Speaker 1In this class, we're going to continue our discussion about prevention and management of peristomal skin complications. We'll focus on peristomal medical adhesive-related skin injuries, peristomal pressure injuries, peristomal pyoderma gangrenosum, and then a number of relatively rare conditions that in your life as an ostomy nurse you may encounter at some point or another. So we'll talk about prevention, presentation and management of folliculitis, mechanical trauma, peristomal pressure injury, pyoderma, bacterial infections such as a stitch abscess, capimedusa. Granulomas, mucosal transplantation, and dermatologic conditions. So we'll start with peristomal medical adhesive-related skin injuries, also known as PMARC. And the first one we're going to talk about is folliculitis. So you know what folliculitis is. It's inflammation and then infection of the hair follicles. In the patient with an ostomy, it's caused by traumatic hair removal with pouch removal. So when you take off the pouch and you have hair, you can rip out the hair. That traumatizes the hair follicle and also creates a pathway for bacterial invasion, typically with staph or strep. So then what you see is you see these pustular lesions corresponding to the hair follicles. And the patient typically reports tenderness and pain with pouch removal. Now, sometimes you can see purulent drainage, not always. So management is pretty straightforward. You're going to clean all the lesions. Typically, the recommendation is that you use a mild antibacterial soap that will help to reduce levels of staph and strep bacteria. Occasionally, you're going to use a mild antibacterial soap that will help to reduce levels of staph and strep bacteria. Occasionally, you'll see a topical antibiotic cream or gel used, but not routinely. Most of the time, if you clean with an antibacterial soap, that's enough. As long as you interrupt that cycle of injury, you stop atraumatic hair removal, you stop the trauma and the inflammation to the hair follicles. Now, if you see these pustular lesions, now, if you see these pustular lesions, now, if you see these pustular lesions, getting worse, if you start to see erythema in duration, getting worse, if you start to see erythema in duration, then you may need to do a culture, then you may need to do a culture, then you may need to do a culture, get the patient on oral antibiotics. get the patient on oral antibiotics. But in clinical practice, that is extremely rare. Most of these patients do not require culture. They do not require oral antibiotics. They just require They just require They just require interruption of the process, interruption of the process, interruption of the process, cleansing with an antibacterial soap, cleansing with an antibacterial soap, cleansing with an antibacterial soap, crusting if you have any open lesions. crusting if you have any open lesions. Now, obviously, Now, obviously, Now, obviously, if you have a patient with folliculitis, if you have a patient with folliculitis, if you have a patient with folliculitis, patient education is needed. patient education is needed. We want to stress to the patient We want to stress to the patient We want to stress to the patient the importance of safe, routine hair the importance of safe, routine hair the importance of safe, routine hair removal. So things they should removal. So things they should keep in mind. It's helpful if you can keep in mind. It's helpful if you can shave in the direction of the hair shave in the direction of the hair shave in the direction of the hair growth. That causes much less trauma growth. That causes much less trauma than if you shave in the direction than if you shave in the direction than if you shave in the direction opposite of that of the hair growth. opposite of that of the hair growth. They may need to shave a little less They may need to shave a little less They may need to shave a little less frequently. Most commonly, we have frequently. Most commonly, we have patients shaving maybe once a week. patients shaving maybe once a week. They're changing their pouch twice a They're changing their pouch twice a They're changing their pouch twice a week. They're shaving once a week. week. week. If they have very heavy hair growth, If they have very heavy hair growth, If they have very heavy hair growth, yes, they may need to shave each time yes, they may need to shave each time yes, they may need to shave each time they change the pouch. But most they change the pouch. But most commonly, it's every other pouch commonly, it's every other pouch commonly, it's every other pouch change. You want them to use either a change. You want them to use either a clipper or an electric shaver. clipper or an electric shaver. We typically find that an electric We typically find that an electric We typically find that an electric shaver is best because it gives shaver is best because it gives shaver is best because it gives them a little bit closer shave, them a little bit closer shave, them a little bit closer shave, but no trauma to the hair but no trauma to the hair but no trauma to the hair follicles. As we have mentioned follicles. As we have mentioned before, it's very helpful to use before, it's very helpful to use before, it's very helpful to use your ostomy powder as a dry your ostomy powder as a dry your ostomy powder as a dry lubricant. So you dust on the lubricant. So you dust on the ostomy powder, knock off the ostomy powder, knock off the ostomy powder, knock off the excess, shave, and then you're excess, shave, and then you're excess, shave, and then you're ready to apply your pouch. If ready to apply your pouch. If you have a patient who has you have a patient who has you have a patient who has recurrent episodes of recurrent episodes of recurrent episodes of folliculitis, you might consider folliculitis, you might consider folliculitis, you might consider a depilatory, but you have to a depilatory, but you have to a depilatory, but you have to be very careful, follow the be very careful, follow the be very careful, follow the instructions by the letter instructions by the letter instructions by the letter because it is a chemical agent because it is a chemical agent because it is a chemical agent and you don't want to swap one and you don't want to swap one and you don't want to swap one problem for another. Also, we've problem for another. Also, we've had a few patients who have had a few patients who have had a few patients who have elected laser hair removal so elected laser hair removal so elected laser hair removal so they don't have to deal with they don't have to deal with they don't have to deal with this on an ongoing basis. What about mechanical damage? Well, mechanical damage Well, mechanical damage Well, mechanical damage typically occurs when somebody typically occurs when somebody typically occurs when somebody rips their pouch off, when rips their pouch off, when rips their pouch off, when someone picks at paste or an someone picks at paste or an someone picks at paste or an adhesive agent to get all of the adhesive agent to get all of the adhesive agent to get all of the residue off and take some of the residue off and take some of the residue off and take some of the skin with it. You can also skin with it. You can also sometimes see mechanical trauma sometimes see mechanical trauma sometimes see mechanical trauma when you have a lot of abdominal when you have a lot of abdominal when you have a lot of abdominal distention post-operatively. So distention post-operatively. So when you have a lot of abdominal when you have a lot of abdominal when you have a lot of abdominal distention, you can get a lot of distention, you can get a lot of distention, you can get a lot of shear at the border of your shear at the border of your shear at the border of your pouch, just like we sometimes pouch, just like we sometimes pouch, just like we sometimes get tape blisters. You can get get tape blisters. You can get blistering around the outside blistering around the outside blistering around the outside edge of your ostomy pouching edge of your ostomy pouching edge of your ostomy pouching system. Contributing factors, system. Contributing factors, who's at risk? Anyone with who's at risk? Anyone with fragile skin. So your older fragile skin. So your older patients, any patient who's on patients, any patient who's on patients, any patient who's on steroids, any patients who's steroids, any patients who's steroids, any patients who's malnourished. Any time that malnourished. Any time that patients are using adhesives and patients are using adhesives and patients are using adhesives and tackifiers incorrectly, so if tackifiers incorrectly, so if tackifiers incorrectly, so if they're applying an adhesive, they're applying an adhesive, they're applying an adhesive, applying a tackifier and not applying a tackifier and not applying a tackifier and not allowing the solvents to allowing the solvents to allowing the solvents to evaporate, not allowing that evaporate, not allowing that evaporate, not allowing that adhesive agent, that tackifier, adhesive agent, that tackifier, adhesive agent, that tackifier, to dry completely. So you always to dry completely. So you always want to remind patients, if want to remind patients, if want to remind patients, if you're going to add an adhesive, you're going to add an adhesive, you're going to add an adhesive, if you're going to add a if you're going to add a if you're going to add a tackifier, follow the tackifier, follow the tackifier, follow the directions. Allow the solvents directions. Allow the solvents to evaporate so you're not to evaporate so you're not to evaporate so you're not trapping chemicals against your trapping chemicals against your trapping chemicals against your skin. Most commonly there's skin. Most commonly there's some element of incorrect removal some element of incorrect removal some element of incorrect removal technique. So from the very technique. So from the very beginning, we stress the beginning, we stress the beginning, we stress the importance of peeling the pouch importance of peeling the pouch importance of peeling the pouch off the skin. Don't rip it off, off the skin. Don't rip it off, peel it off. Push down on the peel it off. Push down on the skin, peel back on the pouch. skin, peel back on the pouch. Push, pull, push, pull. The other push, pull, push, pull. The other reason is not the most common reason is not the most common reason is not the most common reason, but again, it's always reason, but again, it's always reason, but again, it's always helpful to walk the patient helpful to walk the patient helpful to walk the patient through. Show me exactly how you through. Show me exactly how you take your pouch off. Show me take your pouch off. Show me what products you're using to what products you're using to what products you're using to take your pouch off. Walk me take your pouch off. Walk me through what you do when you put through what you do when you put through what you do when you put your pouch on. Walk me through your pouch on. Walk me through how often you're changing your how often you're changing your how often you're changing your pouch. We've got to figure out pouch. We've got to figure out what we need to change to protect what we need to change to protect what we need to change to protect your skin more effectively. your skin more effectively. Now, all of these illustrations Now, all of these illustrations Now, all of these illustrations are classic for mechanical are classic for mechanical are classic for mechanical damage to the skin. So you see damage to the skin. So you see you have defined patchy areas of you have defined patchy areas of you have defined patchy areas of skin loss in areas that are not skin loss in areas that are not skin loss in areas that are not exposed to any kind of drainage. exposed to any kind of drainage. So this has nothing to do with So this has nothing to do with So this has nothing to do with drainage, nothing to do with drainage, nothing to do with drainage, nothing to do with leakage. It can start as a leakage. It can start as a blister. It can present as a blister. It can present as a skin tear, especially along the skin tear, especially along the skin tear, especially along the outer edges, or it can be just outer edges, or it can be just outer edges, or it can be just like you see here, just patchy like you see here, just patchy like you see here, just patchy areas that are well defined and areas that are well defined and areas that are well defined and that involves skin loss. that involves skin loss. How do we manage these? Well, the simplest thing is Well, the simplest thing is Well, the simplest thing is treating the damage itself. treating the damage itself. So we just do our crusting. Typically just with the powder Typically just with the powder Typically just with the powder or with powder and our alcohol or with powder and our alcohol or with powder and our alcohol free liquid skin barrier, free liquid skin barrier, free liquid skin barrier, whichever your preference is. whichever your preference is. It can also be very helpful to It can also be very helpful to It can also be very helpful to take a thin hydrocolloid, take a thin hydrocolloid, take a thin hydrocolloid, cut it out to fit around the cut it out to fit around the cut it out to fit around the stoma, put that down as a base stoma, put that down as a base stoma, put that down as a base for your pouching system. for your pouching system. It just gives you an extra layer It just gives you an extra layer It just gives you an extra layer of protection and an extra of protection and an extra of protection and an extra layer of moisture management layer of moisture management layer of moisture management because these lesions will be because these lesions will be because these lesions will be wet. We've already talked about wet. We've already talked about the critical importance of the critical importance of the critical importance of patient education regarding patient education regarding patient education regarding appropriate use of adhesives, appropriate use of adhesives, appropriate use of adhesives, appropriate use of tachyfires, appropriate use of tachyfires, appropriate use of tachyfires, and the correct approach to and the correct approach to and the correct approach to pouch removal. Most of the time pouch removal. Most of the time it's really helpful to introduce it's really helpful to introduce it's really helpful to introduce patients to adhesive releasers. patients to adhesive releasers. Releasers are silicone-based. They break down or interrupt They break down or interrupt They break down or interrupt the bond and make it much easier the bond and make it much easier the bond and make it much easier to peel the pouch off the skin. to peel the pouch off the skin. They leave essentially no residue. Removers contain solvents. They have to be then washed away They have to be then washed away They have to be then washed away from the skin. So if you're from the skin. So if you're using an adhesive releaser, then using an adhesive releaser, then using an adhesive releaser, then you can just use your standard cleansing approach if you're using an adhesive remover. You want to be very careful to thoroughly clean the skin to thoroughly remove that chemical agent. Now we're going to talk about peristomal pressure injuries. These are not common but we do occasionally see them. So these are by definition lesions caused by pressure in the peristomal area. They're almost always full thickness. They most commonly occur in patients who have peristomal hernias. So when you have a peristomal hernia you have loops of bowel out in the soft tissue creating abnormal pressure against the abdominal wall. And then if you use a pouching system with a rigid component like firm convexity, you're trapping the abdominal wall between high pressures internally and high pressures externally and that's what causes the pressure injury. The clinical presentation is pretty clear cut. You have an isolated, very well defined area of tissue loss over the area of the hernia. And typically it corresponds to the area of convexity to the firm area of the pouching system. The area of damage does not correspond to areas exposed to stool or urine so it's very clear that this is mechanical trauma and not drainage related. And typically the patient will report tenderness and possibly pain in the area of the wound. So obviously the most important element is to break the cycle of injury. So eliminate that firm pouching system. Eliminate firm convexity. But let's talk about how we're going to manage the wound. So you're going to select your dressing based on the depth of the wound, the volume of exudate. Most commonly we'll end up using an alginate or a hydrofiber into the wound to manage the drainage, maintain a moist wound surface. Then we're going to select a flat or all flexible pouch if we can make that pouch work. If we can obtain and maintain a secure seal. If we have to use convexity, we're going to use soft convexity. Now look at the illustration on the bottom left. If the hernia can be reduced. So maybe the patient sits up. They have this big bulge. They lie down. Their belly goes flat. That's a reducible hernia. So if the hernia can be reduced it's very helpful to put them in a binder. But the binder with the hernia reduced so that the binder maintains hernia reduction. And then you don't have the issue nearly so much. If the hernia cannot be reduced then you still might use a binder just to provide support. But if you can reduce the hernia. That's very helpful. We're next going to talk about something you may never see. If you do see it you'll be like oh my gosh I remember reading about this or I remember hearing about this. And that is a bacterial infection around the stoma. These are extremely rare. Sometimes it's a stitch abscess related to a support device. That's probably the most common scenario. So what you end up with you know what an abscess is. You know that it's a development of purulent fluid in the soft tissue underneath the skin. You know that it's always caused by bacterial invasion. So you have it's called a stitch abscess because the bacteria penetrate along the pathway of the suture. And then you end up with a purulent collection of fluid. That's a purulent collection of fluid. place a little drain if there's any kind of significant fluid accumulation, if there's any kind of significant death. If you have systemic indicators of infection, rising white counts, if there's evidence that the infection is spreading to involve surrounding tissue, then they will do a culture, place the patient on oral antibiotics. But most commonly, they just open it and drain it. We'll use an antimicrobial absorbent dressing like maybe a silver alginate or a silver hydrofiber. Then we'll put down a hydrocolloid wafer and pouch right over the wound because we certainly don't want to enlarge the opening in the pouch to expose the wound because that is not going to help to eradicate the infection. So, you're going to get the site drained by the surgical team if necessary, put in your antimicrobial dressing, cover with a hydrocolloid, cover with a pouch, and you're going to change your pouch and your dressing every one to two days until the wound is healed. A more common problem is that the wound is not fully healed. So, if you have a wound that's not more common lesion is peristomal pyoderma gangrenosum. This is a very difficult condition to manage because it's so painful for the patient. Pouch changes are so painful for the patient. So you think, well, what is this? What is PPG, peristomal pyoderma gangrenosum? It's an autoimmune neutrophilic dermatosis that causes painful ulcers around the stoma. Now, pyoderma lesions can actually occur anywhere. They're most common on the lower extremities. They can occur on the abdominal wall. Occasionally, they occur on the scalp. They can occur literally anywhere. But in a patient with a stoma, it's not uncommon to see peristomal pyoderma gangrenosum. Much more common among individuals who have known autoimmune disorders, such as inflammatory bowel disease or rheumatoid arthritis. But some patients, up to 50%, have no known associated autoimmune conditions. And that is known as idiopathic peristomal pyoderma gangrenosum. So here's the clinical presentation. You can have a solitary lesion or you can have multiple lesions. So you can see kind of the range of clinical presentations on these slides. But you can see that frequently, this results in full thickness wounds. It can cause partial thickness, but much more commonly, you'll see full thickness wounds. Probably the hallmark of pyoderma lesions is this. This is a very common lesion that occurs when you have a patient with pyoderma gangrenosum. This is the level of pain associated with these wounds. They are acutely painful. If someone calls me and says, "I think my patient has pyoderma," one of my first questions will be, "Is the wound acutely painful?" If they say, "No, not really," I'm thinking it's probably not pyoderma because severe pain literally is a hallmark of pyoderma gangrenosum. Typically, you'll see purulent gangrenosum. You'll see purulent drainage. Almost always, you'll see dermal destruction with extension into the sub-Q tissue. That means with healing, you get scar tissue and many times when you're caring for a patient with peristomal pyoderma, you'll see scar tissue. You'll see that they've had previous lesions. Also, many times, the borders will be irregular and purplish in color. To the point that you'll see, "Oh, my God, I'm going to have to go through this again and again, and I'm going to have to go through this again, and I'm going to have to go through this again, and I'm going to have to go through this again, and I'm going to have to go through this again, edges. You always have dermal destruction. Most of the time you have extension into the subcube and almost always they're acutely painful. But that purple discoloration is sometimes present, sometimes not. Now I want you to look at the last bullet point. Many times pyoderma lesions demonstrate a phenomenon known as pathurgy. And pathurgy means that minor trauma causes a major flare-up of the underlying process. And trauma can be as minor as pouch removal, especially if we're not using releasers or removers. So even pouch removal can make the condition worse. So we have to be very careful in managing these wounds in these patients. So obviously this is a very difficult condition. We want to diagnose it correctly. How do we do that? There is no specific diagnostic test for pyoderma. It's essentially a diagnosis of exclusion, but a biopsy is extremely helpful. Almost always we have dermatology involved. Almost always they'll be diagnosed with a biopsy. But a biopsy is extremely helpful. Almost always they'll be do a biopsy. The biopsy will not say peristomal pyoderma gangrenosum, but it will usually say something like indicators of acute and chronic inflammation consistent with inflammatory process such as pyoderma. Management. Management is critical for these patients. We want to get these to get these to get these resolved as quickly as possible. And we absolutely need to focus on pain management. So think about oral analgesics. If they're having around the clock pain, they need around the clock analgesics. If they have acute pain associated with pouch change, they probably need premedication. They might also benefit from lidoderm patches. So you know those are sustained release lidocaine patches. So you can see that there are patches that can be placed adjacent to the stoma, adjacent to the wounds. If that's helpful, we'll continue. If it's not helpful, we'll discontinue. Same thing with analgesic gel. So some kind of lidocaine gel might be beneficial when you change the pouch. So some patients find it very helpful to gently remove the pouch using a releaser or a remover. Then apply lidocaine gel. Then apply lidocaine gel to the wound base and allow it to sit for 10 to 15 minutes so they get maximum benefit before they proceed with gentle cleansing and application of a new pouch. Remember this is an inflammatory process. So we need to be managing these patients with anti-inflammatory agents. We cannot do effective management by ourselves. We need dermatology involved because these patients almost always require systemic anti-inflammatory agents. Most commonly steroids like a steroid dose pack or biologic agents. More and more I see people using the biologic agents to treat peristomal pyoderma. Also sometimes they'll use dapsone or doxycycline because of their anti-inflammatory effects. You may sometimes see dermatologists recommending and providing intralesional steroids so that they literally numb the area, draw up the steroid solution, and infiltrate the entire wound area with steroids. Sometimes that helps prevent recurrence. So you can see systemic anti-inflammatory medications. You might see patients being managed with intralesional anti-inflammatories. And the dermatology team might also recommend topical anti-inflammatories. So they might recommend a mid-potency steroid like triamcinolone. They might recommend tacrolimus being applied directly to the wound bed. They might recommend antimicrobial medications. Or anti-inflammatory dressings. Or many times that recommendation will come from you. So we have some limited studies, not a lot, but some limited studies that show that antimicrobial foam dressings such as hydrophera blue can reduce pain and reduce the inflammation associated with pyoderma lesions. If you don't have that, you might do a trial of silver-based alginates or silver-based hydrofiber dressings because, again, they have antimicrobial and some anti-inflammatory effects. Absolutely critical to recommend to this patient that they use an adhesive releaser so that when they take the pouch off, they are not causing trauma. We never want to be the source of pathology and a flare-up. Something you may or may not see, caput medusa, which is the official word for peristomal varices. Now, why would you have varicosities around the stoma? That would occur because of back pressure on the veins surrounding the stoma. Back pressure on those veins would occur in a patient with liver disease and portal hypertension. So anytime we see this and it's most commonly this purple-blue-gray discoloration around the stoma, and frequently you can see the varices underneath the skin. You can see the tortuous and large veins. So a couple of things. If you see varices around the stoma, you want to make sure that the physician is aware because this is a sign of liver disease, of portal hypertension. And secondly, you want to be aware that anytime you see peristomal varices, that patient's at increased risk for peristomal bleeding and possibly for GI bleeding. So the patient might say to you, what is this? What is causing this? And if you say to them, does it hurt? They'll say no. Does it itch? No. Does it interfere with your pouch seal? No. But it looks weird and I don't know what's causing it. So that's the way Caput Medusa presents. Discoloration, usually purple-blue-gray, frequently visibly and large veins, but no other symptoms. So management, we've said we want to make sure the physician is aware because the most effective management of Caput Medusa is management of the underlying causative condition. Can we correct the portal hypertension? Maybe they need a shunt. But definitely the physician should be aware because he or she will be determining workup and management. We definitely want to avoid rigid convex pouching systems since they could potentially cause damage to the skin, potentially unroof one of those enlarged vessels and cause a major bleed. So we don't want that to happen. If we have to use convexity, it should be soft convexity. In general, we prefer a flat, all-flexible pouch in this situation. Critical to teach the patient to routinely use an adhesive releaser or remover. We never want to cause trauma with pouch removal. We don't want to take off the top layer of skin. We don't want to risk unroofing one of those blood vessels. And we need to be prepared to manage minor bleeding and to teach the patient to manage minor bleeding. Now, if it's us and we're changing the pouch and we see minor bleeding either at the level of the skin or the stoma, we can use silver nitrate or we can use Surgicel or one of our other hemostatic agents. We can also use alginate dressing because they promote clot formation. We can use pressure. We can use ice. We want to tell the patient if you ever experience bleeding through your stoma, you can use pressure, you can use ice, and you need to notify your physician immediately. If the bleeding is severe or persistent, you probably need to go to the emergency department. not a problem once you identify what it is and you explain to the patient what it is. So what's happened here, you see you've got this scalloped appearance to the mucocutaneous junction. So normally when they're creating a stoma, they suture the mucosal layer of the bowel to the dermis or the sub-q tissue. If they inadvertently suture the mucosa to the skin, you'll be carrying little islands, little mucosa islands over to the skin and it will literally transplant. So the good thing is it's not painful. It's not going to get worse. It is what it is. It's just little areas of mucosa inadvertently transplanted to the skin. Initially, it looks very much like irritant dermatitis because it's immediately adjacent to the stoma and it's red and it's wet. But when you ask the patient, "Is this painful?" They'll say, "Oh, no, no, no, not at all. Does it itch? No. When I touch it, is it tender? No, I don't feel anything." The only issue they might have is issues with the pouch adherence. If they're sizing the opening in the pouch so that it's sitting right on top of those wet little fingers of mucosa, that could cause premature lifting of your pouching barrier and they might end up having to change their pouch more frequently. That's the only pathologic effect. So how do you manage it? Well, first of all, you just reassure the patient, "Hey, there's nothing wrong here. I thought, you thought, that you had areas of skin that were damaged. That's not what's going on here." It's just where, when they made the stoma, the tissue lining the bowel wall became adherent to the skin itself. So that's why you have this little scalloped edge. That's not going to change. It's going to stay just like that. And the only thing we have to do is we have to figure out how to pick it up. We have to figure out how to pouch around it so that it's not a problem, so that it doesn't cause leakage. So you can size the opening in the pouch to clear that scalloped edge. And then you can use paste or a barrier ring right around the stoma to protect the skin because you have, as you can see, skin interspersed with those little islands. So that's all you have to do. Just work with the pouching system. Figure out how to make it work. maintain a secure seal and reassure your patient. Granulomas are very different. So granulomas, here you have these inflammatory lesions that are caused by an inflammatory response to some foreign body. Most commonly, it's the mucocutaneous sutures. So you have these raised erythematous lesions. It almost looks like a pathologic pearl necklace around the stoma. But these lesions are tender. They bleed very easily, and they can definitely interfere with maintenance of a secure pouch seal. So when you see these and you're like, the patient says it's tender, the patient says it's getting bigger, that they've noticed them the first time a few weeks after surgery, and they're just getting bigger. So you have to be very careful. And then you have to be very careful about the lesions. And bigger and bigger and more and more tender. Then you want to take a cotton tip applicator and you want to gently probe the lesions and see if there are any retained sutures that you can remove. Then you want to cauterize the lesions with silver nitrate. If you have open wet areas you can use your crusting procedure. It can be very helpful to use a convex pouching system because it can help to flatten those lesions out. Let's say you have some refractory granulomas. Like the patient comes in, you know for sure they're granulomas, they're getting bigger, they're tender, they're weeping. You take your cotton tip applicator, you're pretty sure there's a suture in there but you can't find it. You're not able to unroof anything that you can get to. Then you need to send the patient back to the surgeon because the surgeon is going to be able to unroof any retained sutures, remove them, and eliminate the problem. So granulomas are reversible conditions. Remember that the peristomal skin is just that skin that happens to be located right around the stoma. But because it's part of the entire integumentary system, it is subject to the surgery. system, it is subject to the same pathologic conditions as the rest of the skin. And occasionally you'll have a patient who has a dermatologic process such as psoriasis that is involving the peristomal skin. So any kind of dermatologic process can involve the peristomal skin. Now according to some studies, peristomal psoriasis occurs in up to 7% of ostomy patients. I know I haven't seen it that commonly, but some ostomy nurses do see this fairly commonly. They think it's due in part to what's known as the Kaebner Phenomenon, which means that localized skin trauma can cause a flare of the underlying disorder, the psoriasis. So if you have a patient who has a history of psoriasis, you know they're at risk for psoriasis to recur in the peristomal area. How does it present? As this erythematous patchy rash with flaking and scaling, it's usually itchy. It's just like psoriasis anywhere else. So doing your assessment, if you see some kind of dermatologic process and you're like, "Whoa, what is that?" You're going to ask the patient about leakage issues. You're going to ask them about their symptoms. But if you have something like this, it's clear that this is not an irritant dermatitis because it's circumferential. And probably in looking at the back of the removed pouch, you would not see any evidence of leakage of undermining. And then you'd be talking to the patient, you'd be like, "Is this painful?" Well, no, it's more itchy. Itchier than anything else. Very, very itchy. And you see other indicators that this isn't one of your classic peristomal complications. You have this flaking but no blistering. It doesn't really match any area of the pouching system. It's everywhere. It's not just under the tape, not just under the hydrocolloid barrier. So it's like, I don't think it's a sensitivity reaction. So it's clearly not yeast dermatitis. It's not maceration. It's not irritant dermatitis. I wonder if it's a dermatologic process. So you would say to the patient, "Do you have any other dermatologic conditions? Have you ever had anything like psoriasis?" And if they say, "Yes," you're like, "Okay, well, that might be what's going on here." You're going to involve dermatology either way. You either want to do it or not. You want to confirm what you suspect or you want dermatology involved in providing a differential diagnosis and establishing a management plan. So many times they'll recommend topical steroids in gel form, in spray form, in cream form. Never any ointments because ointments, of course, would prevent a secure pouch seal. We know that if this is psoriasis, we want to prevent that Kevner phenomenon, that flare in response to trauma. So we want to give them the best pouching system possible. We want to make sure they routinely use adhesive releasers or adhesive removers and that they use very gentle technique in removing their pouch. And remember, they may benefit from infused barriers to keep the peristomal skin as healthy as possible. So, your dermatologist is your go-to person. If you see something and you're like, "I don't know what this is," if you see something and you're thinking, "Well, maybe it's psoriasis because she has a history of that, but I'm not positive and I'm certainly not positive regarding the best way to manage," if you're pretty sure you know what's going on but the patient fails to respond to your management plan, you're going to want to give them a prescription. And then you're going to want to give them a prescription. or they need to be cream-based. We cannot use ointments because a lot of your dermatologic medications are ointment-based and they will obviously interfere with pouch adhesion. So in summary, there's lots of things that can go wrong with the peristomal skin. We talked about moisture-associated skin damage in a previous class. In this class, we talked about folliculitis and mechanical damage types of PMAR-C, medical adhesive-related skin injury. We talked about the unlikely but possible development of a peristomal pressure injury, more likely when the patient has a peristomal hernia and we're using a pouching system with rigid components. We talked about bacterial infections. In this class, we talked about the possibility of a peristomal pressure injury, again, uncommon but possible. And then we talked about dermatologic conditions like peristomal pyoderma, capomedicid, mucosal transplantation, granulomas, and psoriasis. And we emphasized that any time we're stuck in managing peristomal skin complication, the dermatologist is our go-to referral. So I think that's. That's it for this class. Thank you very much.
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