Skin Problems in Stoma Patients - Causes and Management

Introduction:

Infections or underlying inflammatory disorders may cause the skin around the stoma to be associated with certain skin conditions. This can further complicate the already existing issue for the patient. There are a number of complications a patient may face due to different causes. Prompt recognition and treatment will help improve the quality of living of the already compromised individual. But before the complications can be discussed, one has to understand what a stoma is.

What Is Stoma?

A stoma is a surgical opening a doctor makes in the abdomen if a patient cannot have a natural bowel movement. The surgeon will attach the end of the colon to the stoma; bowel movements will exit the body through the stoma and are collected in a pouch that has to be emptied. The conditions requiring a stoma are:

• Cancer.

• Crohn’s disease.

• Birth defects.

• Injury to the colon.

• A bowel blockage or tear.

• Pouches in the colon are called diverticulitis.

What Are the Problems a Stoma Patients Encounter?

A patient with a stoma may face local problems and subsequent systemic disorders, such as:

• Inadequate blood supply (ischemia).

• Infection- this site can become a site for infection by pathogens.

• Fistula- an undesired passage between the bowel and the skin.

• Prolapse of the bowel out into the skin.

• Leaking of the bowel into the skin causes irritation and erosion.

• The most common complication related to stoma is skin problems.

What Are Skin Problems Related to Stoma?

• Irritant dermatitis.

• Infectious dermatitis.

• Folliculitis (the inflammation of hair follicles).

• Allergic reactions.

• Pyoderma gangrenosum (a rare skin condition associated with painful ulcers).

• Infections: the skin around the stoma may be damp and prone to infections.

• Fungal.

• Bacterial.

• Viral.

1. Skin Infection: Microorganisms may multiply in the skin around the stoma as the area is warm, humid, and prone to infections. The skin infection is more likely if the patient is generally immuno-compromised.

• Bacterial Infections Include:

• Secondary infection in the surgical site.

• Impetigo.

• Bacterial folliculitis or boils.

• Cellulitis.

It is confirmed by swabs.

• Viral Infections Include:

• Viral warts.

• Molluscum contagiosum.

• Herpes simplex.

• Fungal Infections Include:

• Candidiasis or thrush.

• Dermatophyte infection.

• Malassezia.

It is confirmed by skin scrapings.

2. Inflammatory Skin Disease: If the stoma is leaking or because of an underlying skin condition, the skin around the stoma may become inflamed papules, or ulceration may form. Papules due to viral warts, cancer, and Crohn’s disease; ulceration may arise due to trauma. Periodic pouch changes can lead to mechanical trauma. The skin may develop rashes around the stoma.

• Irritant Contact Dermatitis: Irritant dermatitis may develop due to mechanical trauma due to ill-fitting appliances. This might cause mechanical stripping due to frequent friction leading to epidermal damage. Common causes include:

• Frequent contact of skin to bowel content or urine.

• The skin was stripped by the removal of the appliance.

• Certain cleaners or bleaches.

• Constant friction from the appliance.

• Humidity.

• Pre-existing skin conditions such as eczema.

Irritant contact dermatitis may appear as red papules (small bumps) or plaques (patches) and scaling. It is usually sore and itchy. It might affect the entire area or appear as a crescent shape below the appliance.

• Allergic Contact Dermatitis: The appearance of allergic dermatitis is similar to that of contact dermatitis; its occurrence is, however, less common. But allergic dermatitis will affect the entire area in contact with the appliance and even spread to wider areas.

Allergies may be caused due to the material of the appliance or the pouch, such as acrylic resin, fragrance, parabens, or cleansing agents and deodorizers. Patch tests must be done to identify the allergens and avoid them.

3. Psoriasis: It occurs in patients who either are already suffering from psoriasis or have a genetic predisposition to it. The mechanical stripping of skin while removal of the pouch may trigger psoriasis. It presents as sharply defined plaques or patches of scaly red skin. That extends beyond the stoma. It is frequently associated with inflammatory bowel disease.

4. Pyoderma Gangrenosum: It presents as painful ulcers. The ulcers may be bluish, undermined, and with ill-defined edges. The skin surrounding the ulcer may be red and swollen. It may be caused by mechanical trauma due to the pouch, and patients with inflammatory bowel disease may have a predisposition to it.

5. Seborrhoeic Dermatitis: It is similar to dermatitis in appearance to irritant dermatitis or psoriasis. It presents as scaling and rashes.

6. Folliculitis: Hair follicles may cause irritation and, thereby, inflammation. It may resemble candidiasis and presents as a red pus-filled area.

7. Granulomas: Lump-like lesions in the skin are called granulomas. It may occur near the stoma due to

• Poor healing.

• Infection.

• Stomal skin morphs into bowel tissue.

• Crohn’s disease.

8. Color Changes: The skin color around the stoma may change due to inflammation.

• Red or Pink- Due to the formation of new blood vessels.

• Brown Color- Due to inflammatory pigmentation, it may fade eventually.

• Other Colors- This may be due to urinary deposits.

How to Treat Skin Conditions?

• Infections: Proper cleaning with antiseptic can prevent infection. Antibiotics may be required to treat severe infections.

• Dermatitis:

1. Improving the fit of the appliance.

2. Hydrocolloid dressing under the pouch.

3. Antiperspirant to avoid moisture from sweat.

4. Topical steroids.

• Sucralfate: This may be used on erosions.

• Psoriasis: Treatment of psoriasis includes steroids.

• Topical: Tacrolimus

• Systemic: Ciclosporin, Minocycline, Dapsone.

• Folliculitis: Antibacterial powder may help reduce incidence.

How Topical Steroids Can Help Improve the Conditions?

Topical steroids: Used under the bag to treat and prevent inflammatory conditions such as dermatitis, psoriasis, and pyoderma gangrenosum. It should be applied once daily for three to four weeks.

How to Prevent Skin Problems In Stoma Patients?

• The patient must be made aware of the potential skin problems, and adequate care should be taken to prevent them from arising.

• Keep the area clean and dry.

• Use a skin seal or barrier; this prevents moisture.

• Periodically changing the pouch.

Conclusion:

Stoma patients are individuals with pre-existing systemic disorders. The patients often require pouches for the collection and removal of bowel waste as a result of the treatment for their systemic conditions. For this reason, prevention of local and systemic complications that may arise due to the stoma bag is important in improving their quality of life.

Skin problems due to stomas can be significantly reduced or prevented by educating them about the potential complications of the same. Proper cleaning, prevention of mechanical trauma, and use of topical steroids can be used to prevent and treat the conditions.