Published on 18/03/2015 by admin
Filed under Dermatology
Last modified 18/03/2015
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Calum C. Lyon
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Stomas are artificial openings created to maintain proper drainage from internal structures. The most common are colostomies, ileostomies, and urostomies (ileal conduits), formed as either a temporary or a permanent measure. They are ideally produced electively, having been correctly sited by a stoma nurse specialist, but may be created under emergency conditions. Even with the best of preventative measures dermatologic problems will occur in over 50% of patients at some time. These are mostly irritant reactions to body fluids, particularly in the higher-output stomas (ileostomy and urostomy), but a range of common skin disorders, infections, or any dermatosis exacerbated by trauma or irritation may also be seen.
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 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 sizeable hypergranulating polyps and acanthomas can occur where there are leaks. Urostomy dermatitis may also be erosive because of the high output and ileal mucus production, predisposing to leaks. 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 anti-inflammatory 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. Flurandrenolide tape, an occlusive corticosteroid therapy, is particularly useful 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 anti-inflammatories 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 nonspecific dermatitis under occlusion, and pre-existing rashes can become secondarily infected. Treatment involves careful hygiene and the use of specific antimicrobials.
Pre-existing skin that particularly affect stomas are psoriasis, seborrheic dermatitis, cutaneous Crohn disease, pyoderma gangrenosum, lichen sclerosus, and eczema.
Skin biopsy
Wound culture
Patch testing and usage test
Lyon CC, Smith AJ, Griffiths CEM, Beck MH. Br J Dermatol 2000; 143: 1248–60.
This large cohort study documented the many different types of skin disorder that can occur around a stoma. Initial evaluations for patients presenting with inflammation include a bacterial swab, because infections are relatively common and easy to treat. Allergic contact hypersensitivity should be suspected in any patient with persistent disease that is unresponsive to treatment. A biopsy should be performed for any peristomal skin disorder with ulceration or a papular component.
A comprehensive review discussing the various different pathologies that can occur with a stoma, and how to evaluate them.
Persson E, Berndtsson I, Carlsson E, Hallén AM, Lindholm E. Colorectal Dis 2010; 12: 971–6.
Arumugam PJ, Bevan L, Macdonald L, Watkins AJ, Morgan AR, Beynon J, et al. Colorectal Dis 2003; 5: 49–52.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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