The Problem Stoma – peristomal skin problems

Posted 28 June 2013 in

Calum C Lyon MA FRCP
Presented at ACPGBI Liverpool 2013, 1 July

  • Skin problems are common around stomas with approximately two thirds of patients reporting a rash or soreness from time to time. Since 1998 we have run a regular monthly clinic in Hope hospital staffed by a dermatologist, registrar and 2 specialist stoma-care nurses.
  • There are several reasons why peristomal skin may become abnormal (see Table).
  • Irritant reactions to faeces or urine are commonest and a number of patterns are recognised. These include faecal irritant dermatitis especially in ileostomies. These respond to stoma-bag adjustments. Painful hypergranulation tissue +/- bowel metaplasia of skin (6%) occurs as a response to chronic irritation. It responds to cryotherapy or chemical cautery. The risk factors for leaks are well known to stoma nurse specialists and include high output stomas (particularly ileostomies), short stomas (resulting from poor surgical technique, emergency surgery or lack of preoperative site-marking), a high BMI (especially weight gain after surgery which buries the stoma) and parastomal hernias.
  • Primary skin infections account for 6% of skin problems and they will often present very differently to how they do elsewhere on the skin, so infection should always be considered. Infections seen include Staphylococcal folliculitis or impetigo, Streptococcal cellulitis, Candidal dermatitis and tinea corporis. Swabs or skin samples should be taken for analysis
  • Pre-existing skin diseases affecting parastomal skin are common problems, particularly psoriasis and atopic eczema which cause 9% and 5% respectively of the skin problems seen. Like infections they may present unusually in the unique environment around a stoma.

Psoriasis around an ileostomy

• Allergy is rare (<1%) and pyoderma gangrenosum is surprisingly common (>4%). New diseases like peristomal lichen sclerosus and nicorandil ulceration have emerged.

Pyoderma gangrenosum in Crohn’s disease

Nicorandil ulceration around an ileostomy

• In recent years we have seen fewer irritant reactions as patients and healthcare teams are better informed. At the same time we are seeing increasing referrals for UC/Crohn’s related disorders not necessarily involving stomas eg genital Crohn’s and Hidradenitis suppurativa
• More than 10% of peristomal rashes cannot be readily attributed to a primary skin disease, allergy or infection. In these cases there is likely to be a low-grade irritant process related to the occlusion of the stoma appliance. These patients can be treated symptomatically using intermittent applications of topical steroid preparations as for any inflammatory non-infective peristomal eruptions
• A number of treatment approaches have been developed,
o Tacrolimus in orabase paste for PG
o Sucralfate powder for eroded
o Phototherapy for psoriasis with a toilet roll inner tube to protect the stoma
o Haelan tape for PG and overgranulation
o Foam & gel steroid preparations scalp treatments for inflammatory stoma problems (non-greasy)
o Botox for short contracted stomas
o Use of permanent sub-dermal fillers to correct skin contours around stomas and thereby prevent leaks
o Use of potent steroid or tacrolimus ointments applied for 2 hours daily with a bag held in place with a belt and no adhesive. This allows very active therapy for inflammatory conditions but the patient needs to be still for 2 hours.


Peristomal skin disorders classified according to primary source
Source of skin problems Examples Effects on skin
Appliance (pouch) Potential allergens or irritants in appliances such as solvents, adhesives and tackifiers

Occlusion of the skin (heat, humidity) and skin stripping from removing and replacing appliance results in increased transport of potential allergens or irritants across the skin Damage to the skin barrier function resulting in dermatitis usually irritant in nature. True allergic sensitisation to materials in the pouch is very rare.
Accessories
1. Pastes (filler)
2. Wet cleansing wipes
3. Deodorising sprays or drops
4. Skin barrier wipes/ lotions
5. Adhesive removers Irritant Contact Dermatitis (ICD)

ICD; E.g. alcohol in pastes and wipes, karaya (powder & pastes).

Allergic Contact Dermatitis (ACD) ACD; commoner causes include fragrances or preservatives.
Other materials are very rare causes e.g. polymers in pastes and wipes
Stoma effluent where there are leaks Irritant reactions including dermatitis and granulomas
Stool; particularly where the constituency is more liquid than solid or the volume produced is high. More proximal stomas in those with short bowel will produce larger volume with greater enzymic content. Measures to thicken the stool should be considered including diet advice and antimotility drugs such as loperamide or codeine.
Stoma Type; loop stomas are associated with more skin complications. Higher output stomas are more likely to be associated with leaks (see above) Irritant reactions including dermatitis nd granulomas
Structural integrity: short, buried or prolapsed stomas are more prone to leaks
Skin Genetic problems (rare);
dry skin conditions e.g. ichthyosis; blistering diseases e.g epidermolysis bullosa (various type) Any primary skin problem that causes inflammation, dryness or weakened skin prone to erosion will impair bag adhesion and cause leaks that precipitate irritant reactions that in turn can worsen the primary skin problem (see specific skin diseases)
Acquired skin disease (common) can have unexpected appearance under occlusion. Eczema and psoriasis are common and present as wet red or flaky areas of inflammation
Pemphigoid (rare) presents with wet and eroded areas. Pyoderma gangrenosum is rare in the general population but relatively commoner in ostomates