Problems with the peristomal skin can be very uncomfortable for the patient and can make getting a good pouch seal difficult. There are many skin complications that can occur. We’ll talk about three of the more common issues.

Fungal infections, or candidiasis, are opportunistic infections that can occur once the peristomal skin has been compromised. Their host is often old, immunocompromised, or with a history of recent antibiotic use. These infections thrive in moist, dark, warm places--the perineum and under the ostomy skin barrier are ideal locations. Assessment findings include erythema, maceration and papules. Satellite lesions are found at the periphery. The patient may complain of itching and burning. Treatment involves making sure the pouch is completely containing the effluent, keeping it from having contact with the skin. The skin must be dry prior to the application of the skin barrier. Before the barrier is applied a topical antifungal powder is liberally applied. Treatment continues until the skin returns to its intact state.

Irritant dermatitis is usually a result of effluent coming in contact with the skin as a result of a stoma opening cut too large or the effluent seeping underneath the skin barrier. Patients may complain of burning and the resultant skin damage resembles a chemical burn. This is frequently seen in patients with ileostomies, due to the caustic nature of the effluent. Skin will be red, moist and often times denuded (the epidermis is gone and the dermis is exposed making these areas extremely painful). The areas in question will resemble those seen in patients with severe urinary incontinence who are not on skin care regimes, or kids with bad diaper rashes. Treatment consists of keeping the effluent off the skin by re-evaluating the current system. A skin barrier powder can also be applied to help dry the skin.

Allergic Dermatitis is due to a contact sensitivity reaction to potentially any product that comes in contact with it. Some clinicians recommend a routine patch test for all patients when a new product is used. Again, the area will be red and the patient will experience intense itching, followed by what resembles hives. The area will become edematous and the skin may crack open. The dermatitis is confined to the area of skin where the product was applied-so it might be a square-shaped area of affected skin-exactly the size of the skin barrier. Management includes discontinuing the offending product, and initiating the use of antihistamines.

There are many stoma complications that can occur. Let’s examine four of them.

Mucocutaneous Separation is a postoperative complication that occurs when the stoma separates from the skin. It may be the result of impaired wound healing (secondary to diabetes, steroid use or infection) or tension related to surgical technique. Treatment includes filling the separation defect with an absorbent product and a pouching system that protects the area from effluent. As the separation heals the stoma needs to be assessed for stenosis (narrowing of the stoma at the skin or fascial level) or retraction.

Retraction is a condition where the stoma sits below the skin’s surface level. The stoma seems to disappear when the patient sits up. Causes of stoma retraction include post-op weight gain, infection, malnutrition, scars or adhesions, and mucocutaneous separation. These stomas can cause effluent to undermine the pouch surface leading to skin breakdown. Using convex inserts, pouches with built-in convexity, and wearing an ostomy belt can all help to pop the stoma up in order to get a adequate pouch seal. Sometimes a surgical revision is warranted.

Prolapse could be thought of as the opposite of retraction, and involves the bowel telescoping into the stoma. This area can be susceptible to trauma, challenging to pouch, and is sometimes very offensive to the patient. Causes may include pulling the colostomy through an abdominal incision, using a large fascial opening in the abdominal wall, or the presence of an obstruction when the colostomy was created. A careful selection of products that are flexible can avoid this type of trauma. By carefully measuring the stoma opening when the patient is standing, since that is usually when the prolapse will be at it’s biggest, will help to ensure proper stoma placement, tension and positioning. Patients can be taught to apply the pouch after they have gently applied pressure or even ice for several minutes in order to reduce its size.

There are a variety of challenges that should be avoided. Pouching a patient with two stomas, pouching a stoma that has a surgical wound dehiscence, pouching in patients receiving irradiation treatment, pouching morbidly obese patients, stoma necrosis and parastomal hernia are all challenges that are seen and overcome using proper product selection and good technique. And if you’re lucky, you’ll have a certified ostomy nurse available who lives for these very challenges!