night to facilitate sleep. Mini pouches (or stoma caps) are for times when stool volume is known to be low and when discreteness is desired (i.e., swimming, sexual activity).

Drainable versus Closed-End Pouches

Drainable
Drainable pouches are those with an open "tail" that require a clip or velcro for closure. The clip or velcro is removed or opened when emptying of the pouch is required. Closed-end pouches are sealed at the bottom are thrown away when half filled with stool.

Drainable pouches are best used for ileostomies or for colostomies when the stool is thin and frequent. As emptying is frequent, the pouch is allowed to drain through the tail and into the toilet at the discretion of the individual. Because stool is thinner, it drains easily from the pouch. It is a more cost-effective means of management when emptying is frequent.

Closed-End
Closed-end pouches are primarily intended for individuals with a colostomy. As stool tends to be thicker, it may be harder to drain easily from a drainable pouch. A closed end pouch allows the individual to remove it in its entirety and discard it in the garbage, immediately replacing it with a clean new pouch. For most individuals with a colostomy, this means one to two pouches daily. Most closed-end pouches also have charcoal filters which releases deodorized gas.

Pre-Cut versus Cut-to-Fit

Pre-Cut
Pre-cut flanges imply that the opening of the barrier is pre-cut according to standard sizes determined by the manufacturer. Cut-to-fit implies that the barrier must be cut by the individual according to the size of his/her stoma.

Pre-cut barriers are best used once the post-operative swelling of the stoma has settled (at about 6 to 8 weeks). The chosen pre-cut opening should be 1/8 (3-4 mm) larger than the base of the stoma. As most manufacturers have standard pre-cut measurements, you may find that your size is not available. The stoma must also be essentially round in shape in order to use pre-cut barriers, as oval openings are not generally available.

Cut-to-Fit
Cut-to-fit barriers are a good choice in the initial weeks after surgery, as the stoma will shrink during this time and adjustments to the opening will be required. It is also a good option when stomas are oval or irregularly shaped allowing for a more precise cut and opening.

Accessories

There is certainly a wealth of additional products that can be used in conjunction with pouching choices. Not all are required, and use may be based on personal preference rather than need.

Belts
Belts may be required to ensure adhesion of an appliance, but also may be desired for personal comfort and security. Some prefer to use belts during physical activity to allow for extra support. Belts tend to provide support and security just at the lateral level (i.e. they pull at 3 and 9 o'clock of the peristomal area). Belts also work best if they are in-line with the natural waist and do not "ride-up" higher than the level of the pouch.

Stoma Protectors
Stoma protectors are hard plastic devises that are worn over the stoma and appliance to protect the stoma from any trauma. These are most commonly used during times of physical labor, or during sports activities when the risk of damage is high.

Additional Barriers
Barriers come in different formats, including pastes, plates or rings. These may be helpful to fill in dips and creases, accentuate convexity or assist with adding wear-time to an appliance. The appropriate choice and use of an additional barrier should be done in conjunction with an ET.

Deodorants
While appliances and pouches are odour-proof, pouch deodorants (as well as room deodorants) are available to alleviate odour while emptying.

Your ET or ostomy supply company can provide you with information regarding all of the products.

Changing the Appliance

The following steps are for a two-piece system appliance change and are generic. All ostomy companies provide directions for their specific product on the packaging.

Gather All Your Supplies
If using a two-piece system you will require:

• Flange and pouch

• Closure clip if applicable

• Paste (tube or strip) if applicable

• Measuring guide (your stoma will need to be measured and the pattern adjusted for the first 6 weeks following surgery)

• Pen, scissors, mirror

• Wet/dry cloths

• Bag to dispose of soiled appliance

Appliance Removal

• Many people with ostomies find it quite convenient to change their appliance in the shower during a quiet time. Over time, most individuals will sense quiet times and active times.

• Appliance changes should be planned, regular events, rather than emergency responses to problems.

• Remove the appliance with care. Keep one finger against the skin as you lift the flange — roll/push motion. Many people find removing the appliance in the shower under running water facilitates removal of the appliance.

• Dispose of appliance. Save closure clip if applicable.

Stoma and Peristomal Cleansing

• With a dry cloth, remove excess stool and mucous from stoma.

• Cleanse the stoma and peristomal skin with warm tap water. Scant bleeding on the cloth would be normal. The stoma is lined with blood vessels which may bleed when cleansing.

• Excess peristomal hair may be removed with scissors or electric razor. Any peristomal hair should be removed about every 2 to 3 appliance changes. This prevents irritating the hair follicles. An electric razor is the best method to remove hair. The stoma can be protected by using an old toilet paper roll.

Observe the Stoma and Peristomal Skin

• Using a mirror, observe the stoma and peristomal skin. The skin should always be healthy and free of any signs of redness or irritation. The stoma should always be red in colour, moist and smooth.

• The stoma should be measured for the first six weeks following surgery. The opening to the appliance should be 1/8 inch larger (3 to 4 mm) than the base of the stoma itself.

Prepare the Flange

• Trace and cut the opening of the stoma on the back of the flange.

• Remove backing paper.

• Apply a bead of paste (if applicable) around the opening only. The paste does not need to be spread or smoothed in place.

Centre the Flange

• Stand in front of mirror to help center the flange over the stoma.

• Avoid skin wrinkles underneath. Pushing or stretching your abdomen will help to avoid wrinkles.

Attach the Pouch

• Fit the pouch to the ring of the flange. Start from the bottom and walk the pouch up and over. An audible clip is often heard.

• If using a system with a lock — click in place.

• Gently tug downward on the pouch to ensure the pouch is securely in place.

• Add deodorant drops if needed.

• Apply closure through the use of a clip or velcro.

• Hold hand over the appliance for 2 to 3 minutes to encourage adhesion to the skin.

To Empty Pouch

• Empty pouch when it is one-third to one-half full.

• Sit directly on toilet.

• Place tissue in the toilet bowel to avoid splashing.

• If using closure clip, remove and place in a safe area. “Cuff” the tail portion of the pouch. If using velcro closure, undue it and open tail portion of the pouch.

• Slowly empty the contents into the toilet bowel. The pouch may need to be “milked”.

• A rinse bottle filled with warm water may be used to gently flush the inside of the pouch. This is not a necessary step.

• Wipe the inside and outside of the tail portion of the pouch.

• Add deodorant drops as necessary.

• Reapply closure clip or velcro.

Special ConsiderationsFor Individuals with an IleostomyAs the stool from an ileostomy tends to be more irritating than that of a colostomy, protection of the skin is very important. Protruding or raised stomas are ideal and help to facilitate protection of the skin. The type of barrier selected can also help to protect the skin as some barriers are more resistant to the effects of the stool and can be worn for longer periods of time (up to a week) without damage or irritation. These barriers are known as extended wear barriers. Regular wear barriers tend to "melt" or wash away more quickly with stool from an ileostomy, and so more frequent changes are required (about every four days).

Pouches for ileostomies tend to be drainable or open-ended. This means that the stool would be drained or emptied into the toilet through the tail portion of the pouch. The tail portion is closed either with a closure clip or a velcro style closure.

For Individuals with a ColostomyThe stool from a colostomy tends to be less irritating to the skin, and because it is usually formed it tends not to undermine the appliance. As a result, stomas for colostomies can be somewhat flush. Again, because the stool tends to be formed, the barrier will not melt or wash away as quickly and so regular wear barriers are usually sufficient to provide a seal. Initially, you may want to change the flange every four to five days, but as the stool becomes more formed and regulated, you may find that the wear-time can be stretched to six to seven days.

Pouches for colostomies can be either drainable (open-ended) or closed-end. Closed-ended pouches are generally discarded when half full of stool. You can discuss options with your ET to see which will best suit your needs and lifestyle. Colostomy pouches may also have the option of a gas filter which will allow the gas to pass out of the pouch deodorized by a charcoal filter. It will not prevent the sound of gas from escaping into the pouch. Using pouches with a gas filter is best when the stool is formed, as liquid stool tends to clog the filter and render it ineffective.