Speaker 1In this class, we're going to talk about prevention and management of peristomal skin complications. We're not going to get into details regarding specific types. We're going to talk general principles of prevention. We're going to review products that are available. And then we're going to talk about classification of peristomal skin complications. And then in future classes, we'll talk about the specifics. So we're going to identify principles for the protection of peristomal skin. We're going to talk about potential threats to peristomal skin integrity. We'll discuss general principles of management for peristomal skin breakdown and kind of a pathway for differential assessment. Thank you. So when you think about it, peristomal skin is exposed to multiple potential threats on a routine basis. First of all, we're routinely applying adhesive products and then removing adhesive products. If we do not maintain a secure seal, then that skin is exposed to urine or stool. And the other thing that we frequently don't think about is that peristomal skin is routinely occluded. Unlike skin everywhere else on the body. So when we put that pouch on, we're occluding the skin, occluding the pores in the skin, and maintaining that condition for essentially 24 out of 24 hours. And what does that do to the peristomal skin? So we have some guidelines for protection. Definitely we want to protect against mechanical trauma with pouch removal. We want to protect against urine, stool, and chemical irritants. We definitely need to be alert to the potential that any product we use can act as an allergen or a sensitizer. So we need to monitor for that. And then we need to consider infused barriers if we have a patient with sensitive skin, if we have a patient who develops recurrent issues with dry skin, itching, or refractory breakdown. So talking about protection against mechanical trauma. Watch your patients when they remove their pouches. Some people are very gentle, and that's great. And others want to just grab the edge of the pouch and snatch it off. So we have to teach our patients. You have to take care of your skin. You want to be really gentle. You want to baby this skin. So do not snatch it off. It's not a Band-Aid. You want to use your push-pull technique. You want to think about use of silicone-based adhesive releasers that help to break down the adhesive bonds and make it much easier to remove the pouch. Also, these products significantly reduce the discomfort associated with pouch removal. So a positive in two ways. Number one, it's a lot easier and more comfortable for the patient. And number two, it's a lot better for the skin. And we have to teach the patient, don't scrub your skin. Don't pick at your skin. If there's a little bit of paste residue on your skin, that's okay. Paste is protective. So role model for your patients, no picking. And reinforce to your patients, no picking. What about cleansing? Patients will ask you all the time, should I use alcohol? Should I use Betadine? What should I use to keep my skin clean? I should use one of those antimicrobial soaps, right? No, we want to be really gentle and we want to keep the peristomal skin as healthy as possible. So routinely, we use warm water. We use a soft cloth or a very soft paper towel. And gentle technique. If they use soap, it's not wrong to use soap, but you've got to get it all off. You have to eliminate any soap residue, which can of course cause drying, can act as an irritant. Easy in the shower. So if they take their pouch off in the shower, they can use soap, they can use shower gel, they can use whatever. Because they're going to easily rinse away all the residue. But if they're standing at their sink and they put soap on, they have to really work to get all that soap off. So that's why we teach patients routinely, use water. Water's not going to cause any problems. Water-based wipes are also a great choice for emergency kits, for travel, for camping. You have to caution patients against using wipes that have any emollients in them. Sometimes they'll think, well, what about baby wipes? Well, you don't want to use baby wipes for peristomal skin cleansing because baby wipes have emollients. And that's going to interfere with pouch adhesion. So water-based wipes are great. Emollient-based wipes are not. A lot of your patients are going to have a hairy abdomen, and they're going to need to routinely remove the peristomal hair to prevent traumatic removal and folliculitis. The best options are either a clipper or an electric shaver. They can also use a safety razor. They have to be taught always shave away from the stoma. Always use a lubricant. And powder, ostomy powder, is a great choice. It acts as a dry lubricant so you can dust it on, then shave, then dust off the excess. So many times that's what we teach patients. Dust on the ostomy powder, then use your electric shaver or your clipper or your safety razor, and then dust off the excess. Now let's talk about protection against drainage. So typically that is urine or stool. Occasionally you might be dealing with drainage from around a G-tube or a J-tube. Or with fistula drainage. So here are the things you have to remember. Any drainage from the small bowel, the pancreas, or the stomach is highly damaging. Because all of those fluids contain enzymatic agents that are proteolytic. So they'll rapidly break down the skin. In addition, the pH is very hostile to the skin. Gastric contents, very acidic. Abnormally acidic. Pancreatic. Very, very alkaline. So you have to worry about enzymatic damage. You have to worry about damage because of altered pH. And finally, you have to consider the volume and the consistency. The higher the volume, the more liquid the consistency, the greater the damage to the skin. So what do we do? First of all, we size the opening in the pouch to minimize content or contact between the drainage and the skin. So if my stoma is one and a quarter inches, I want the opening in my pouch to be one and a quarter inches or no more than one and three-eighths inches. I want it to be very close to the stoma so that I minimize contact. And then I want to think, okay. How do I protect that little sliver of skin? If I have any exposed skin at all and I have enzymatic drainage, I have to protect that little tiny bit of skin. So I could use a barrier ring. I could use squeezable paste from a tube. But I always have to protect that skin. And then I have to teach patients, if your skin starts to itch, if your skin starts to burn, if you sense that you have any undermining, any leakage, don't tape it up. Change it. Because if you tape it up, you're trapping that very irritating, very damaging fluid right against your skin. Exactly what you do not want to do. What about irritants and allergens? So people think, well, wouldn't they make all of these products hypoallergenic? And yes, they do. They spend a lot of time in the laboratory testing products, eliminating any components that are known to be allergens and sensitizers, trying to create a barrier and adhesive product that will not act as a sensitizer, will not cause any kind of allergic reaction. But the reality is everyone is different. And a product that works great for me, might act as a sensitizer for you. So despite all the work that's done in the laboratory, the reality is that any product we use can act as an irritant or an allergen for selected individuals. So when you look at your caseload of patients, going to have some that do great with Hollister, but you'll have a few that are like, don't put Hollister on me. I can't tolerate that barrier. Same thing with Convitec, same thing with Coloplast, same thing with New Hope, same thing with Marlin. Any product on the market can be a sensitizer for selected individuals, so we just have to be aware of that. One thing we should always teach our patients to do is if you're using any kind of adhesive product, remember there are solvents in that product. You have to allow the solvents to evaporate. You have to allow that adhesive to dry, or you're going to be trapping chemicals next to your skin, so use products correctly. And then finally, tell patients if you start developing any kind of problem, if you're starting to have itching, if you're starting to have a problem with your skin, if you're starting to have itching, if you take off your pouch, you see a red area, you see a bumpy rash, call me. You need to come into the clinic. We need to figure out what you're reacting to. We need to modify your pouching procedure. So if you look at the illustration on top, it's very clear that that patient is reacting to the tape border of the pouching system they're using, so we need to discontinue use of that pouching system, allow the skin to recover, and then substitute a different pouching system with a different kind of tape border. If you look at the illustration on bottom, it looks like that patient is reacting either to the barrier or to something that they used over the entire pouching surface. So you're going to have to walk that patient back through. What happened? You took your pouch off. Did you use anything? Did you remove your pouch? How did you clean your skin? Did you put anything on your skin before you applied the pouch? And let's look at your pouching system. We want to protect against the negative impact of occlusion, but that's really hard to do. So if you look at the illustration on top, if you look at the far left, that's what healthy skin looks like under the microscope. It's loaded with ceramides. And ceramides are naturally produced skin oils, skin lipids. And then you look on the far right, and you see damaged skin, skin with atopic dermatitis. That skin is itchy, dry, overreactive. And look how depleted it is in ceramides. And we have some data that suggests that the more skin is occluded, the more ceramides are in the pouching system, and the more ceramides are in the pouching system, and the production is reduced and the more vulnerable that skin becomes. So there are clinical indicators as well. You don't have to do a biopsy and look under the microscope. You can go by what the patient tells you. Do they say their skin feels dry? Are they complaining of itching? It turns out that itching is pretty common among people with an ostomy, people who wear a pouch all the time. Do they have peristomal breakdown that responds poorly to our standard management approaches? All of those are indicators or potential indicators of low ceramide levels. If you have patients who are developing these problems, they're complaining their skin feels dry, their skin looks dry, they're complaining of increasing problems with itching, they're having episodes of skin breakdown that don't resolve as you would expect them to, then think about using an infused barrier. Or if you have a patient who tells you at baseline, "I have very sensitive skin. I react to a lot of things," it might be a good idea to use an infused barrier from the beginning. Now, right now in the States, we have ceramide-infused barriers. In the UK and Australia, they also have barriers that are infused with aloe vera and some with manuka honey. Moving forward, companies are very focused on creating barriers that promote skin health. In the past, they've been very focused on creating barriers that maintained adhesion, that resisted breakdown, that protected the skin from stool and urine. But now, they're taking that another step. And I think it's really important to take that another step. They're like, "Well, what if in addition to protecting the skin, what if we try to promote skin health by giving back ceramides, by providing aloe vera, by providing manuka honey?" So, you're going to see more options to use infused barriers in the future. What else do we have available? Well, we have liquid skin barriers. All of you have access to liquid skin barriers. All of you have access to skin barriers. Skin Prep, Sure Prep, Kavalon, there's many different ones on the market. So you know what they do, they create a clear protective film over the skin. It's like a thin layer of breathable plastic that puts a thin barrier on the skin and helps protect the skin from anything that's put on it. Also helps protect the skin from adhesive trauma. So when you're taking the pouch off, instead of pulling against the top layer of skin, now you're pulling against that thin layer of liquid plastic that formed on the skin. So it helps protect against adhesive trauma, helps protect against moisture. Now one thing you need to be very aware of, because this is actually a change in thinking. Originally, ostomy nurses tended to use these liquid skin barriers under the skin barrier. Every pouch. They taught patients, clean your skin, dry your skin, treat any damaged skin, and then coat your skin with this liquid skin barrier, whichever one. But the companies have now formulated the hydrocolloid barriers to essentially melt into the skin so that they form a very tight bond with the grooves in the skin. And they point out that for most people, they will get a better seal if they apply that hydrocolloid directly to dry intact skin. They further point out that if we put on that liquid skin barrier, we create a coating over the natural little grooves in the skin. And then the hydrocolloid is sitting up on top of the coating instead of melting into the skin. So. The companies who make the barriers are telling us you're probably going to get a better seal if you teach your patients to apply the product directly to clean dry skin. And if you omit application of those liquid barriers. So just be aware of that. Sometimes we will use liquid barriers as our primary skin protection. So if we're using an adhesive only product. Like a security cap with a colostomy or some urinary pouches that are adhesive only and do not have a barrier ring. Then a liquid skin barrier may be just what you need to provide an extra level of protection against adhesive trauma, against adhesive removal, and against exposure to moisture. Now these products are available. Both in alcohol-based and alcohol-free versions anytime you're dealing with very very sensitive skin anytime you're dealing with damaged skin you want to use alcohol-free also available both in spray-on and wipe-on versions spray-on can be easier but actually either one's equally effective and again remember that these products have solvents. These products have solvents. They start out liquid and then they dry to a thin transparent film. Those solvents need to evaporate. So you want the patient to allow time for the product to dry before they put anything on top of it. The other product that we use routinely to protect the peristomal skin are hydrocolloid barriers. So when you look at the peristomal skin. When you look at your pouching systems you see hydrocolloid barriers on almost all of them you'll see them on one piece pouches you see them as the base for two piece pouches and you'll see them in adjunct accessory forms so what do they do well hydrocolloids provide solid protection against urine and stool they're actually very resistant to stool and fairly resistant to urine so that's great. because we want protection against urine and stool they also as you know are very conformable. So they help to provide a good pouch seal because they can kind of melt into the skin and adapt to the peristomal skin contours. So if you have a little crease, usually they'll just melt into that crease. Infused hydrocolloid barriers, as we have already discussed, may also promote skin health by providing ceramides or aloe or manuka honey. Now let's just look at the options available, the ways we can get hydrocolloid barriers. So of course, if you look at the illustrations on top, you see the hydrocolloid barrier as a component of a one-piece system and as the base of a two-piece system. But we now also have paste strips, which you see in the middle. And those paste strips can be used to fill creases. They can also be wrapped around the stoma. We also have barrier rings, like you see on the bottom left. And then we have squeezable paste, tube paste. All of those are variations of the same thing, protective hydrocolloid barriers. So you'll get hydrocolloids as a component of the pouching system, but you also have the option to use accessory hydrocolloid products to provide a better seal, to create a flat pouching surface, to provide more resistance to drainage, to prevent contact between the drainage and the skin. Now adhesive products are a third category of products that we have available to help maintain a secure seal. Adhesive products are not routinely used. We use them in selected situations when we need added adhesion to get a secure seal. Probably the most common example, we have patients who have very dry skin. And we know that hydrocolloids do not bond as well when the skin is very dry. So sometimes in those situations, we'll add a layer of adhesive to increase the initial bond between the pouching system and the skin. At this point, adhesive products are available in a spray-on form, which you see on top, and in a paint-on form, which you see on bottom. Now the spray-on form is silicone-based. It's essentially safe for all patients, including children and neonates. Usually we apply a spray-on to the back of the pouching system, then we allow it to dry for one to two minutes until it feels very tacky. You can apply it to the peristomal skin. Now when you look at the can, sometimes it will say, "Do not apply directly to skin." I didn't notice that for a long time. A patient pointed it out to me. She's like, "Is this what you just sprayed on my skin?" I'm like, "Uh-huh." She's like, "Well, it says here on this can, 'Don't put it directly on the skin.'" I'm like, "It does?" I'm like, "Oh my goodness." So I called the company, and they're like, "Well, we put that on there because this product is frequently used to adhere facial prosthetic devices, and we don't want anybody spraying it on the face." I'm like, "Well, it would be good if you put 'Don't spray it on the face' instead of 'Don't spray it on the skin.'" But anyway, I want you to know that it can be safe. applied to the peristomal skin if you need to do so. Most of the time we do just apply it to the back of the pouch, let it dry, and then press the pouch into place. What about paint-on adhesives? So there are a number of paint-on adhesives available to you. A number of them are latex-based. So if your patient's latex sensitive, you need to check that out. There are some available that are not latex-based, but if you're not careful and if you don't look for that feature, you'll end up with one that is. The paint-on adhesives in general are known as bonding cement. So if you look at the illustration on bottom, it says bonding cement. Bonding cements work best if you apply one layer to the skin and the second layer to the back of the pouch because then the two layers bond to each other and you end up with a very secure seal. Now you can apply bonding cements just to the back of the pouch or just to the skin and that will increase adhesion, but your very best outcomes occur when you put a layer on the skin, a layer on the pouch, and they bond to each other. As is true with the silicone-based adhesive spray, critical to allow the bonding cement to dry, to allow the solvents to evaporate. So now let's talk about peristomal skin complications. We've talked about peristomal skin protection, we've talked about products we have to help protect the peristomal skin. At this point, we have many products, we have a lot of technology at our disposal to help protect peristomal skin. Despite that, look at the prevalence. Studies indicate that at least 29 and up to 63 percent of our patients experience peristomal skin complications, at least periodically. I find that surprising with everything we have to protect the peristomal skin. You would think that the numbers would be much lower, so clearly we have a lot of work left to do. We know that peristomal skin complications are a very negative outcome and they cause the patient a lot of difficulty. First of all, once you develop any kind of peristomal skin breakdown, it becomes a lot harder to maintain a secure seal, because now you're dealing with inflamed, possibly weeping skin that nothing wants to stick to. So you get increased risk of leakage, then you get increased damage, and you get into this vicious cycle. And don't forget anxiety. Anxiety is a big component of that cycle. So you have skin breakdown, you have leakage, now you have a lot of anxiety that it's going to happen again. And we've talked to patients who said, "You know what? I just thought I just canceled everything. I just stayed home. I didn't feel like I could safely go to work. I didn't feel like I could safely go to school. I was worried that my pouch would come off at any time, plus my skin was itching and burning and stinging. I was miserable." So you see all the bad things that happen. Increased anxiety, increased discomfort, pain, increased itching. "I'm changing my pouch more often. Now I'm paying more money out of my pocket to keep a pouch in place." I'm probably going to end up going back to the clinic. A lot of patients go to the emergency department because they don't know what else to do. And that, of course, is very costly to the healthcare system. But look at the last bullet point. That's probably the most important. And that is that studies show that peristomal skin complications can reduce quality of life to a level comparable to a patient with advanced heart failure. And what have we talked about over and over? Our goal is to maintain very high quality of life. We want this ostomy to be a nuisance, nothing more. We want that person to be able to do all the things that they want to do and that they were doing before surgery. So let's look at the types of complications that can occur. And then we'll look at, we're going to look at them first just from a classification standpoint. And then we'll go through them one at a time, talk about how they present and how we manage them. So currently peristomal skin complications are generally divided into peristomal moisture associated skin damage, peristomal medical adhesive related skin injury, then pressure injury, and inflammatory lesions like pyoderma. So looking first at peristomal moisture associated skin damage, the most common types are maceration, pseudovarucous lesions, and irritant contact dermatitis. Now, maceration and pseudovarucous lesions occur primarily as a result of just the exposure to moisture. Irritant contact dermatitis occurs primarily with exposure to enzymatic drainage or drainage with very alkaline or very acidic pH. Yeast dermatitis is more common in patients who have taken antibiotics recently, but actually can occur at any time in any patient if moisture is allowed to accumulate at the peristomal skin surface because, as you know, yeast thrives in a moist condition. And finally, allergic contact dermatitis. When the skin is moist, when the skin is damaged, it becomes more vulnerable to penetration by irritants and allergens. So allergic contact dermatitis is actually classified as a type of moisture-associated skin damage. Now, medical adherence. Adhesive-related skin injury primarily includes folliculitis. We talked about if you have a patient who has a lot of peristomal hair, if that hair is not routinely removed in an atraumatic manner, then removal of the barrier is going to snatch that hair out. You're going to get inflammation of the follicle, bacterial invasion of the follicle, and then you get. folliculitis. So we want to prevent that by managing peristomal hair. Mechanical skin damage. We try to prevent that by teaching patients don't pick, don't scrub, don't snatch your pouch off. But if you look at the third slide down, you see patchy areas of folliculitis and traumatic skin removal. So you can always get that. So we have to, again, teach our patients how to protect their skin. Peristomal skin injury, pressure injury, is likely to occur if you have a rigid pouch component and a very tense abdominal wall. We see it most commonly in patients who have a peristomal hernia. So they have a lot of internal abdominal pressure. And then if we put that patient. If we put that patient in a pouching system that contains rigid components, we can end up with a pressure injury. Fortunately, that's uncommon, as is peristomal pyoderma gangrenosum, which is an acute inflammatory reaction most commonly seen in patients with inflammatory bowel disease. Now each of these will be discussed in more detail in later classes. So let's look big picture. Always our goal is to prevent peristomal skin complications. It begins, as you have heard, preoperatively with pre-op teaching and, most importantly, with pre-op stoma site marking because if we can assure that that patient ends up with a stoma on a flat pouching surface, then we're in the best position to maintain a secure pouch seal. And to provide effective protection for the peristomal skin. Postoperatively, our focus shifts to assessing the peristomal skin contours, to assessing stoma height, and more importantly, location of the os in relation to the peristomal skin. And creating the best match possible between the pouching system and the peristomal skin. And the abdominal surface. So we've spent time talking about that. We'll continue to talk about that in subsequent classes. We want to make absolutely sure that our patients get appropriate follow-up. They need home health care. They need outpatient follow-up. So that their pouching system can be adjusted and modified, as indicated. We know that stomas change size and shape. So we want to make sure that their pouching system can be adjusted and modified, as indicated. change the products you're using? Have you gone to a different kind of pouch, a different kind of liquid barrier, anything different? Because that could help explain a sensitivity reaction. You want to be very alert to their medical history. Do they have a history of inflammatory bowel disease or rheumatoid arthritis? You're particularly alert to those factors if they tell you that this started just as, I don't know, I took my pouch off and and there was this, I don't know, sore there. And it really hurt. That's really why I changed my pouch because I was having all this pain right here. And then I took off my pouch and I saw that sore. I don't know what to call it, a sore. And then I did that thing with the powder you taught me but it didn't get any better. Every time I took off my pouch it was worse. That suggests pyoderma. What are the key observations? Well, before you even take the pouch off, you want to observe their pouching system in place. Do they have a lot of bordering tape? That suggests that they're trying to hold the pouch on, that they might have what some ostomy nurses call a silent leak, where drainage is undermining. But because they have some so much tape on their skin it doesn't get all the way out, the patient thinks the pouch is intact. So be very alert to multiple layers of tape. Be very alert to any evidence that this pouch is leaking at the periphery, especially if the patient seems unaware. Before you take the pouch off, look to see, is there exposed skin all the way around the stoma? Does it look like the patient is sizing the opening in the pouching system larger than the stoma and leaving skin exposed? Be very alert to that. Be alert to any damage extending beyond the borders of the pouching system. And then when you take the pouch off, look at the back to see which aspects of the barrier are eroded, are stained, are swollen within the pouch. Do you see any damage on the pouch? Do you see any damage on the side of the pouch? drainage. That gives you a lot of insight into patterns of leakage. Now the distribution and location of skin damage is very helpful in your differential assessment. If the damage is inferior, medial, and lateral to the stoma like you see on the top left, that is classic distribution for irritant dermatitis due to leakage because the drainage is not going to go proximally, it's going to go distally and to each side of the stoma. If you have damage that matches one component of the pouching system like the top right, that's classic presentation for irritant dermatitis. So you have to think, okay, what kind, what component of the pouching system matches this area of erythema, blistering, whatever. If you have a solid maculopapular rash, it's solid in the center and then you have distinct border lesions, satellite lesions, that's classic for yeast dermatitis. Again, if you come down the right side, you see that on the second slide down. If you have patchy brachial breakdown, a lot of times that's mechanical in nature. If you have a defined crater under a rigid component of the pouching system, that's typically pressure injury. And then the last slide on the bottom is classic pyoderma, where it's like it's a very painful ulcer that just occurs spontaneously. It doesn't match an area of pressure. It's hard to explain why it's there, how it developed. Classic PPG. Symptoms also help you to do accurate differential assessment. So itching. If the patient complains of itching, or if you see them doing this, I've had patients come in and they're scratching, they're not even aware they're scratching. That is common with a yeast rash, with yeast dermatitis, candidiasis, and also with an allergic reaction. Allergic reaction. Sensitivity reaction. Burning pain is commonly seen with irritant dermatitis. Now, any kind of peristomal skin breakdown is going to create sensitivity and tenderness. But with irritant dermatitis, it's frequently hurting all the time. Burning all the time. If any drainage flows over it, it's acutely painful. If they complain of constant severe pain that is worsened by any kind of manipulation, removal of the pouch, application of the pouch, peristomal skin care, that's consistent with pyoderma. So in summary, one of our goals as ostomy nurses is to prevent or promptly manage any peristomal skin complications because we know they have a very negative impact on the patient's quality of life. When we look at prevention, we are trying to protect the peristomal skin against mechanical damage, traumatic removal, folliculitis, picking and scrubbing. We're trying to prevent contact between the skin and the drainage so that we prevent irritant dermatitis. We're always alert to the potential for a sensitivity reaction and ready to modify our pouching system accordingly. And we want to be very aware that peristomal skin is constantly occluded, and that that might result in dry skin, low levels of ceramides, increased issues with itching and breakdown, and that some of our patients will benefit from routine use of infused barriers. If our patients are suffering from peristomal skin disorders, we're going to want to be very aware that peristomal skin is constantly occluded. And that that might result in dry skin, low levels of ceramides, increased issues with itching and breakdown, and that some of our patients will benefit from routine use of infused barriers. If our patient develops a peristomal complication, we first need to determine what are we dealing with. Is this moisture associated skin damage? And if so, what type? Is it medical adhesive related? Is it a pressure injury? Is it pyoderma? We want to be very thorough in our assessment. We want to hear the patient's symptoms. We want to observe distribution. We want to consider risk factors. And if we cannot figure it out, we want to involve dermatology. In subsequent classes, we'll talk about each of these complications in more detail in terms of how they present and how we manage them. Thank you.
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