Ostomy surgery is a life-changing intervention with a relatively high risk of postoperative complications, all of which can greatly impact a patient’s quality of life. Compromised peristomal skin integrity is reported to be the most common postoperative complication following the creation of a stoma, with the literature reporting incidence rates of up to 60% and a significant impact on both the patient and the healthcare systems which support them. Knowledge of the appropriate product or appliance to prevent or manage peristomal skin complications is key.
Ostomy surgery is an intervention performed to create an artificial opening in a patient’s abdomen, as a means of diversion for faeces or urine. There are three types of stoma, which include:
Colostomy: this is a slightly raised stoma formed through the colon, yielding a soft, semi-solid output. The associated appliance generally needs to be changed 1–3 times daily. In the UK, 6400 colostomies are formed each year in the UK, most commonly due to colorectal cancer
Ileostomy: this is formed through the ileum and has a small spout. The output has a loose consistency, with pouches requiring emptying 5–7 times in a 24-hour period; it is suggested that the associated appliances are changed every 3 days. Every year, 9000 ileostomies are formed in the UK, mainly due to inflammatory bowel disease
A urostomy: also termed an ileal conduit, this is formed through the ileum as a diversion for urinary output. It consists of a small spout, and the associated appliance requires changing every 3 days. In the UK, 800 urostomies are former each year, most commonly owing to bladder cancer (O’Flynn, 2019).
Although sometimes necessary for the management and treatment of certain conditions, the creation of a stoma can greatly impact a patient’s quality of life. As the creation of a stoma interrupts the gastrointestinal tract’s absorptive process at the point at which it is formed, both the nature of its output and the ability of the ostomate to absorb nutrients from their food are affected, which means that the appropriate management of stomal output and the maintenance of adequate nutrition is critical to maintaining a patient’s physiological and psychosocial wellbeing (Burch, 2006). However, a frequently neglected aspect of ostomate care, which should be comprehensive and holistic, is the care of the skin surrounding the stoma. In order for an ostomy pouching system to adhere properly, the peristomal skin must be dry and intact; however, peristomal skin complications (PSCs) are incredibly common, presenting a constant challenge for the great majority of individuals with a stoma. Indeed, it is believed that PSCs are the most common postoperative complication following the creation of a stoma, with the literature reporting PSC rates ranging from 18–60% and suggesting that peristomal skin problems account for about 40% of all visits to stoma care nurses (Meisner et al, 2012).
The real cost of peristomal skin complications
PSCs have a significant impact on not only the affected individual and their personal support network, but can also represent a substantial clinical, economic and societal burden in the long term. For instance, in Meisner et al’s (2012) population-based cost modelling study, conducted to determine the financial burden of PSCs, the estimated total average cost for a 7-week treatment period (including appliances and accessories) was found to be €263 for those with PSCs (n = 1742), compared to €215 for those without (n = 1172). Meisner et al (2012) also demonstrated that, based on French unit costs, treatment of a ‘mild’ PSC was estimated to add extra cost in the range of €19–40 per patient over a 7-week period; for moderate PSCs, the estimated extra cost was in the range of €23–88 per patient over ostomies without PSCs; for those with severe PSCs, a significantly higher estimated added cost in the range of €106–196 per patient was found over the 7-week treatment period.
Similarly, healthcare resource utilisation (HRCU) by patients with stomas in a UK context was more recently evaluated by Mthombeni et al (2023), who found that both new and established stoma groups had significantly higher HCRU (all P<0.0001) and associated costs (all P<0.01), driven by inpatient admissions. In individuals with a newly created stoma, the cost burden was found to be particularly high: in colostomy patients versus controls, costs were £3227 versus £99 per person; in those with an ileostomy, costs were £2576 versus £78 per person; and, in those with a urostomy, costs were £2850 versus £110 per person (Mthombeni et al, 2023). The proportion of individuals in the stoma group requiring medication for skin issues was also much greater when compared to the controls (colostomy: 19% versus 4%; ileostomy: 18% versus 3%; urostomy: 19% versus 4%) (Mthombeni et al, 2023). Additionally, data from a systematic review of 23 studies suggest that PSCs specifically lead to increased HRCU and consequently higher healthcare costs, associated with longer hospital stays, higher hospital readmission rates and higher numbers of clinic and emergency room visits, compared to patients without skin complications (D’Ambrosio et al, 2022).
This purely economic perspective does not take into consideration the psychosocial impact of PSCs, which can be significant. Indeed, it has been found that ostomates experience feelings of stigmatisation, embarrassment, fear of the unknown and discomfort with odours and sounds, which were reported to be exacerbated when leaks are experienced, making individuals more likely to withdraw from social activities, thereby demonstrating that stoma leaks and compromised skin integrity affect quality of life (O’Flynn, 2019). Ostomised patients can even begin to exhibit disorders such as anxiety or depression, which result in a loss of confidence in their social and family relationships and in their ability to return to their normal daily activities (D’Ambrosio et al, 2022). Therefore, the ability of healthcare professionals to correctly identify a potential PSC and implement preventative measures in the form of peristomal skin care is absolutely essential to mitigating the devastating effect of PSCs on patients’ wellbeing and healthcare systems in general.
Identifying peristomal skin problems
Typical, healthy peristomal skin should resemble the rest of the skin of the patient’s abdomen; in patients with lighter skin tones, the peristomal skin should not be reddened and, in patients with darker skin tones, it should not present any darker discolouration (Stelton, 2019). The peristomal skin should also be clear of lesions of any kind (Stelton, 2019).
In contrast, PSCs present themselves in a number of different but evident
ways upon skin assessment, which should involve:
- Checking if skin is broken, oozing, weeping, ulcerated, erythematous or bleeding
- Establishing if the consistency of effluent has changed in appearance or colour and reviewing periodically
- Evaluating the efficacy of treatment
- Checking the back of the pouch for signs of effluent leakage
Observing for adaptations that could cause skin problems, such as the use of soap or wipes, and assessing patients’ technique for appliance removal (O’Flynn, 2019).
The most common types of PSC include: irritant dermatitis, which is defined as skin irritation caused by stoma output (faeces or urine) coming into contact with the skin and is particularly common following ileostomies, due to the digestive enzyme and electrolyte content of output being extremely corrosive; mechanical injury (skin stripping), which can occur when the adhesive parts of the pouch system are removed, with the epidermis adhering to the tape and separating from the dermis to cause an open wound; and candida infection, which can occur under the ostomy skin barrier because of the dark, warm, moist skin environment which presents as scattered papules, white pustules, skin redness and feelings of ‘burning’ or itching (Stelton, 2019).
Seeking a solution
There is a wide range of products and appliances available to mitigate the risk of effluent leakage and, thereby, PSCs; however, the sheer degree of accessible options can present a challenge in itself, making it difficult for clinicians to make the optimal choice, which can result in potential overuse and misuse of products, leading to unnecessary expense for the NHS and poor patient outcomes, as described in several patient reports (O’Flynn, 2019). Generally, the following appliances are reported to assist in the prevention of leakage:
- Convex appliances, which reduce leaks from poorly spouted stomas by pushing the pouch into the abdomen, ensuring the stoma sits further inside the pouch
- Flexible hydrocolloid flanges, which minimise skin maceration by protecting the skin and absorbing moisture
- Stoma collars, which form a leak-proof barrier extenders, which aid adhesion, but should never be used to stop a leak, as the effluent could gather underneath them, causing further erosion of the area
- Hydrocolloid wafers, which absorb moisture for large excoriated areas (O’Flynn, 2019).
Further information on the appropriate usage of various appliances and products can be found in Table 1. However, a general overview of a selection of products and appliances and their benefits can be found below.
Table 1. Peristomal Skin Conditions and Treatments
| Condition | Treatment |
|---|---|
| Skin creases | Cleanse the skin; ensure creases are dry; apply barrier cream or film. Fill with paste, strip paste or a seal |
| Leak caused by creases | Cleanse the skin; apply barrier cream/film; and level the skin with paste or seals before applying pouch |
| Leak caused by parastomal hernia | Cleanse the skin; apply barrier cream/film; level the skin; and use flexible, convex appliances and hernia support |
| Leak owing to a retracted stoma | Cleanse the skin; apply barrier cream/film; use convex appliances to prevent leaks |
| Skin stripping | Use adhesive removers to prevent irritation to peristomal skin; assess patient's technique and educate; apply barrier film to protect the skin |
| Sore skin | Use protective powder as first line, dusting off excess powder, then use a barrier film or cream. Resize aperture and check patient technique |
| Wet skin | Use protective powder to dry the area; use a cool hairdryer at a distance if very wet to ensure effective adherence of pouch; apply barrier film |
| Folliculitis | Use an adhesive remover and shave the area regularly |
| Pyoderma gangrenosum | Steroid treatment and/or a dermatology review |
Notes: Adapted from O'Flynn (2019)
Convex baseplates apply pressure to flatten uneven peristomal skin and form an effective adhesive seal, as well as increase protrusion of a poorly spouted stoma, to decrease the risk of effluent leakage (Cronin, 2023). In three case studies describing the use of the Aura Plus Soft Convex (CliniMed), this appliance was found to restore peristomal skin integrity: swelling to a patient’s abdomen and a ring of erythema in the region of their stoma were noted to be significantly and visibly improved after 2 weeks of use; in another patient experiencing moisture-associated skin damage and skin stripping, their condition visibly improved after 1 week of use, with the skin no longer wet and sore and the area of skin discolouration reduced (Cronin, 2023).
To prevent skin stripping, adhesive remover products, in either a spray or a wipe form, can be used to ease the stress on the skin during pouch removal. Many of these products are silicone-based, such as the CliniMed CliniPeel® Medical Adhesive Remover range, and are often formulated with oil and water to enable fast application and drying and break the adhesive bond without leaving a residue (Chandler, 2015).
To protect peristomal skin that is at risk of damage, there are barrier films available, which are obtainable as either a wipe or spray. Barriers form a thin layer, repelling moisture and potential irritants, thus protecting the skin (O’Flynn, 2019). Barrier products should be durable, easy to apply and gentle on the skin; should not interfere with the absorbency of pouches, dressings or incontinence wear; and demonstrate rapid absorption and drying times (O’Flynn, 2019). A study by Dykes et al (2012) compared two barrier films (Derma-S Barrier Film (Medicareplus International) and Cavilon Barrier Film (3M)) and found both had a protective effect by delaying the removal of stratum corneum, provided a protective transparent coating that was quickly absorbed while not affecting adhesion of dressings or pouches, and resulted in reduced erythema, excoriation, maceration and pain for patients. These silicone-based barrier products are also reported to last longer as a skin barrier compared with traditional alcohol-based products (Chandler, 2015).
Products to help adherence include adhesive paste, strips and seals. Adhesive paste will often come in a tube and is thick in consistency; adhesive strips are similar, but are more mouldable. Adhesive paste and strips can be used in skin dips or creases located under the stoma flange, with the additional adhesive capable of preventing stomal output from seeping into the dip or crease (Burch, 2023). Seals are often known by multiple names, including a ‘donut’ or ‘washer’, due to being round with a hole in the centre; some can be stretched to fit any stoma shape and size, while others come with pre-made apertures in different sizes. A seal is useful if additional adhesion is required around the entire stoma (Burch, 2023). Some combination products, which simultaneously maintain skin integrity and improve adhesion, are also available, such as Independence Fusion from Independence Products Ltd, a unique 2-in-1 glue and barrier film applicator.
Conclusions
Although sometimes necessary to the management and treatment of certain conditions, the creation of a stoma can greatly impact a patient’s quality of life, and effective management of any postoperative complications and empowerment of the patient by healthcare professionals can only be achieved through person-centred, comprehensive care that takes into account all potential challenges faced by the ostomate, including PSCs. It is fortunate that the scope of products and appliances available to both prevent and manage PSCs is wide-ranging, but this very degree of choice can present a challenge in itself. Whichever option is chosen to preserve peristomal skin integrity, patient involvement in the decision-making process is key, and the preservation and, if possible, enhancement of the individual’s quality of life should be central to the support provided by stoma care practitioners.
Francesca Ramadan is a Freelance healthcare writer
francescaramadan@gmail.com