Stoma care

Published on 18/03/2015 by admin

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Last modified 22/04/2025

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Stoma care

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

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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.

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 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.image

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.

Specific investigations

First-line therapies

image Change appliance D
image Absorbent powders D
image Antibiotics D
image Topical corticosteroids B

Second-line therapies

image Sucralfate C
image Tacrolimus ointment or pimecrolimus cream E
image Intralesional corticosteroids E

Third-line therapies

image Topical cromolyn sodium E
image Oral dapsone E
image Cyclosporine D
image Tumor necrosis factor-blocking drugs E
image Collagen injections E
image Lipectomy E
image Stoma revision surgery E

Synchronous panniculectomy with stomal revision for obese patients with stomal stenosis and retraction.

Katkoori D, Samavedi S, Kava B, Soloway MS, Manoharan M. BJU Int 2009; 105: 1586–9.

Suction lipectomy or surgical paniculectomy can correct leakage problems particularly in morbidly obese patient with retracted stomas and without the need for laparotomy.

Table 225.1

Peristomal skin disorders according to primary source

Source of skin problems Examples Effects on skin
Appliance (pouch) Chronic occlusion (common)
Potential allergens or irritants (very rare) in appliances such as adhesives and tackifiers		 Damage to skin barrier function resulting in dermatitis
Accessories: (1) pastes (fillers); (2) wet cleansing wipes; (3) deodorizing sprays; (4) skin barrier wipes/lotions; (5) adhesive removers Irritant contact dermatitis (ICD) ICD, e.g. alcohol in pastes and wipes, karaya (powder and pastes)
Allergic contact dermatitis (ACD) ACD, especially fragrances or preservatives
Stoma effluent where there are leaks Urine, especially if infection is present Irritant reactions including dermatitis, granulomas, and chronic papillomatous dermatitis
Stool, particularly where the constituency is more liquid or volume produced is high. More proximal stomas will produce larger volume with greater enzymic content. Measures to thicken the stool should be considered including diet advice and antimotility drugs, e.g., loperamide.
Stoma Type: loop stomas are associated with more skin complications. As above
Structural integrity: short, buried or prolapsed stomas are more prone to leaks
Skin Genetic problems (rare), e.g., ichthyotic or bullous disorders Any inflammatory or scaly skin disease may impair bag adhesion and cause leaks that precipitate irritant reactions that in turn can worsen the primary skin problem
Common, acquired disorders such as eczema or psoriasis can present atypically under occlusion. Rarer disorders may be more frequent than expected because of the population affected, e.g., pemphigoid in older patients with colostomies and pyoderma gangrenosum in young adults with ileostomies for inflammatory bowel disease
Infections Dermatophyte, Candida and viral infections present typically. Bacterial infections may mimic or secondarily affect common disorders such as eczema Eroded dermatitis, folliculitis, and occasionally ulceration

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