Even with diligent ostomy care, we may encounter problems with our stomas or peristomal skin from time to time. Learning about these problems ahead of time can help you recognize a problem early on and cultivate habits that help prevent these problems from happening. Here we will discuss some of the most common ostomy-related skin issues and what you can do about them. If you are having trouble with your skin it is always a good idea to consult with your physician or with a certified wound care professional such as a Wound, Ostomy, and Continence Nurse (WOCN).
Most of the wound care issues that occur with ostomates are related to the peristomal skin. Your peristomal skin is the skin directly around your stoma that is covered by your appliance (the blue area feature in this photo). (pic source- personal)
I have had to deal with issues from a fungal infection, mucocutaneous separation, and an adhesive allergy. But do not fear! With proper preventative care and the knowledge that you will have about these issues, you can address many of these problems yourself.
Some signs and symptoms of more serious problems are listed below. If you experience any of the following symptoms you should consult with a WOCN or other medical professional to rule out more serious complications.
Contact your doctor if you experience any of the following:
- Fever in the postoperative period or fever with a peristomal wound
- Significant pain or swelling of the peristomal skin with or without the presence of a wound
- Foul-smelling drainage from peristomal skin or wounds (including surgical incisions and drain sites)
- Separation of the stoma from the peristomal skin that extends around the entire stoma
- A stoma that looks dark or “dusky” as this could be a sign of inadequate blood flow
- Bleeding from your ostomy (not the stoma tissue) as this could indicate a gastrointestinal bleed that would require immediate medical intervention
- Pain at the stoma site
Peristomal skin issues
Dermatitis
Dermatitis is a fancy word for skin irritation. Peristomal skin irritation can be caused by output coming in contact with the skin, mechanical trauma, or contact with a product or pouching system that causes an allergic reaction. Below you will find descriptions of each type of dermatitis and what you can do to treat these problems and prevent them in the future.
Irritant dermatitis
What is it?
Irritant dermatitis is caused by exposure of the peristomal skin to output such as urine or stool.
What does it look like?
Areas can start out pink and become red and weepy if there is significant skin damage. If left untreated the skin can be painful and even bleed.
How do I treat it?
REMEMBER: always change your pouch if you think there may be a leak starting. If your skin is pink or red but there are no open, weeping areas, the most important treatment is preventing further exposure of output on that area of the peristomal skin. If the skin is open and weeping you can use the crusting method to help the skin heal. See below to find out how to use the crusting technique.
Tips for prevention:
Issues with pouching and the leakage of output onto the skin are the most common cause of irritant dermatitis. It is essential to ensure that your appliance fits well and you are getting a good seal to treat this problem. Change your appliance on a regular basis to ensure that the wafer maintains its integrity.
Mechanical dermatitis
What is it?
Mechanical dermatitis is caused by removing the appliance too forcefully or scrubbing the peristomal skin too aggressively. It can also be caused by forceful hair removal in the peristomal area.
What does it look like?
Mechanical irritation can look similar to irritant dermatitis, causing areas of pink or red skin. If multiple skin layers were removed there can be wet, weeping areas.
How do I treat it?
If the skin is open and weeping you can use the crusting method to help the skin heal.
Tips for prevention:
The adhesive on your appliance is built to endure sweat, showers, and vigorous activity. Be gentle when removing your appliance. ALWAYS use an adhesive remover wipe or spray to loosen the adhesive first.
Allergic/contact dermatitis
What is it?
You can have an allergic reaction to any product used in your ostomy care including pouching systems, wipes, paste or barrier rings, or even the soap you use to cleanse the skin.
What does it look like?
One of the most important signs of an allergic reaction is pruritus or itching. When I had an allergic reaction to my appliance the skin was constantly itchy, no matter what I did. The pattern of irritation will give clues as to what may be causing it. If you have an area of redness that is in the exact shape of the wafer, you might consider whether the wafer is the source of the irritation. An allergic reaction can be mild to severe, and continued use of the offending product may lead to skin blistering and breakdown.
How do I treat it?
Discontinuing the use of the product that you are allergic to is the only way to prevent the irritation from continuing. Some allergic reactions are severe enough that your WOCN may want to prescribe a steroid spray for you to use. If you have skin breakdown, use the crusting method to help heal your skin.
Tips for prevention:
I developed an allergic reaction to my appliance nine months into using the product! There is no way to prevent developing an allergy to a product, but it is helpful to keep your ostomy routine as simple as possible to be able to quickly narrow down which products are causing irritation should you have a reaction.
Folliculitis
What is it?
Folliculitis is irritation of the hair follicles that lie under the wafer of your appliance. It can be caused by mechanical irritation or infection. People who shave the peristomal skin are more at risk of developing folliculitis.
What does it look like?
You will see small red bumps where the hair grows out from the skin under your wafer.
How do I treat it?
You can dust powder over any open area of the skin to help it heal. If you have hair around your stoma you should clip it short to avoid irritation of the follicle when removing your appliance. Avoid shaving, if possible, as this causes tiny cuts in the surface of the skin and may lead to further irritation. Be sure to follow the tips for prevention below.
Tips for prevention:
Always use an adhesive remover product when taking off your pouch. Since folliculitis can be caused by forceful pouch removal; try using the “push-pull” method to remove your appliance. Remove your pouch by pushing down on the skin and pulling gently on the pouching system.
Fungal infection
What is it?
Peristomal fungal infection occurs when there is skin damage and a warm, moist environment that causes an overgrowth of fungus that naturally can be found on our skin. People who live in warm, moist climates are more susceptible to fungal infections and it can also be more likely if you are immunocompromised or have recently taken antibiotics.
What does it look like?
Fungal infections cause the pink or red skin irritation found in many peristomal issues, but there are “satellite lesions” or pink/red dots
that can be seen around the edges of the irritation.
How do I treat it?
You can use an antifungal powder such as miconazole or nystatin. Nystatin is only available as a prescription, but the active ingredient found in several over-the-counter antifungal powders is miconazole. You should always have skin issues evaluated by a wound or ostomy care specialist, but if you do not have those resources immediately available you can consider trying an over-the-counter product. The crusting method can be used to apply antifungal powder.
Tips for prevention:
The most important way to prevent fungal infection is to make sure that the peristomal skin is completely dry before you put on your appliance. I notice that I need to change my wafer a little more frequently in the summertime because I live in a hot and humid climate. You can tell if your appliance is becoming oversaturated with moisture if the appliance turns white and soft.
Stoma related wound issues
Stoma bleeding
What is it?
A stoma with a good blood supply should appear beefy red. A little bleeding from the stoma when it is wiped or rubs against something is normal. If you are experiencing significant bleeding from your intestine, not the stoma itself, contact your doctor or seek emergency care immediately.
What does it look like?
You may see small areas of bleeding from your stoma from time to time. As long as it is a small amount of blood that stops bleeding after a minute or two on its own you should not be concerned.
How do I treat it?
As mentioned above, a small amount of bleeding is normal but call your surgeon or seek emergency medical care for a cut on your stoma or stomal bleeding that does not stop after a few minutes.
Tips for prevention:
Be gentle when wiping your stoma. Be sure to smooth out the rough edges if your wafer is cut-to-fit, as these edges can injure your stoma while putting on your appliance. Be aware of clothing that is tight or rubs on your stoma, as you may not detect bleeding immediately due to the lack of sensation in your stoma.
Granuloma
What is it?
Granulomas are a reaction of your skin to irritating material, such as sutures. This causes an overgrowth of tissue.
What does it look like?
Granulomas are red, moist, bumps that are found at the border where your stoma meets your skin. They look similar to the tissue of your stoma.
How do I treat it?
If the granuloma is painful or causing issues with pouch adhesion, it may be necessary to treat the lesion. Your surgeon or a wound and ostomy nurse can use silver nitrate to remove the extra tissue. Several treatments may be needed to remove the lesion. If the granuloma is not painful or causing pouching issues it may resolve spontaneously over time. After a failed attempt to remove a granuloma I had after surgery I decided to just give it time and it healed on its own.
Tips for prevention:
There is no real prevention for granulomas. The most important thing is to make sure that it is not affecting the adhesion of your appliance and causing leaks.
Mucocutaneous separation
What is it?
Mucocutaneous separation occurs when the stoma separates from the surrounding skin. This can be partial or circumferential. It normally appears in this first post-operative month.
What does it look like?
You will see the skin split away from the base of your stoma where it is sutured to the skin.
How do I treat it?
Partial separation can be filled with an absorptive material such as stoma powder or calcium alginate. This should be covered with a protective barrier or barrier ring to help prevent output from getting into the wound and promote healing. If you experience a circumferential or complete separation of the stoma from the surrounding skin resulting in retraction of the stoma, you should contact your surgeon immediately.
Tips for prevention:
Early post-operative issues with mucocutaneous separation are often the result of issues with attaching the bowel to the skin during surgery. It can also be caused by the weakening of skin as a result of steroid use, malnutrition, or infection. Staying healthy overall and keeping your peristomal skin healthy is the best prevention.
Other ostomy-related skin issues
Pyoderma Gangrenosum
What is it?
Pyoderma is a skin condition that primarily occurs in patients with inflammatory bowel disease (IBD) like ulcerative colitis or Crohn’s.
What does it look like?
Typically it starts as a red area on the peristomal skin that becomes ulcerated and painful.
How do I treat it?
Treatment of pyoderma gangrenosum requires the involvement of your healthcare team. You should contact your surgeon immediately if you experience an ulcerated wound on the peristomal skin that does not respond to conservative techniques like crusting.
Tips for prevention:
There is nothing you can do to prevent pyoderma, but it is important to be aware that you may be at higher risk for one of these lesions if you have IBD.
These are some of the issues that you may encounter as an ostomate. Hopefully, this article will help you anticipate and manage the wound care issues that may occur. Always reach out to your medical team if you have questions about ostomy-related wounds and their treatment.
TIP: How to get a good fit on your appliance
Try remeasuring your stoma and ensuring that the wafer is cut so that there is very little to no visible skin between the appliance and your stoma (aim to see no more than ⅛ inch of skin).
If you use a flat wafer you may want to consider convexity. My stoma sticks out at least a half-inch and I still get better wear time and virtually no leaks by using a convex wafer.
If you have creases or skin folds that make pouching challenging, try using a barrier ring/strip and/or paste to fill in uneven areas and create a more even surface for pouching.
Alcohol-free products will reduce the drying and irritation of your peristomal skin and keep it healthier. Some products are specially formulated with the same protective lipids in your skin such as ceramide. These can also reduce the drying and irritation of the skin by ostomy appliances.
TIP: Coloplast Brava protective barrier sheets
This product is a great tool to know how to use for skin breakdown. When the skin damage from my allergic reaction to an appliance was at its worst, I used protective sheets to heal my skin.
TIP: The crusting method
Many of the problems that occur with peristomal skin damage can be fixed by using the crusting method to allow the skin to heal. Here is how to use the crusting method to absorb the moisture from weeping wounds, ensure good appliance adhesion, and allow the skin to heal:
Crusting method:
- Make sure your peristomal skin is clean and dry.
- Sprinkle powder on your peristomal skin and brush off or shake your belly a little to remove the excess powder. You can use a soft brush to help remove the excess powder but you should wash this brush between applications to prevent infection.
- Use a barrier wipe or a light layer of barrier spray over the powder to seal it to the skin. You can let this air dry or use a hairdryer on low to dry the area.
- You can repeat this process two to three times but the more powder you apply, the more of a chance that it will compromise the seal of your appliance. Remember- powder is NOT adhesive. It may take several times trying the crusting method before you feel confident with the technique.
