Stoma care

Management Strategy

Although all irritant reactions share similar histological features, the clinical appearance depends on the type of stoma and the source of irritation. Ileostomies have a high output with a pH of nearly seven containing degradative enzymes and irritant bile acids, so severe dermatitis and erosions may be seen. Irritated colostomies generally have a milder dermatitis, often due to occlusion, but sizable hypergranulating polyps and acanthomas can occur where there are leaks or irritation from ill-fitting appliances. Urostomy dermatitis may also be erosive because of the high output and ileal mucus production, predisposing to leaks. The pH may be higher than that of healthy skin, especially in the presence of urea-splitting bacteria and this can rapidly worsen skin irritation. Chronic papillomatous dermatitis is a distinct eruption comprising aggregating hyperplastic papulonodules that usually affects leaking urostomies. It responds to appliance modifications and acidification of the urine.

Input from an expert stoma nurse is essential when managing irritant reactions. They can advise on the most appropriate appliance so that mechanical trauma to the skin or stoma and exposure of normal skin to effluent can be avoided. Patients anxious to avoid leaks, smells, etc., sometimes wear bags too tightly or change them excessively, frequently resulting in skin damage and irritation. The stoma nurse specialist is trained to identify and resolve such issues.

It is appropriate to treat symptomatic irritant inflammation with antiinflammatory preparations such as topical corticosteroids , tacrolimus, or pimecrolimus . The choice of vehicle is very important, as oily creams, etc., will prevent proper adhesion and cause leaks. Products useful on peristomal skin include a range of foams, lotions, and gels formulated for scalp, ear, or eye disorders, and corticosteroid asthma inhalers. Fludroxycortide tape , an occlusive corticosteroid therapy, can be particularly useful for smaller affected areas because the stoma device can be applied over the tape. Leaks and inflammation are sometimes inevitable despite appliance changes. It may be necessary to use topical antiinflammatories intermittently, with care taken to avoid steroid atrophy. Hypergranulation can be treated with silver nitrate, cryotherapy, or cautery ± shave or curettage.

Allergic contact dermatitis is rare, as ostomy manufacturers strive to minimize allergens in their products. When it occurs, it is mostly due to perfumed deodorizers and excipients in topical products (e.g., biocides in wet wipes). Usage tests are particularly helpful in identifying the offending product, even if patch testing fails to identify the precise allergen. Treatment is as for irritant reactions.

Skin infection is not uncommon in the moist and warm environment under a stoma bag, especially folliculitis in those who shave their abdomens. All rashes should be swabbed for culture and sensitivity, because bacterial infection can present as a non-specific dermatitis under occlusion, and preexisting rashes can become secondarily infected. Treatment involves careful hygiene and the use of specific antimicrobials.

Preexisting skin diseases that particularly affect stomas are psoriasis, seborrheic dermatitis, cutaneous Crohn disease, pyoderma gangrenosum, lichen sclerosus, and eczema.