The skin is a multifunctional organ. One of its main functions is to act as a barrier to protect the body from the outside world. If this barrier is breached the body is at risk of infection, while the surrounding skin is at risk of damage. Because stomas are a breach of the skin designed to remain open, the surrounding skin requires scrupulous care to maintain its health. However, the wide range of stoma care products available can make it difficult to select the appropriate ones and to maintain an effective care regimen.
VOL: 100, ISSUE: 19, PAGE NO: 34
Liz Brewster, RGN, DN, is stoma care clinical nurse specialist, Morecambe Bay Primary Care Trust.
- This article has been double-blind peer-reviewed
- Download a print-friendly PDF file of this article here
Risks to peristomal skin
The skin has its own defence against interference in the form of resident flora and natural acidity, while the keratinocytes found in the stratum corneum pack tightly together and form a physical barrier. However, peristomal skin is at risk both from contact with gastrointestinal content and from external interference from irritants such as surgical adhesives and alcohol-based adhesive removers. These points should be borne in mind when choosing a suitable pouch for a newly formed stoma:
- Is the patient allergic to any form of adhesive? Perform a patch test if in doubt;
- Is the stoma situated in a ‘dip’? Consider a convex appliance if so;
- Does the appliance need changing more than two to three times daily? If so consider a drainable appliance;
- If extra tape is required to ensure adhesion, a belt may be more appropriate;
- On removal, is a residue of adhesion left on the skin?
- Does the appliance suit the patient’s lifestyle? For example is it closed, drainable, one-piece or two-piece?
To remain healthy the skin should maintain an average pH of 5.5 (Bryant, 2000). This means peristomal skin is at risk from body fluids which, combined with bacteria and enzymatic activity will cause the skin to become irritated and lead to breakdown. Small bowel content is particularly aggressive and can excoriate the skin. This can cause pain and infection, which may progress to extensive erosion of deeper layers. Although colonic stomas have a less aggressive effluent, spillage can still lead to excoriation. It is therefore vital to select a suitable and well-fitting appliance and to use appropriate products correctly to avoid causing damage to the skin (Figs 1-3).
Skin defences will quickly become impaired in a moist alkaline environment (Cameron and Powell, 1996), and as faeces and urine are alkaline in nature, it is important to prevent spillage onto peristomal skin. Prolonged contamination can be catastrophic. The enzyme activity in bowel effluent will quickly ‘digest’ peristomal skin, leading to complete stripping of the epidermis and ultimately skin loss. It then becomes extremely difficult to maintain any sort of adhesion. Excessive or forceful cleaning with alkaline soaps can also damage vulnerable skin, so the peristomal area should be cleansed gently, preferably with warm water at each appliance change. A mild baby soap is acceptable if adhesive residue is a problem but the suitability of the appliance must be assessed.
Epidermal stripping caused by excessive use of adhesive tapes reduces the protective barrier of the skin (Bryant, 2000) and ‘window frame’ excoriation may be caused by adhesive tapes applied around stoma pouches (Fig 4). If extra adhesive is required, the suitability of the pouch should be questioned. Shaving the peristomal area should also be kept to a minimum to reduce the risk of folliculitis.
Routine skincare should be as simple and uncomplicated as possible. Ordinary, warm tap water is generally sufficient. This should be made clear to the patient, preferably while she or he is still in hospital. Non-sterile tissues or medical wipes are best. Cotton wool should be avoided as it tends to shred and leave fibres on the skin. Swabs, sterile or otherwise, are not necessary. Any further agents such as barrier creams or films for maintaining healthy skin should be assessed individually (Elcoat, 1986).
The skin should be blotted dry using tissues or a soft cloth kept particularly for that purpose.
Selecting skincare products
There is often a temptation to use skin preparations in the routine care of peristomal skin (Matado, 1993). However, this is generally unnecessary if the skin is healthy. There must be a clinical need and proper assessment is vital in deciding when they are required and which to use:
- If the skin is too dry, which can occur in older people, a very thin application of a barrier cream may be useful;
- If the skin looks red and does not return to normal after a few seconds on removing the appliance, consider a skin film. Reassess after a couple of weeks as films can be drying to the skin;
- If there is a breakdown of mucocutaneous margins, a hydrocolloid compound in the form of a powder (Orahesive-Convatec) will adhere to moist areas;
- Leakages due to ‘channelling’ under the appliances may benefit from the application of a paste preparation (Stomahesive Convatec) or (Strip paste - Coloplast). A paste such as Stomahesive is best applied with a syringe and to a specific area. Once it dries it becomes brittle and is difficult to remove;
- Adhesive removers are useful if adhesive residue clings to hair in the peristomal area and for removing paste residue.
The skin retains moisture and anything which dries it out leaves it at risk and contraindicates the aims of moist wound healing (Winter, 1962). However, while the peristomal area should remain healthily lubricated, it must not be allowed to become macerated.
Hydrocolloid adhesives will absorb low levels of secretion and their action is not based on a reaction with the skin. Instead they adhere due to body heat and will generally maintain healthy peristomal skin (Machado, 1992). Most are made from a combination of gelatine, pectin, carboxymethylcellulose and polyisobutylene. It is this combination, which varies slightly among products, that allows body heat to stimulate the hydrocolloid to adhere. Absorption and adhesion may be impaired if there is any barrier between the hydrocolloid and the skin, such as alcohol in skin wipes or lanolin in barrier creams.
However, patients often have difficulty in removing a hydrocolloid appliance after soaking in a hot bath. They should be advised to bathe with the appliance removed, providing output is controlled. With an unpredictable or very loose output that necessitates leaving the appliance in situ, it is better to remove the appliance while the skin is still moist. The skin must be thoroughly dry before the new appliance is reapplied.
Emollients and creams
Emollients and barrier creams can be beneficial if the skin becomes dehydrated but must be chosen carefully, particularly as some contain lanolin, an allergen for some. All should be used sparingly and the surplus wiped away.
Water-based cream is both protective and hydrating but should also be used sparingly. None of these barriers should alter the pH of the skin.
Skin films can have a drying effect and should be used only when there is a clear clinical need. Some of these products contain alcohol and should not be used on excoriated or broken skin. The film’s content should be checked before application.
Adhesive removers are often prescribed for use if an adhesive pouch leaves a residue. These can be abrasive and drying to the skin, removing its natural secretions. If a pouch leaves sufficient adhesive to warrant the use of remover, the suitability of the pouch should be questioned. Adhesive removers can sometimes be useful, for example after a hot bath or if the patient holidays somewhere with a significantly different climate.
Pastes, powders and fillers
The many available pastes, powders and fillers have a variety of uses. While extremely effective in the care of fistulas, their use in stoma care is questionable. Stomas are kept open while the purpose of fistula care is to effect healing. The advent of convex appliances has reduced the need for ‘filling’ creases and clips.
Skin problems caused by an ill-fitting appliance are easily recognised and can be treated readily by improving the fit of the pouch. It is not acceptable to treat damaged skin without first removing the cause of the damage. Too often, hydrocortisone and antifungal creams are prescribed when what is required is a minor alteration to the fit of the pouch to make it leak-proof.
Fungal infections are easily recognised (Lyon and Smith, 2001). They generally overlay excoriated skin, look shiny and are intensely irritating. A compound topical preparation in the form of cream, lotion or spray should be applied topically each time the appliance is changed. Ideally the preparation should be allowed to be absorbed for a few minutes before the surplus is removed.
While there is a place for skin protection products in peristomal skincare, their use should be in response to clinical need after nursing assessment. They should not be regarded as a long-term solution to a problem and must never be used to facilitate the use of ill-fitting or inappropriate pouches.