Home Books Fitzpatrick's Dermatology in General Medicine, 8e

Chapter 97. Skin Problems in Ostomates

Calum C. Lyon; Michael H. Beck

Skin Problems in Stoma Patients at a Glance

Peristomal skin is chronically occluded and subject to pressure, shearing forces, and fecal/urine soiling. Some skin problems are therefore inevitable.
Two-thirds of ostomates develop dermatological problems. Irritant reactions, common skin diseases, and infections are the most common.
The occlusion under a stoma appliance can result in unusual clinical appearances of common dermatoses. All rashes should be swabbed to exclude primary or secondary infection.
Allergic contact dermatitis is relatively uncommon. Nonetheless patients should be advised to minimize exposure to potential allergens especially fragrances and preservatives.
Some dermatoses are commoner than expected around stomas, particularly psoriasis, pyoderma gangrenosum, and lichen sclerosus.
Liaison with stoma nurses (ET therapists) and surgeons is essential to provide an effective service for patients with peristomal dermatoses.

A stoma is a surgically created opening onto the skin of part of the gastrointestinal or urinary tract in order to drain the effluent from that viscus. The most frequently performed stomas are ileostomies, colostomies, and ileal conduits (urostomies or urinary diversion). The commonest indications for stoma surgery are inflammatory bowel disease, malignancy and neurological problems. A patient with a stoma is usually termed an “ostomist” or “ostomate.”

Epidemiology

There are estimated to be more than 1.4 million ostomates in the United States and 100,000 in the United Kingdom and Ireland. Some stomas are temporary, with surgical anastomosis delayed, pending resolution of the acute disorder. Temporary stomas are often “loop stomas” where a loop of bowel is brought to the skin surface and part of the wall removed to allow preferential drainage into a stoma pouch in order to relieve a distal problem, for example, perianal ulceration. Such stomas are more frequently associated with skin problems secondary to leaks.1 Many stomas formed for malignant indications can be seen as palliative procedures.

A stoma appliance is essentially a device for collecting stoma effluent with a high degree of comfort and security until it can be disposed of. There continues to be promising advances in the design of stoma bags. Essentially, the device is a pouch or bag held in place over the stoma by an adhesive skin barrier made solely or partly from hydrocolloid. Many ileostomists and urostomists use two-piece appliances where the barrier remains on the skin for 2–4 days and is detachable; disposable bags are changed as necessary. Appliances with convexity on the surface next to the skin are available for patients with short or buried stomas (Fig. 97-1). Useful recent innovations include softer convex appliance that apply less pressure on the skin and collars or sleeves that fit snugly around the stoma before applying the bag thereby reducing the chance of leaks of effluent or intestinal mucus under the barrier.