Stoma Dermatitis: Prevalent but Often Overlooked

Clinical Importance

The high incidence of peristomal skin disorders eventually affects the patient's quality of life and recovery from surgery and can even result in a higher cost of care due to misuse of medical resources. The most significant problem that occurs with peristomal skin irritations is that the loss of skin integrity affects the adhesion of ostomy equipment.^[4] Constant irritation prevents proper sealing of the ostomy pouching system, which inevitably leads to leakage of stoma effluent. The continuation of the fluid leakage and the skin erosion cycle can lead to poor adaptation to the ostomy equipment and even infection. In addition to causing general pain and discomfort, stoma dermatoses can have psychosocial effects on the patient as repeated leaks and persistent odor can lower the ostomy patient's self-esteem, cause embarrassment, or even lead to social isolation or depression.^[2] These complications also increase the cost of care and the usage of valuable materials because the patient's constant discomfort will lead to more frequent changes of ostomy equipment in an effort to create a better seal.^[27]

In addition, a few studies found that many patients did not even realize they were living with a peristomal skin condition. Of 202 patients who were given questionnaires and clinical examinations in a study conducted in 2006 by Herlufsen and colleagues, 45% were diagnosed with a peristomal skin disorder by dermatologists.^[28] Only 38% of those patients diagnosed with the disorder had indicated on the questionnaire that they had a peristomal skin issue. Furthermore, this study classified skin issues as mild, moderate, or severe, based on the extent of skin involvement. Of the patients who were diagnosed with a mild skin condition, 67% did not indicate having any skin irritation on the questionnaire; 41% of patients diagnosed with a moderate skin condition and 56% of patients diagnosed with a severe skin condition also failed to recognize any dermatologic complications. Without proper knowledge or regular examinations, many patients do not even realize they are living with a peristomal dermatitis, placing them at risk for infection and an increased potential for leakage issues.

Likewise, a case-control study conducted by Nybaek and colleagues in 2009 observed that of 199 ostomy patients, 90 (44.8%) were found to have peristomal skin complications.^[3] Only 43% of the patients who were diagnosed with a skin complication had noticed it before coming to the clinic, and only 16% had sought medical attention for the complication in the past. The authors concluded that patients seem to have a high threshold for identifying the presence of skin irritations, and their constant peristomal skin problems may become normal to them. Due to a lack of medical education, ostomy patients often come to terms with the appearance and texture of their postoperative peristomal skin and thus dismiss the possibility of a true medical complication.

Cite this: Stoma Dermatitis: Prevalent but Often Overlooked - Medscape - Jun 01, 2010.

Table 1. Differential Diagnosis of Stoma Dermatitis
Disease	Distinguishing Features
Irritant dermatitis	Often chemical etiologies (feces, urine), erythema, eroded skin, pain
Mechanical dermatitis	Erythema in area of pressure; abraded skin
Allergic contact dermatitis	Rash only in area of exposure; erythema; pruritus; eroded skin; positive patch-test results
Chronic papillomatous dermatitis	Due to chronic exposure; papillomatous skin lesions; coalescent papules; may be HPV related; histology may show pseudoepitheliomatous hyperplasia
Seborrheic dermatitis	Scaling eczematous rash that can affect many areas like scalp, eyebrows, stomal opening
Psoriasis	Well-defined erythematous plaques typical; psoriasis may be present at other sites (preexisting condition)

HPV = human papillomavirus.

Table 2. Review of Allergic Contact Dermatitis Cases
Age (yr)	Sex	Type of Stoma	Positive Patch-Test Results	Reference
70	Female	Urostomy	Fragranced stoma bag deodorizer	^[5]
41	Female	Urostomy	Epoxy resin; urostomy pouch (Bristol Meyers Squibb)	^[11]
77	Female	Urostomy	Epoxy resin; ileostomy pouch (Bristol Meyers Squibb)	^[12]
47	Female	Ileostomy	Epoxy resin	^[14]
40	Female	Colostomy	Karaya seal ring	^[16]
57	Male	Colostomy	2-Benzotriazol (Tinuvin P)	^[17]
74	Male	Colostomy	Diaminodiphenylmethane 0.5%; rubber seal ring of stoma bag (Colodress, ConvaTec)	^[18]
48	Female	Colectomy Ileostomy	Polyisobutylene (adhesive ring of ostomy bag)	^[19]
48	Female	Colostomy	Balsam of Peru 25%, cinnamic aldehyde 2%, geraniol 5%, benzyl alcohol 5%, isoeugenol 4%, Gantrez ES-225 5%, Stomahesive paste (Bristol Meyers Squibb)	^[20]
14	Female	Colectomy	Gantrez ES, Stomahesive paste (ConvaTec), balsam of Peru, propylene glycol	^[21]
76	Male	Colectomy	Stomahesive paste (ConvaTec), rosin	^[22]
63	Female	Colectomy Ileostomy	Dansac soft paste, Stomahesive paste (ConvaTec), Gantrez ES	^[23]
69	Male	Colostomy	DOR ostomy deodorant, balsam of Peru	^[24]
58	Female	Colostomy	Adhesive remover wipe (ConvaCare, ConvaTec)	^[25]
57	Female	Urostomy	Nickel sulfate 5%, adhesive remover wipe (ConvaCare, ConvaTec), d-limonene	^[25]
58	Male	Urostomy	Braum Monodose ointment, tetracaine, cinchocaine, lavender oil absolute 2%	^[26]

Table 3. Potential Allergens to Consider for Patch Testing
Patch Testing for Stoma Allergy	Specific Allergens
Standard tray	Caines
Plastic, glues series	Epoxy resins, including bisphenol A
Cosmetics	Karaya powder
Fragrances	Diaminodiphenylmethane
	Polyisobutylene
	Balsam of Peru
	Ostomy equipment, including ostomy bag and rubber sealing ring
	Ostomy equipment accessories: deodorant, adhesives, adhesive cleansers
	2-Benzotriazol (Tinuvin P)
	BHT
	Gantrez
	Colophony