Speaker 1In this class we're going to continue our discussion of prevention and management of peristomal skin complications with a specific focus on peristomal moisture associated skin damage. So we've already talked about common types of peristomal skin complications, now we're going to focus on the clinical presentation of different types of PMASD and management options for each type of MASD. So remember that we currently divide peristomal skin complications into those that are caused by exposure to moisture, so maceration, pseudovarucous lesions, irritant contact dermatitis, and allergic contact dermatitis all fit within the umbrella of peristomal moisture associated skin damage. Peristomal medical adhesive related skin injury comprises folliculitis and mechanical damage. And then we have two additional types of peristomal complications. Peristomal pressure injury. And peristomal pyoderma gangrenosum. But in this class we're going to talk primarily about moisture associated skin damage. We've talked before about measures for prevention of peristomal skin complications. I'm going to summarize them again. They're critically important. So pre-op stoma site marking to give us the very best chance of having a stoma located on a flat pouching surface. Post-op assessment and management to establish a secure pouching system based on abdominal contours, stoma height, and location of the os. Provision of post-op follow-up, both home health and then long-term follow-up in the outpatient arena so that we can adjust the pouching system as indicated. We know stoma shape and size is going to change with healing. We know abdominal contours are going to change with healing. We know that many, many times we need to add convexity, add a belt, change the basic pouching system. We have to educate the patient and the caregiver on an ongoing basis. As we make adjustments, they have to make adjustments. So every change we make. Is tied to critical patient and caregiver education. And again, we always want to make sure that our patient and our caregiver knows how to manage minor irritation because many times if they manage minor irritation correctly, they can keep it from turning into a major problem. So every patient, every caregiver needs to know how to recognize. Beginning. Beginning skin damage and how to respond with crusting. Okay, so now let's focus on peristomal moisture associated skin damage. We're going to talk first about maceration. So maceration is just over hydration of the skin. We see it in many different scenarios. You see it when you keep your hands in water too long and they become soft and pruney. Um. You can also see it around a stoma because that skin can easily become over hydrated. The problem is when the skin becomes over hydrated, it becomes extremely vulnerable. It looks soft, it is soft, it's much less resistant. All of the skin cells when they're over hydrated, they're stretched, the cell membrane is now very thin. So it takes nothing to cause breakdown in the skin. Also over hydrated skin is much more vulnerable to penetration by irritants and by pathogens. When do we see maceration in our ostomy population? Most commonly with urinary diversions because you think, okay, well they're going to have very high volume, very liquid drainage. They're going to be running over the skin almost constantly. So yes, those patients would be very vulnerable to maceration, but we can also see this in our ileostomy patients because they also have high volume drainage. So those are the two patient populations that are at greatest risk for over hydration. Clinical presentation is really pretty straightforward and easy for us to understand because we've talked about over hydration in other situations. So the skin will look soft, it'll look moist, it'll feel moist. It will appear lighter in color than the surrounding skin. And typically the area of involvement will match areas of over hydration of the barrier. So when you take off the pouch, you look at the back of the pouch, you look at the skin and you're like, yes, the skin looks over hydrated in this area. That matches the area of the barrier that is over hydrated. So how do we manage this? Well we can treat the over hydrated area with crusting. That's a great choice because we put on the powder, dust off the excess, and the powder absorbs some of that excess moisture. Figuring out what's causing it is really the challenge. So treatment of the skin itself, not a big deal. But figuring out what caused it. So we have to again evaluate our patient lying, sitting, twisting, standing. Try to determine what's going on here. Do we have drainage that's undermining the seal and that is why we're getting this over hydration? Is the issue that the patient's not changing the pouch often enough and that's why we're getting over hydration? Is the issue a lifestyle issue? Maybe the patient's going to the gym and working out and sweating a lot but not changing the pouch after their workout. So maybe we need to change that component of their routine. So we want to make sure that our pouch is fitted correctly. We want to make sure that we're not getting any undermining. We want to make sure that the opening in the pouch is sized correctly. If there's evidence that we're not obtaining and maintaining a secure seal, we might think about adding adhesive to see if that makes a difference. Also, sometimes it's helpful to change the type of barrier. If we have a patient in a standard wear hydrocolloid barrier, they might benefit from shifting to an extended wear hydrocolloid barrier. Remember the difference. Extended wear barriers are designed to handle moisture more effectively. They have greater ability to absorb without loss of seal than a standard wear barrier. So it's always a good checkpoint when you have a patient with a urinary diversion or an ileostomy. Do I have this patient in an extended wear barrier? Did they, the patient, inadvertently order the wrong barrier? When they ordered their supplies, just double check that point. Not routinely, but occasionally, you might have to recommend an antiperspirant to the peristomal skin. So this is most likely to be an issue when you have a young patient. They're working out, they're playing tennis, they're jogging, they're working outside. They tell you, "I sweat all the time," and you take off the barrier, and yes, the whole barrier looks overhydrated. The entire peristomal skin area looks overhydrated, and it doesn't appear to be related to any kind of undermining, any kind of leakage. Then the patient might tell you, "Yeah, I sweat a lot. I change the pouch twice a week, but I go to the gym five times a week." So then we have a couple of interventions we can recommend. You can say, "Okay, I'm going to try you on an antiperspirant to the peristomal skin." And you can go to the drugstore and you can look for antiperspirants that do not leave a powdery film. And what you're trying to do is shut down sweating right in this area. That's what antiperspirants do. So that can be a very effective intervention. Apply an antiperspirant. The other thing you might have to recommend to your patient is, "Okay. let's look at your schedule for going to the gym because I think you're probably going to need to change your pouch every time you go to the gym. It looks like you're sweating so much that it's overwhelming the barrier's ability to absorb the moisture. We'll try the antiperspirant first. If that's not enough, we might have to increase the frequency of your pouch change to kind of match your workout routine. And you want to make sure they're managing external moisture appropriately. So after you get out of the shower, dry well, take your hair dryer on a cool setting, dry the tape and the fabric back into your pouch. If you don't dry the tape with the hair dryer on a cool setting, then that's trapping moisture next to your skin. That can be part of the problem. Okay. Pseudo-verrucus lesions, much less common. We don't see these very often, but as an ostomy nurse, you have to know them when you do see them. So these are wart-like lesions, and that's why they're called pseudo-verrucus. Verrucus lesions are warts. Pseudo-verrucus means they look like warts, but they're really not. So these look like warts, but they're caused by chronic overhydration of the skin. The wax isn't irritant to the skin. By far, most likely to occur among your urostomy patients. Occasionally, we will see them in high-output ileostomies, but not frequently at all. I would say out of all the pseudo-verrucus lesions I've seen, probably 90, 95% have been in my urinary diversion patients. So what do they look like? They look wet, but they have that wart-like appearance, as you can see from this illustration. They typically occur right around the stoma. They're usually clustered at the base of the stoma. Sometimes they extend to the stoma itself. The area of involvement is going to match the overhydrated area on your use barrier. So when you take off the pouch, you look at the backing, you look back at the skin. Again, it's a match. It's like this is the area that is chronically wet. Now, do patients have any symptoms, any discomfort? Yes. Interestingly, they do. So they frequently will complain of itching, tenderness, sometimes bleeding. And because these lesions are wet and irregular, they can interfere with the pouch seal. So they might also tell you that it's not going to be good for you, but they might also tell you that it's not going to be good for you. So it's a good thing that since I've developed these, whatever they are, it seems like I have more trouble keeping my pouch on. So how do we manage these pseudovaricose lesions? We've got to get them flattened out and dried up. So we begin with silver nitrate. That's a great initial approach. It helps to cause sloughing of the top layer of macerated skin. So silver nitrate first. You'll have to do more than one treatment. Most of the time. Then you can do your ostomy powder, so silver nitrate, then ostomy powder, which has a drying effect. You can use your liquid skin barrier. It's not essential. So ostomy powder with or without the liquid skin barrier. Critical to assure a secure seal so you prevent further contact between the peristomal skin and the drainage. Most of the time you're going to need to use a barrier ring so that it will contour right around the stoma, cover the pseudovaricose lesions, manage the moisture from the pseudovaricose lesions, and support your pouch seal. You might need to add convexity. You might need to add a belt. You might need to add adhesive, but almost always you'll need to add a barrier ring. If you're already using an extended wear barrier, you probably should switch to an extended wear barrier because it's very clear. You'll need that additional moisture management that you get from an extended wear barrier that you're not going to get from standard wear. The other thing you could use, and you can see this is one of the options in that central illustration, you could consider a pouch with an adhesive foam. Instead of a hydrocolloid barrier. Now, I think the only company that makes adhesive foam right now is New Hope. But what that adhesive foam does is a closed cell foam so it will not absorb moisture. So it gives you a secure seal, but it doesn't turn into a wet ring. So if you're having problems resolving either maceration or pseudovaricose lesions, even with an extended wear barrier and a barrier ring, think about a trial of adhesive foam. Make absolutely sure your patient is changing the pouch often enough. You might need to, at least on a short-term basis, move them to an every two to three day pouch change frequency just to keep the skin drier. Make sure they're sizing the opening in the pouch. Remember, most of these lesions occur in your urostomy patient population. Also remember that these are more likely to occur when the urine is concentrated in alkaline. So in addition to focusing on your pouch seal, in addition to focusing on topical management of these lesions, make sure that the patient's drinking enough fluid and that you're maintaining, uh, an acidic urine. You might need to add vitamin C to acidify the urine. If it is a patient with an ileostomy, uncommon, but if it is a patient with an ileostomy and you have very high output liquid stool, then consider agents that thicken the stool, possibly some of your anti-diarrheal agents like Imodium, possibly products like Psyllium that help take liquid to more of a gel form. Probably the most common peristomal complication is irritant contact dermatitis. Definitely the most common among the peristomal moisture associated skin damage. And here you have erythema, and you have patchy skin loss, and you have pain related to prolonged contact between the skin. And that liquid enzymatic stool. By far the most common among your ileostomy patients because that's where you have high volume liquid enzymatic drainage. So very, very irritating to the skin. And if you have an ileostomy that empties at skin level, the patient's even higher risk. It's more difficult to protect the skin and you're more likely to see this irritation. Irritant contact dermatitis. Now the presentation is exactly as you would think. In the skin that is exposed to this drainage, first you develop erythema, then you start to get patchy areas of denudation. Patchy areas of skin loss that occur immediately adjacent to an either inferior or medial lateral to the stoma. Exactly where the drainage goes. So it typically is right adjacent to the stoma. When you take off the old pouch and you look at the back of the pouch, you look at the wafer and then you look at the skin, you're like, "Yes, I have a match." Between the areas of erosion on the barrier and the areas of damage on the skin. And what the patient will tell you is, "This hurts. This is so sore. The drainage flows over. It burns and it stings. It itches, but I wouldn't dare scratch it because it hurts so bad if anything touches it." So the overwhelming subjective complaint is pain, tenderness. And then they'll also tell you it's almost impossible to keep a pouch on. I put my pouch on on Monday. I'm lucky if it's still on Tuesday night. It seems like it's just sitting on a wet surface and it just keeps coming out. And of course, now we're into that vicious cycle. So management. We have to stop the leak. That's what's causing the skin damage. So yes, we can treat the skin damage with crusting, but we have to stop the leak. To stop the leak, we have to get the driest skin surface possible. So many times it's helpful to take a hair dryer on a cool setting. And essentially blow the skin dry so that we're dealing with a drier, pouching surface. Crusting, as we've already said, you can repeat your layers so you can dust on ostomy powder, dust off the excess, let that set. But if it's very wet, very damaged skin, you're probably going to need at least two or three layers of powder to create a gummy pouching surface instead of a wet pouching surface. Many times it's helpful to take a thin hydrocolloid cut it out to fit around the stoma, put it over the irritated, damaged area so you have a pouching surface that your pouch will stick onto. It also helps because hydrocolloids are designed to absorb some moisture. And yes, your pouch backing is hydrocolloid. It's like giving you another layer. So a layer to protect and treat the skin. That layer, also serves as a foundation for the pouching surface itself, or the back of the pouch, the barrier wafer. Anything you have to do to establish a secure seal. So do you need to add convexity? Do you need to add a belt? Would it help to put a barrier ring right around the stoma? Because again, it gives you a little bit of additional moisture control. Drainage management. But your primary focus is getting a good match between your pouching surface and the underlying abdominal surface. Because we have to stop the undermining. So probably the most common interventions are the addition of convexity, the addition of a belt that holds the pouch securely against the skin, and the addition of a belt that holds the pouch securely against the skin. So that prevents or significantly limits any kind of tracking undermining. Make absolutely sure that the opening in the pouch is sized correctly. Again, we're trying to minimize contact between drainage and the skin. Probably we'll need to increase the frequency of the pouch seal or the pouch change until we get the skin healed. So maybe this person normally changes their pouch seal or the pouch change until we get the skin healed. So maybe this person normally changes their pouch twice a week, but right now they might need to change their pouch three times a week, every two days, until we get the skin healed. Once again, if thin drainage is part of the problem, think about strategies to thicken the drainage. So spend a lot of time here. This is what's going to turn everything around. So get the skin as dry as you can. Do several layers of pouching. Think about adding a powder. Think about adding a hydrocolloid so that you have additional moisture management. Think about would it be helpful to add a barrier ring before you then add your pouch. Should you make the pouch convex? Should you select a convex option? Think about adding a pouch. Should you need to add a belt? Now as an ostomy nurse, you're going to get to where you can recognize yeast at 100 yards probably. So when you see yeast, these two illustrations are classic. What you have is a maculopapular rash that is solid in the center, it thins at the periphery, and you have distinct satellite lesions right around the edge. It's caused primarily by Candida albicans, so it's also not a good thing. It's also known as peristomal candidiasis. Now risk factors. Number one risk factor is moisture because that is a great environment for yeast to grow and reproduce. But antibiotic administration is another risk factor because as you know, antibiotics knock down the normal bacterial counts. When you knock down the inhibiting bacteria, it allows the yeast or the bacteria to grow. So moisture, antibiotics, steroids, poorly controlled diabetes, immunosuppression are all risk factors. But the number one risk factor is a wet peristomal surface. That's all yeast needs to get a toehold and to begin to replicate and to create problems. So clinical presentation, we've talked about some of this. The problem is you have a rash that's solid in the center. You have those distinct satellite lesions. It will appear red in people with fair skin. In people with dark skin, the involved area will be lighter in color. But the distribution is exactly the same. Solid in the center, distinct satellite lesions. And what the patient tells you is it's itchy, but it's also kind of tender. It's so itchy, I have to rub it. But when I rub it, it's a little bit sore. And when you ask, the patient might report that they also have a rash in the axilla or in body folds. They may not, but yeast can become systemic. How do we manage this? Primarily by crusting with an antifungal powder. Now, over-the-counter myconazole products are excellent choices for treating peristomal yeast. So the patient can literally walk into a drugstore and look for anything that says antifungal. So they can get monostat derm. They can get Lotrimin antifungal. They can get just generic myconazole. Anything that has myconazole is going to work. Now, they could also use prescription nystatin, but it's more expensive. It requires a prescription. And actually the spectrum of activity is narrower, so you're going to typically get better results with a least expensive or a less expensive product. So typically we just send people to the drugstore. only pouching system. This was a urostomy. The surface to the pouching system was round and I thought they're reacting to the adhesive on the pouching system. But then I noted, you know what, the reaction goes all the way up to the stoma. And actually when I sized the opening in this pouching system, it cleared the stoma itself by a quarter of an inch. But I don't see that quarter of an inch of skin being spared. I don't see any sparing. So I had the nurse walk me through what they did when they changed the pouch. The patient's still in the hospital. Nurses were changing the pouch. And they had used compound tincture of benzoin all the way up to the stoma. So this patient was actually, she was actually, she was actually, she was actually, she was actually reacting to the benzoin and not to the pouch. So very important to have the patient or the caregiver walk you through exactly how they went about changing the pouch, everything they used on the skin, so that you don't misinterpret what the patient might be reacting to. So you will see erythema. You will see, you may see blistering. The erythema is usually fairly uniform. So you can stand back and you can get the pattern. So when you look at the illustration in the center of the slide, it's pretty clear that the patient was reacting to something on the border. It was the tape border. They were not reacting to the barrier ring, just to the tape border. But if you look at the one on bottom, it's like, well, they're reacting to the entire system. And what they were actually reacting to was an adhesive agent that was applied to the entire peristomal skin surface. So you'll see erythema with or without blisters, typically fairly intense itching, definitely some tenderness, and they might report difficulty maintaining the pouch seal, especially if they have blistering that would create a wet surface or if they're scratching a lot. So we've already talked about this. You've got to walk them through every step of their pouch change procedure to see what it is they're reacting to. If you're not sure, you can do patch testing. So you can either refer them to a dermatologist to do patch testing, or you can take the inside of the arm, make sure it's clean and dry. Apply the products that you think might be causing the reaction, and then cover them with occlusive tape and monitor their response. And then you'll see what it is they're reacting to. How do you manage an irritant dermatitis? Well, obviously, the most important thing is to identify the sensitizing agent and eliminate it. So if you're reacting to the tape border, the first thing I'm going to do is cut away the tape border. And use hydrocolloid barrier strips or something to secure the outer edge until your skin calms down. And then I'm going to change you to a different pouching system with a different tape border. So it's going to involve a little bit of trial and error. If you reacted to one major company's products, it does not mean you will react to another company's products. So I've had people react to Coloplast, but they do fine with Convitec and Hollister. I've had them react to Convitec. I've had them react to Hollister. So they can react to any one company's products and be fine with other companies. So you want to tell them that right up front so they won't be so worried. I had one patient who came in, she was panicked. She had had a urinary diversion since she was a child. She had started reacting. She had gone to a dermatologist. He's like, "You can't wear that pouch anymore." And she's like, "Oh my God, what am I going to do?" So we had to say to her, "Look, there are many pouches out there. We will find one that works for you." I have never had a patient who was allergic to all of the pouching systems on the market. There's something that will work for you. So just because they react to one hydrocolloid barrier strip, it doesn't mean they're going to react to another. Just because they react to one tape doesn't mean they'll react to another. Remember that if they do have a sensitivity to hydrocolloids, we could always use an adhesive foam. There's also a non-hydrocolloid barrier from Marlin known as SkinShield that they could use. There are trio silicone rings that are not hydrocolloid based. So there are options. So you just want to assure the patient up front, "We're going to get through this. We're going to test you. We're going to figure out what you're reacting to. We're going to modify your pouching system. There's enough products on the market. We're going to find something that works for you." In the meantime, what do we do about this acute inflammatory response? What do we do about the itching? You could use a topical antihistamine gel like Benadryl gel that you can get over the counter. It dries flat. You could use an over-the-counter steroid cream, so hydrocortisone cream that massages in. You can't use an ointment, but you can use a cream. So if they have major problems with itching, think about a topical antihistamine gel, a topical steroid cream. Also remember that once your skin is ticked off, it's likely to react to all kinds of things. It's mad. So you want to keep your pouching system as simple as possible. You want to minimize potential things that your skin might react to. So typically, we will use either a topical steroid, a topical antihistamine, and then a barrier-based pouch, and maybe that's it. Keeping it very simple until that whole inflammatory response has settled down. So summarizing peristomal moisture-associated skin damage, you see the most common types. Maceration, where our whole goal is manage the moisture, figure out where it's coming from, eliminate the moisture, use powder in the meantime to create a drier pouching surface. You want to keep it very simple until that whole inflammatory response has settled down. You want to keep your pouching system as simple as possible until that whole inflammatory response has settled down. So you want to keep your pouching system as simple as possible until that whole inflammatory response has settled down. You might need to add a barrier ring, you might need to add a belt, you might need to add adhesive. You've got to totally reevaluate your pouching system. Allergic contact dermatitis is all about figuring out what the patient's reacting to, eliminating that, modifying your pouching system so they're not using that sensitizing product anymore, using a topical antihistamine gel or a topical steroid cream.
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