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The management of stoma-
related skin complications
There are approximately 100,000 people in the United Kingdom living with a stoma (Lee, 2001).
Each year in Great Britain, 20,000 new stomas are formed. Skin problems are a common occurrence
among this patient group. Careful and thorough history taking will often give clues to the cause of
the problem and in combination with a careful physical examination, a correct diagnosis can be made.
Simple measures to treat skin excoriation can then be implemented, or in some cases, the patient may
require referral to a stoma care nurse for specialist treatment and advice.

                                                                 Anjela Vujnovich

                                                          post-operative bleeding or infection,      consequences, it is impor tant to
                                                          but also the risk of a stoma-related       remember that intact skin is essential
   KEY WORDS                                              complication, which can be immediate       for the normal use of a stoma
                                                          or delayed. It has been reported that      appliance (Smith et al, 2002). Any area
   Faecal/urinary skin excoriation
                                                          47% of stoma patients will suffer          of skin that has become excoriated,
   Leakage                                                at least one stoma complication            is weeping or bleeding, can cause
   Trauma and allergy                                     (Lyon and Smith, 2001). Shellito           the stoma appliance to leak. This, in
   Education                                              (1998) suggested that the greatest         turn, causes the skin to deteriorate
                                                          risk of developing a stoma-related         further, causing further appliance leaks,
                                                          complication is usually within the first   hence, the vicious cycle continues. If
                                                          five years following surgery. Arumugan     the patient is experiencing frequent
                                                          et al (2003) reported that 50% of          appliance leakage, they will lose

      reviously, two-thirds of all stomas                 patients had developed one or more         confidence in the appliance that they
      would have been permanent. As                       complications within twelve months         are using which will have a major
      surgery has continued to develop                    after stoma-forming surgery.               impact on their activities of daily living
and evolve, it is now estimated that it is                                                           and physiological well-being. Patients
an even 50% split between permanent                         Stoma-related complications include:     may report being too scared to
and temporary stomas. Patients may                        8Parastomal hernia                         leave their house for fear of the
undergo stoma-forming surgery for a                       8Stoma retraction                          appliance leaking.
variety of reasons, including:                            8Stenosis of the stoma
8Cancer of the bowel or bladder                           8Prolapse of the stoma                        Skin excoriation can occur at any
8Inflammatory bowel disease                               8Parastomal granulomas                     time and for many reasons (McKenzie
8Diverticular disease                                     8Mucocutaneous separation.                 and Ingram, 2001). Dermatitis from
8Familial adenomatous                                                                                stoma effluent repeatedly leaking onto
8Polyposis                                                    While these complications are fairly   the skin is the single most common
8Ischaemic bowel                                          common, by far the most common             cause of peristomal skin complications
8Obstruction                                              stoma-related complication is a skin-      (Lyon and Beck, 2001). Patients who
8Incontinence                                             related one.                               present with a skin complication will
8Abdominal trauma                                                                                    usually fall into one of five categories:
8Congenital malformations.                                   A review of the literature will find     8Faecal/urine dermatitis
                                                          figures ranging anywhere from 5%            8Trauma
    As with any surgery, there is always                  (Shellito, 1998) to 42% (Borwell, 1996);   8Infection
a risk of complications. With stoma-                      with Lyon et al (2000) suggesting that     8Pre-existing skin conditions
forming surgery, there is not only                        73% of people with a stoma will self-      8Allergy (Lyon and Smith, 2001).
an immediate surgical risk such as                        report a skin-related complication.
                                                                                                        Within each of these categories
Angela Vujnovich is Lead Nurse in Stoma Care, St Mark’s      While a minor skin problem may          there will be different causes. Each will
and Northwich Park Hospital.                              not at first appear to have any serious     have different signs and symptoms that

  36      Wounds      UK,   2006,Vol 2, No 3
                                                                                                        Clinical PRACTICE DEVELOPMENT

will affect individual patients in various    2002). Ideally, urinary pH should be                 taking a history, the next step should be a
ways, as well as having different modes       slightly acidic and range between 6–7.5              physical examination of the patient.
of treatment.                                 (Fillingham and Douglas, 1997). An
                                              alkaline urinary pH of 7–8 can lead to                   Start by looking at the patient’s
     Education of the patient with a new      complications with the peristomal skin               abdomen with the appliance still
stoma in the immediate post-operative         and stoma, such as stomal bleeding,                  on. Observe the patient in different
phase can minimise the risk of potential      ulceration, urinary tract infections,                positions. Watch how the appliance
skin problems arising (Vujnovich, 2004).      odour and urinary calculi (Fillingham                changes, moves and moulds to the
A trained stoma care nurse based in the       and Douglas, 1997). Eventually, stoma                contours of the patient’s shape in these
hospital usually undertakes this. However,    stenosis, pseudoepithelial hyperplasia and           different positions. Some appliances
as most skin complications will develop       hyperkeratosis may occur (Walsh, 1992).              may be too rigid for the shape of
after the patient has been discharged                                                              the patient’s abdomen. Skin folds
from hospital, district and practice nurses   Patient and skin assessment                          may develop on moving, causing the
will encounter people with a stoma in         When first encountering a patient who                appliance to lift slightly off the skin,
the community.                                says that they have excoriated skin, it is           which allows stoma effluent to seep
                                              important to take a thorough history                 underneath the appliance. It is then
     This article focuses on faecal or        of the problem. Asking appropriate                   important to watch the patient change
urinary skin excoriation, as this is the      questions will often give numerous clues             their stoma appliance. Pay particular
most common cause of stoma-related            as to the cause of their skin complaint              attention to how the patient removes
skin complaints. Trauma and allergy           (Vujnovich, 2004) (Table 1).                         the appliance and how they clean and
will also be mentioned. Treatment for                                                              dry their skin. If the patient is roughly
faecal or urinary skin complaints can be          All questions should be fully explored           pulling their appliance off, this may
commenced by a healthcare professional        to gain a better understanding of the skin           cause trauma to the skin; likewise, over-
in the community with some knowledge          complication. Once you have completed                vigorous cleaning could destroy the skin.
of stoma and skin care. In instances
where treatment has been started with
no signs of improvement, the patient               Table 1.
should be referred to their stoma care             History of skin problems
nurse. Skin complaints such as infections
                                                   Questions to ask:                            Rationale:
and pre-existing skin conditions should
be referred to a stoma care nurse or               When did this problem first appear?           Indicates how long the problem has
dermatologist, as often the treatment                                                           been present
required can impair the adherence of               Has the appearance of the excoriation        The excoriation may be improving or
stoma appliances, leading to secondary             changed?                                     worsening, changes may indicate different
skin complications.                                                                             stages of excoriation
                                                   Have you had this problem, or any problem    May suggest past history of pre-existing
Faecal or urine dermatitis                         with your skin before?                       skin problems
Faecal irritant reactions are more
common around ileostomies than                     What treatment did you try last time or      Previous treatment that may have been
colostomies, due to the corrosive                  this time?                                   effective in the past, may be effective this time
nature of the effluent. The effluent of            Do you notice leakage at particular times?   Problems may only be reported at particular
ileostomies is strongly alkaline and                                                            times (ie. during exercise, at night,
contains unabsorbed waste products                                                              when sitting)
and enzymes that break down protein.               What appliance are you using?                Is this appliance appropriate now?
Protein is a major constituent of
the outermost layers of the skin                   Are you using any accessories with your      Allergies are common to accessories rather
and protects the skin from harmful                 stoma appliance?                             than stoma appliances
substances. The stratum corneum is                 How many times a day/week do you change      May indicate too frequent appliance changes
resistant to quite acidic fluid, but it is         your appliance?                              or leaving the appliance in place for too long
more vulnerable to alkaline substances             How many leaks a week do you experience?     Vicious circle of frequent leaks causing
(Stevens and James, 2003). When                                                                 deterioration in skin, causing further leaks
ileostomy fluid leaks onto the skin, the
                                                   How many times a day do you empty            Stoma output may be high, the appliance may
enzymes break down the protective
                                                   your appliance?                              get too full before emptying, causing drag on
layers of the skin and cause excoriation.
                                                                                                the skin
    Urine that is in prolonged contact             Has the stoma effluent changed?               Stoma output may have increased, become
with the skin will lead to maceration                                                           more loose
in patients with a urostomy (Collett,

                                                                                                          Wounds      UK,   2006,Vol 2, No 3        37

    Once the appliance is off, look               During your physical examination      Poorly-shaped stoma
carefully at the back of the base             you may notice an area of excoriated      It is ideal for all stomas to have a spout.
plate to assess where any leakage or          skin directly round the stoma. The        Due to the corrosive nature of the
seepage of effluent has been occurring,        area may appear red and angry, areas      effluent, this is more imperative when
subsequently affecting this area of skin.     of skin may be missing and shallow        dealing with ileostomies and urostomies,
Visible tracks of effluent on the base         superficial ulcers and dried blood may    rather than colostomies. Spouts
plate will indicate where stoma effluent       be present. Patients will complain of     encourage the effluent to fall out into
has been on the skin.                         pain or a burning sensation at the        the appliance, rather than trying to track
                                              site. This may be at the circumference    underneath the base plate onto the skin.
    Now, carefully examine the area           of the stoma, or to one side. A           The optimal shape of an end ileostomy
surrounding the stoma. The distribution       circumferential ring of excoriated        should have a spout long enough to
of the excoriation will be determined by      skin would indicate that the patient is   avoid skin excoriation and should
the leakage of the stoma effluent on the       cutting the aper ture in the appliance    point forwards and slightly downwards
skin. For the skin to become excoriated       too large for the stoma, allowing skin    (Hall et al, 1995). In the case of a loop
it must be in contact with faeces or          to be exposed to faecal or urinary        ileostomy, the proximal end where the
urine. Pull apart any skin folds to see if    effluent. If the excoriation is only      effluent exits should be everted longer
the excoriation is present in the folds.      present in one area around the stoma,     than the distal end (Blackley, 1998). All
                                              usually a crescent shape at the bottom    colostomies should have a spout of a
   Signs of peristomal excoriation include:   of the stoma, it may be that the          few millimetres (Nicholls, 1996) to avoid
8Well-defined erythema                        patient is not lining up the aper ture    excoriation (Figures 2 and 3).
8Presence of oedema                           with the stoma in the middle, but
8Blister formation                            slightly off-centre, thereby exposing     Retracted stoma
8Areas of denuded skin                        skin only in one place.                   A retracted stoma is where the stoma
8In severe cases, there may be                                                          has shrunk into a skin fold or dip in
  necrosis                                    An alkaline urinary pH of                 the abdomen (Figure 4). Patients with
8The patient may describe a burning           7–8 can lead to                           a retracted stoma will usually report
  sensation at the site                       complications with the                    frequent leaks, as the output is not
8Itching.                                                                               flowing into the stoma appliance but
                                              peristomal skin and stoma,
                                                                                        leaking underneath the base plate
Diagnosing the cause                          such as stomal bleeding,                  onto their skin. This will cause the
Your history-taking and physical              ulceration, urinary tract                 skin quickly to become excoriated,
assessment should have given you clues        infections, odour and urinary             leading to further leaks. Retraction
as to the underlying cause of the skin        calculi (Fillingham and                   can be caused by: technical difficulties
excoriation. Faecal or urine excoriation      Douglas, 1997).                           at the time of operation in mobilising
will be caused by the following reasons:                                                the bowel to reach the abdominal
8Remodelling of stoma                         Poorly-sited stoma                        surface; failure to site the patient pre-
8Poorly-sited stoma                           All patients having elective surgery      operatively so that the surgeon has to
8Poorly-shaped stoma                          that may result in a stoma should         guess the most appropriate position of
8Retracted stoma.                             be seen pre-operatively by the            the stoma; or, weight gain.
                                              stoma care nurse for pre-operative
Remodelling of stoma                          education, and to mark the most           Appliance left on for too long
Most newly-formed stomas are                  appropriate site for the stoma.           There may be various reasons why
oedematous immediately after surgery.         Ideally, the patient’s belt line should   a patient leaves their appliance on
Over the first six to eight weeks this        be avoided, the stoma should be           for too long. Some patients try
oedema will reduce and the stoma will         located within the abdominal rectus       to use fewer bags to reduce the
remodel itself. It is important that a new    muscle, all creases, skin folds (Figure   need for further prescriptions and
stoma is measured at least weekly in          1), previous scars should be avoided,     charges, while others may think
the first two months. This ensures that       and the patient should be able to see     that it only needs to be changed
the appliance aperture is cut to the          the stoma when in various positions,      when it begins to leak. Of more
correct size for the stoma. It is ideal to    such as sitting and standing. However,    concern are the people that find
see 2–3mm of skin around the stoma.           in emergency situations, pre-operative    their stoma so abhorrent that they
This provides the skin with maximum           siting is not always possible and         try to ignore it, rather than face
protection from the corrosive fluid,          the surgeon is often faced with the       changing the appliance. These issues
but is not too tight for the stoma to         dilemma of where to place the stoma.      must be explored. Patients that are
be damaged by a tight-fitting appliance.      An abdomen may look flat with no          finding it difficult to come to terms
After eight weeks the stoma has usually       skin creases when the patient is on       with their stoma will need support
stopped remodelling and pre-cut               the operating table, but will change      and reassurance. Counselling from a
appliances can be ordered.                    dramatically when sitting or standing.    trained professional may be required.

 38    Wounds   UK,    2006,Vol 2, No 3

                                                                                                    skin in a matter of days. However, if the
                                                                                                    stoma is poorly-sited, poorly-shaped or
                                                                                                    retracted, these measures alone will not
                                                                                                    stop the excoriation deteriorating or
                                                                                                    help it to heal. The underlying cause of
                                                                                                    this excoriation being the fact that the
                                                                                                    stoma is poorly-sited, poorly-shaped
                                                                                                    or retracted and the stoma effluent is
                                                                                                    tracking underneath the appliance causing
                                                                                                    the leakage, which then excoriates the
                                                                                                    skin (Figure 5). In these instances, the
                                                                                                    patient will need assessment from a
                                                                                                    trained stoma care nurse.

                                                                                                         With modern developments of
                                                                                                    stoma products, situations like these
                                                                                                    can be managed conservatively without
Figure 1. Poorly-sited stoma in skin folds.                                                         the need for further surgery to re-site
                                                                                                    the stoma. Accessories, such as paste
                                                                                                    and seals, can be used to build up
                                                                                                    creases to enable the appliance to stick
                                                                                                    to a flat surface. Convex appliances
                                                                                                    raise the profile of the stoma, or the
                                                                                                    end pointing downwards, by applying
                                                                                                    a little pressure around the peristomal
                                                                                                    skin and forcing the stoma out into the
                                                                                                    appliance. This encourages effluent to
                                                                                                    fall out into the appliance rather than
                                                                                                    tracking underneath the appliance onto
                                                                                                    the skin. A belt can be attached to
                                                                                                    the appliance to apply further gentle
                                                                                                    pressure to raise the profile of the
                                                                                                    stoma and hold the appliance in place.
                                                                                                    In extreme cases, paste, seals, a convex
                                                                                                    appliance and a belt may all be needed
Figure 2. Excoriated skin around the circumference of the stoma.                                    to manage the situation conservatively
                                                                                                    and prevent skin excoriation. If it comes
High output stoma                                       aperture of the appliance is cut to the     to this level of intervention, it may be
The normal output for an ileostomy                      correct size. If the stoma is not round     more appropriate for the stoma to
can range from anywhere between                         then a template of the stoma shape          be surgically re-fashioned or re-sited,
500–1000mls in twenty-four hours.                       must be made so that the patient has        although this does not guarantee a
Anything over 1000mls is considered to                  the correct shape of the stoma to cut       trouble-free stoma.
be a high output. The corrosive nature                  the aperture to. It may be beneficial
of ileostomy effluent will damage the                   to use a protective barrier such as             If the underlying cause of the
skin and erode the stoma appliance                      Cavilon™ No Sting Barrier Film (3M          excoriation is weight gain on the part
quicker. Patients may have to change                    Health Care, Loughborough) (Schuren         of the patient, and their stoma is now
their appliance more frequently as the                  et al, 2005). On application to the skin,   retracted, it may be helpful to advise
appliance will start to erode if left on                Cavilon™ film forms a waterproof            the patient to lose weight. If the stoma
for long periods.                                       barrier that will act as a protective       has sunk because of the skin folds, it
                                                        membrane between the skin and faecal        may be necessary to use a convex
Treatment of excoriated skin                            and urinary effluent. The patient should    appliance.
All excoriated skin should be treated                   be advised to change the appliance
in the same way. Patients should be                     every two days until the excoriation            All patients with a high output
advised to cleanse the area with warm                   clears up.                                  stoma should be given a barrier
tap water and dry thoroughly. All                                                                   protection agent, such as Cavilon™
stomas should be re-measured using                         If the diagnosis is that the patient     No Sting Barrier Film, as a prophylactic
a measuring guide (usually found in                     has been incorrectly measuring the          to avoid skin excoriation, rather than
the appliance box) to ensure that the                   stoma, then this treatment will heal the    treating it after it has occurred.

  40     Wounds      UK,   2006,Vol 2, No 3

                                                                                                      Poor change technique
                                                                                                      Patients should always be observed
                                                                                                      changing their appliance to assess
                                                                                                      their technique (Myers, 1996). Patients
                                                                                                      may strip their appliance off their
                                                                                                      abdomen as quickly as possible without
                                                                                                      supporting the skin. Vigorous rubbing
                                                                                                      of the skin when cleaning to ensure
                                                                                                      that all traces of effluent are removed,
                                                                                                      can also lead to damage. Some patients
                                                                                                      may have difficulty in lining up the
                                                                                                      aperture with the stoma, and may be
                                                                                                      placing it off-centre, thereby exposing
                                                                                                      the skin to effluent on one side.

                                                                                                      Treatment of trauma
                                                                                                      There are many different
Figure 3. Stoma with excoriation tracking along skin crease.
                                                                                                      recommendations as to the frequency
                                                                                                      of appliance changes. Drainable, one-
                                                                                                      piece appliances or the base plates of
                                                                                                      two-piece appliances can be changed
                                                                                                      anywhere from every day to every
                                                                                                      four days. The average wear time is
                                                                                                      two to four days (Allen, 1998). If the
                                                                                                      peristomal skin is in excellent condition,
                                                                                                      the patient can decide what is the
                                                                                                      best routine for them. As long as their
                                                                                                      skin stays in perfect condition, this is
                                                                                                      acceptable. However, if they leave their
                                                                                                      appliance on for several days and their
                                                                                                      skin begins to deteriorate, they must
                                                                                                      change their appliance more frequently.
                                                                                                      For colostomists, it is suggested that
                                                                                                      they should change their one-piece
Figure 4. Retracted stoma in skin folds.                                                              closed appliance as necessary (Black,
                                                                                                      2000), which may be once or twice
                                                         Physical irritation                          daily, depending on their output.
                                                         Physical irritation specifically refers
                                                         to trauma caused to the skin by                  A careful assessment must be taken
                                                         factors such as rubbing, pressure, the       to understand why the appliance is
                                                         patient’s appliance change technique,        being frequently changed. It may simply
                                                         or radiotherapy. Causes of physical          be that the appliance is inappropriate
                                                         irritation include:                          for the stoma effluent, and changing to
                                                         8Frequent appliance changes                  a more appropriate one would solve
                                                         8Poor change technique                       this problem. On questioning, some
                                                         8Treatment of trauma                         patients will report feeling dirty with
                                                         8Radiotherapy and chemotherapy.              faeces sitting in the appliance on their
                                                                                                      abdomen and they only feel clean
                                                         Frequent appliance changes                   when they change the appliance. In
                                                         When an appliance is changed too             these cases, patients require support
                                                         frequently, the outer skin cells that        and advice. Explain to the patient
                                                         provide the skin protection are constantly   the damage that frequent appliance
Figure 5. Excoriation around the stoma. Note the         being stripped off. The skin will have       changes, or over-vigorous removal or
ulcers directly under the stoma, and to the left and     a similar appearance to excoriation          cleaning and drying does to their skin
right, caused by over-frequent appliance, removal        caused by effluent leaking onto the skin.    by repeatedly removing its protective
and over-vigorous cleaning to the area. The stoma is     It will appear excoriated which may be       layers. Patients should be encouraged
also flush with the skin, potentially causing effluent     weeping or bleeding, and areas of skin       to gently remove their appliance using
leakage to the skin.                                     may be denuded or ulcerated.                 one hand to pull the appliance, while

  42     Wounds     UK
                    UK,   2006,Vol 2, No 3

the other suppor ts the skin. The                occurs two to three weeks after            adhere to the skin, they should be
patient should demonstrate placing               commencing therapy.                        advised to use an electric razor rather
the new appliance in place. Two-piece           8Moist desquamation — skin blisters         than a wet razor while receiving
appliances, where the base plate can             and sloughs off exposing the dermis.       radiotherapy. Perfumed products should
be left in place for several days, and           Raw skin may be apparent and               not be used in the treatment area. Loose
the patient can change the bag as                bleeding may occur. Exudate may be         clothing, preferably made from natural
needed, will allow the skin to repair            serous, white, yellow or green.            fibres, should be worn to prevent friction
itself in-between base plate changes.           8Necrosis — this rarely occurs              over the area. Any exudate should be
Patients who experience difficulty                (Faithful, 2001).                          blotted dry with sterile gauze. Moist
lining the aper ture with the stoma may                                                     desquamation should not be routinely
find a mirror useful, or a two-piece                 Occasionally, patients can develop      cleaned unless there is evidence of
appliance where they can line the               stomatitis when receiving some              infection. Trauma of repeated cleansing
aperture and the stoma up and then              chemotherapy agents. These include 5-       will increase desquamation and damage
clip the bag in place.                          flurouracil, methotrexate, doxorubicin,     granulating tissue.
                                                bleomycin and mitomycin C. The stoma
Radiotherapy and chemotherapy                   can become oedematous and inflamed.         Allergy
Skin problems related to radiotherapy           This will not cause the patient any pain,   It is important to mention allergy
and chemotherapy are relatively                 as the stoma has no nerves. Patients        (Figure 6), as most patients will report
uncommon. Often the most common                 should be advised that they might need      that their excoriated skin is due to an
side-effect after chemotherapy and              to adjust the aperture of their appliance   allergy to their appliance. A true allergy
radiotherapy is diarrhoea, which can            to fit the oedematous stoma correctly       to a stoma appliance is rare and only
lead to appliance leakage problems              (Porrett and McGrath, 2005).                accounts for 0.6% of stoma-related
and excoriated skin. When patients                                                          skin problems (Lyon and Beck, 2001).
are experiencing diarrhoea during the                                                       Suspected skin allergy from stoma
course of their treatment, drainable
                                                 If the patient has skin                    products can be broken down into two
appliances or a two-piece system                creases, it is important to                 categories; namely, an allergy to:
(where the base plate can be left in            pull them apart to look                     8The appliance
place for several days, but the bag             for excoriation. If there is                8Accessory products.
changed as needed) should be used               excoriation in the creases,
while the diarrhoea persists.                   it is likely that faeces or                 Assessment
                                                                                            Signs and symptoms of skin allergy
    The severity of skin reactions after
                                                urine are tracking along                    include:
radiotherapy will depend on the total           these creases causing the                   8Erythema
dose of radiation, the size of the area         problem.                                    8Margins are indistinct and blurred and
being treated, and the condition of the                                                         may spread beyond the area of the
skin before commencing radiotherapy.                                                            appliance
Skin breakdown is most likely to occur          Prevention and treatment                    8Blister formation
in moist areas, skin folds, such as the         Any patients undergoing radiotherapy        8Papules and vesicles are often seen
groin, or in areas of recent surgery,           should seek advice about skin care          8Lesions may become painfully eroded
such as the perineal region after an            from the centre providing their                 and crusted
abdominal resection (McGrath and                treatment. Different centres will           8Itching.
Fulham, 2004).                                  have varying recommendations
                                                for prevention of damage. Patients               When examining the skin, it is
    Skin damage following radiotherapy          should be advised to wash the skin          important to look at the distribution of
can be classified as:                            within the treatment area with a mild       the excoriation on the skin surrounding
8Erythema — skin becomes pink,                  soap. Moisturising creams should be         the stoma. This will often give the
   dry and itchy, may have a rash-like          applied, although alcohol, petroleum,       best clue as to the cause of the
   appearance or spots, and feels hot           lanolin (Korinko and Yurick, 1997),         dermatitis. The skin must be in contact
   and appears similar to sunburn. It           and metallic-based creams, such as          with the appliance to develop an
   occurs two to three weeks after              zinc (Lyon and Smith, 2001), should         allergic reaction to a stoma appliance.
   commencing radiotherapy and                  be avoided. Moisturising cream will         If the patient has skin creases, it is
   resolves two to three weeks after            hydrate the skin. To help soothe            important to pull them apart to look
   stopping therapy.                            the erythema the moisturiser may            for excoriation. If there is excoriation
8Dry desquamation — characterised               be placed in the fridge before use.         in the creases, it is likely that faeces
   by dry, flaky, superficial skin loss which   Creams should not be applied within         or urine are tracking along these
   is often itchy. It is often the precursor    two hours prior to treatment. If            creases causing the problem. If the skin
   of moist desquamation, especially            patients need to shave their abdomen        crease shows no signs of excoriation,
   if onset is early in treatment. It           to enable the stoma appliance to            an allergy may be the cause of the

 44    Wounds    UK,   2006,Vol 2, No 3

                                                                                        of stoma and skin care. In some cases,
                                                                                        patients may need to be referred to a
                                                                                        trained stoma care nurse for specialist
                                                                                        advice and treatment regarding stoma
                                                                                        appliances. WUK

                                                                                        This article is taken from ‘Skin Care
                                                                                        in Wound Management: Assessment,
                                                                                        prevention and treatment’, published
                                                                                        by Wounds UK, Aberdeen. For further
                                                                                        information, please go online to:

                                                                                             Key Points

Figure 6. Allergy to stoma appliance.                                                    8 Approximately 100,000 people
                                                                                           in the United Kingdom are living
excoriation. While patients can develop      test can be tried. Usage testing
                                                                                           with a stoma (Lee, 2001).
an allergy to stoma appliances, it is        involves the patient placing the same
more common to develop an allergy            appliance and any accessories they
                                                                                         8 Any area of skin that has
to a stoma accessory, such as a              may be using on the opposite side of
                                                                                           become excoriated, is weeping
fragranced stoma bag deodoriser. In          their abdomen to their stoma. These
                                                                                           or bleeding, can cause the
several European studies, fragrances         will be left on for several days to
                                                                                           stoma appliance to leak.
have been demonstrated to be                 see if any rash develops. This test will
second only to nickel as a cause of          only demonstrate that the patient
                                                                                         8 Dermatitis from stoma effluent
allergic contact dermatitis (Lyon and        is sensitive to some component
                                                                                           repeatedly leaking onto the
Beck, 2001). It is essential to watch        of their stoma products. Fur ther
                                                                                           skin is the single most common
the patient do a complete appliance          investigations may be required.
                                                                                           cause of peristomal skin
change. The patient may be using
                                                                                           complications (Lyon and Beck,
potentially irritant substances, such as         Patients requiring patch or prick
a deodoriser, perfumed cleansers, or         testing should be referred to a
medicated wipes.                             specialist dermatology department
                                                                                         8 Patients that are finding it
                                             with experience in performing this
                                                                                           difficult to come to terms with
Treatment                                    test (Lyon and Beck, 2001). An allergy
                                                                                           their stoma will need support
Patients should be advised to wash           to a stoma appliance or accessory can
                                                                                           and reassurance.
their skin with lukewarm tap water.          be confirmed with a positive patch
Perfumed products should be avoided          test. Appliance manufacturers are
                                                                                         8 All excoriated skin should
and the use of barrier preparations          often willing to give information about
                                                                                           be treated in the same way.
should only be used if advised by a          compounds used in their products
                                                                                           Patients should be advised to
clinician who has experience in the          so that the source of the allergy can
                                                                                           cleanse the area with warm
field of stoma and skin care. Any            be identified and avoided in future
                                                                                           tap water and dry thoroughly.
accessories the patient is using should      product usage (Lawson, 2003).
be stopped immediately.
                                                                                         8 Often the most common
                                                                                           side-effect after chemotherapy
    If an allergy to an appliance is         Skin problems are common among
                                                                                           and radiotherapy is diarrhoea,
diagnosed, the patient should change         patients with a stoma. Patients may
                                                                                           which can lead to appliance
the type of appliance to one with a          develop a skin problem for a variety
                                                                                           leakage problems and
different adhesive, flange or wafer.         of reasons, many of which are
                                                                                           excoriated skin.
True allergic dermatitis will resolve        beyond their control. Careful and
when the patient is no longer                thorough history-taking will often
                                                                                         8 Suspected skin allergy
exposed to the allergen (Lyon and            give clues as to the cause of the
                                                                                           from stoma products can
Beck, 2001). The application of a            problem. Combine this with a careful,
                                                                                           be broken down into two
topical steroid to the allergy may           physical examination and a correct
                                                                                           categories; namely, an allergy
hasten its resolution.                       diagnosis can usually be made. Simple
                                                                                           to: the appliance or accessory
                                             measures to treat skin excoriation
Testing for allergy                          can be commenced by healthcare
If an allergy is suspected, a usage          professionals with a basic knowledge

 46      Wounds     UK,   2006,Vol 2, No 3
                                                                                                        Clinical PRACTICE DEVELOPMENT

                                                  Korinko A, Yurick A (1997) Maintaining            Myers C (1996) Stoma Care Nursing: A
References                                        skin integrity during radiotherapy. Am J          patient-centred approach. Arnold, London
Allen S (1998) Ileostomy. Prof Nurse 14(2):       Nurs 97: 40–4
                                                                                                    Nicholls RJ (1996) Surgical Procedures. In:
107–12                                            Lawson A (2003) Complications of                  Myers C, ed. Stoma Care Nursing: A patient-
Arumugan PJ, Bevan L, MacDonald L,                Stomas. In: Elcoat C, ed. Stoma Care              centred approach. Arnold, London
Watkins AJ, Morgan AR, Beynon J, Carr             Nursing. Hollister, London
                                                                                                    Schuren J, Becker A, Sibbald RG (2005) A
ND (2003) A prospective audit of stomas,          Lee J (2001) Common stoma problems:               liquid film-forming acrylate for peri-wound
analysis of risk factors and complications and    a brief guide for community nurses. Br J          protection: a systematic review and meta-
their management. Colorectal Dis 5(1): 49–52      Community Nurs 6(8): 407–13                       analysis (3M™ Cavilon™ No Sting Barrier
Black P (2000) Holistic Stoma Care. Baillière                                                       Film). Int Wound J 2(3): 230–8
                                                  Lyon CC, Smith AJ, Griffiths CEM, Beck
Tindall, China                                    MH (2000) The spectrum of skin disorders          Shellito P (1998) Complications of
Blackley P (1998) Practical Stoma Wound           in abdominal stoma patients. Br J Dermatol        abdominal stoma surgery. Dis Colon Rectum
and Continence Management. Research               143(6): 1248–60                                   41(12): 1562–72
Publications Pty Ltd, Australia                   Lyon CC, Beck MH (2001) Irritant                  Smith AJ, Lyon CC, Hart CA (2002)
Borwell B (1996) Managing stoma problems.         reactions and allergy. In: Lyon CC,               Multidisciplinary care of skin problems in
Professional Nurse Wallchart. MacMillan           Smith AJ, ed. Abdominal Stomas and their          stoma patients. Br J Nurs 11(5): 324–30
Magazines                                         Skin Disorders: An atlas of diagnosis and
                                                  management. Martin Dunitz Ltd, London             Stevens P, James P (2003) Anatomy and
Collett K (2002) Practical aspects of stoma                                                         physiology associated with stoma care. In:
management. Nurs Standard 17(8): 45–52            Lyon CC, Smith A (2001) Abdominal Stomas          Elcoat C, ed. Stoma Care Nursing. Hollister,
                                                  and their Skin Disorders: An atlas of diagnosis   London
Faithful S (2001) Radiotherapy. In: J Corner,     and management. Martin Dunitz Ltd, London
C Bailey, eds. Cancer Nursing: Care in context.                                                     Walsh BA (1992) Urostomy and urinary pH.
Blackwell Science, Oxford: 222–61                 McGrath A, Fulham J (2005)
                                                                                                    In: Fillingham S, Douglas J, eds. Urological
                                                  Understanding chemotherapy and
Fillingham S, Douglas J (1997) Urological                                                           Nursing. 2nd edn. Baillière Tindall, London
                                                  radiotherapy for the individual with a
Nursing. 2nd edn. Baillière Tindall, London       stoma. In: Porrett T, McGarth A, eds.             Porrett T, McGrath A (2005) Stoma Care.
Hall C, Myers C, Phillips RKS (1995) The          Stoma Care. Blackwell Publishing, Oxford          Blackwell Publishing, Oxford
554 ileostomy. Br J Surg 82: 1385
                                                  McKenzie FD, Ingram VA (2001) Dansac              Vujnovich A (2004) Peristomal faecal/urine
IMS Health Incorporated Group (2004) New          invent convexity in the management of             dermatitis and allergy. Gastrointestinal Nurs
Patient Audit. IMS Hospital Group, London         flush ileostomy. Br J Nurs 10(15): 1005–9         2(5): 25–31

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