Preventing and solving peristomal skin problems

Having a stoma is often a lifesaving and liberating thing. However, an ostomy can present potential problems, and the most common of these is red, itchy or sore skin around the stoma. That is why one of the key goals of good stoma care is to protect this area, known as the peristomal skin.

Sore skin is not normal

Peristomal skin problems may be fairly common, but they are definitely not normal. The good news is that the vast majority of peristomal skin problems can be resolved. With peristomal skin, like everything else, prevention is better than cure. However, if you do notice any bumps or discolouration (red or purple patches) in the peristomal area, or if your skin feels itchy, sore or painful, this is not normal, and you may have a peristomal skin problem.

It is essential that you contact your GP or stoma care nurse as soon as possible, as they will have the specialist skills and experience necessary to help determine the cause of the condition. Many conditions appear similar with sore, red and bumpy skin. However, to treat a peristomal skin problem, you need to determine its main cause. This is most commonly contact with moisture, sometimes mechanical stress and, more rarely, an infection or other cause. If a stoma care specialist has trouble determining what is troubling your skin, they can refer you to a dermatologist.

Once the cause has been identified, the underlying problem can be resolved, and your skin can be restored to a healthy, happy condition. This often means adapting your stoma care routine—including the accessories and pouching system you use—to better suit your individual needs.

Sometimes, while the underlying problem is being taken care of, the damaged skin itself will need some extra protection while it heals. Your nurse can teach you to apply a stoma powder, barrier film or wound dressing to the affected area. Stoma powder is applied in a crusting technique; the excess is dusted off and allowed to dry, to seal the powder in place. Application may be followed by a non-sting barrier film. These treatments can be continued as required to protect the skin, prevent further damage and reduce discomfort until the skin has healed.

Contact problems

Most peristomal skin problems are caused by unwanted contact with moisture and are, therefore, known scientifically as moisture-associated skin damage (MASD).

This moisture typically includes the output (effluent) from the stoma, which is corrosive and irritating to the skin, causing what is known as contact dermatitis. The stoma’s output should not normally touch the skin, because an effective pouching system should form a seal that prevents this from happening. If MASD does occur, it suggests your pouch is leaking. This is more common with ileostomies and urostomies than colostomies, due to the relative consistencies of their output. Not only can leaks damage the skin, but they can create odour, weaken the adhesive and cause further leaks. Your nurse will need to help you refine your stoma care routine to form a moisture-proof seal and protect your skin.

No one’s body stays the same for long, and it is normal for a stoma and the surrounding skin to change over the person’s lifetime. This is especially the case in the first months after your operation. This means that what is the right pouching system one year may not be quite right the next, and you will need to see a specialist regularly (at least once a year) to ensure you’ve got the best fit for your body. The first thing to be sure of is that the central hole (aperture) is exactlythe right size and shape to fit around your stoma, whether you get your pouches pre-cut or cut-to-fit.

The next thing to do is to ensure that the pouch has a flat surface to stick to, without leaving gaps for anything to leak through. Few tummies are perfectly flat, and they typically change shape over your lifetime and as you move about. It is common to have dips, creases and folds in the peristomal area, and these can appear or deepen if you gain or lose weight or develop a parastomal hernia or bulge. The most efficient and cost-effective solution may be to find a pouch that fits perfectly to your body. For example, if your stoma is retracted below the surface level of your skin, you may want to try a convex pouch, with guidance from your nurse. If a pouch alone can’t create a perfect fit, fortunately, any gaps can be filled in using filler pastes or gels, accessories that can fill in gaps and create a flat surface for attaching the pouch.

If forming a perfect seal between the pouch and your stoma remains difficult, you can try using washers, rings or discs. These accessories help seal over this narrow gap to reduce the chance of leaks. If the whole pouch is having trouble staying in place, you can try using flange extenders, which are strips and tapes that extend the pouch’s adhesive area and keep it secure.

Although stoma output is the most common cause of contact dermatitis, there are other substances that can irritate the peristomal skin. This could be something you use as part of your stoma care routine, such as a soap, solvent or adhesive material, especially if you develop an allergy. Therefore, it is safest to keep the number of accessories you use to a minimum. Likewise, it is usually best to wash your stoma with plain warm water alone, especially as soaps or wipes can alter the protective pH of the skin or leave a residue that prevents the pouch from sticking. If you think your skin might be having an allergic reaction, ask your stoma care nurse for alternative products made from different materials to try. A dermatologist may be able to provide a patch test to help identify the culprit.

Mechanical problems

Mechanical skin problems are known scientifically as medical-adhesive related skin injuries (MARSIs). Peristomal MARSIs can appear when removal of the sticky (adhesive) part of your pouch pulls at the top layer of the skin, damaging it and leaving it exposed. Pouch removal should be a painless, problem-free process, and the appearance of a MARSI suggests that it is being removed too roughly and/or too frequently.

This could just require a change of technique, and your stoma nurse can show you how to remove the pouch gently and carefully, while pressing down on the skin. Mechanical problems can also appear if you are too rough when cleaning the peristomal area, so it is worth being careful, sticking to plain water and not using anything rough to scrub it with.

It is also worth noting that the hydrocolloid adhesive used in most stoma pouches can become stronger the longer it is worn, as it absorbs moisture from your skin. Therefore, it may be worth carefully timing pouch removals or trying different pouches to find one that stays easy to remove. If gentle removal remains difficult, you can ask to be prescribed an adhesive remover wipe or spray. These accessories are designed to loosen the sticky part of the pouch for easy removal.

If your pouch fills quickly and needs to be replaced more than once a day, you can consider switching from one-piece to a two-piece pouch. A two-piece pouch comes with a baseplate that attaches to the skin and a number of removable bags. You should be able to empty a number of bags before having to change the adhesive baseplate.

It is also worth watching out for daily activities that can could pose mechanical challenges. When doing something that might weaken or knock the pouch loose, you can add security with a supportive belt or protective stoma shield or cap. Likewise, clothes should not be so tight that they make it hard for the stoma to drain into the pouch.

Conclusion

If left untreated, peristomal skin problems can be very uncomfortable, which can also take an emotional toll. Fortunately, they are rarely something anyone has to live with. A stoma care specialist should be able to help you identify and fix the problem. The key is to be willing to ask for help and try out new things.

Sinéad Kelly O’Flynn is Clinical Nurse Manager in Community & Complex Care for Bluebird Care, Ireland

sineadkoflynn@gmail.com