Skin Issues

 

Articles Included:

·        Does Your Stoma Hurt?

·        Frequently Asked Questions

·        Basics of Good Skin Care

·        Product Complacency

·        Adhesions and Other Pains

·        Stoma Bumps

·        Fungal Rashes

·        Skin Care

·        More Skin Care

·        Skin—The Forgotten Organ

·        Skin Protectors

·        Perianal Wound

·        Allergic Reactions

·        Skin Sealants

·        Push the Skin

·        Stomal Prolapse

·        Wonders of Milk of Magnesia

·        Skin Care Basics

·        Reasons for Skin Breakdown

 

Does Your Stoma Hurt?

By Victor Alterescu, ET 

 

     Quite often people tell me their stoma hurt.  This surprises me a great deal since stomas don’t have any sensation.  You could cut, burn, do virtually anything to the stoma and you would not feel a thing.  That’s hard to believe but true.  Stomas do not have receptors for pain.

     Sometimes the lack of stoma sensation can lead to problems.  For example, an incorrectly fitting ostomy system may cut into the stoma, but no pain will be felt.  A stoma can be badly damaged before the problem is noticed.  For this reason, it is important not to wear your barrier for more than a week.  It is necessary to see the peristomal skin and see if the stoma is in good condition.

     Actually, when people talk about stoma pain, they are usually talking about pain from the skin or tissue from around the stoma.  Peristomal skin is full of nerve receptors that are sensitive to such things as heat, cold, chemicals and adhesives that can cause significant pain.  It is the skin or surrounding tissue that is sensing the pain and not the stoma itself.

     In addition, severe pain may be caused by a blockage either in the bowel or at the point where the intestine comes through the skin.  These are different types of nerves that will sense this effect.  Plus, the systems in the body are related and when one system is causing a problem another may cause a sensation to take place alerting us.  These types of systems should not be confused with the absence of felling in the stoma.

     If any unusual symptoms or irritations are noticed, contact your ET nurse for an evaluation.  He/she can offer advise and treatment for virtually any problem you have with your stoma.  Do not settle for mediocrity in ostomy management.

 

Frequently Asked Questions

By Secure Start, Hollister Incorporated

 

Q  How do I know if my stoma is healthy?

A  Each person’s stoma is unique.  The stoma is always red and moist, much like the mucus membrane in you mouth.  A stoma is not painful, as there are no nerve endings in it.  Minor, temporary bleeding of the stoma is normal if it is rubbed or hit.

 

Q  How often should I change my ostomy system?

A  You should expect predictable, sustained wear time from your pouching system.  This is related to the type of skin barrier used, the shape of the barrier—convex or flat—and a number of other factors; i.e., climate and your activity level. 

     Some people prefer to change their pouches daily, while others wear their pouching systems for up to seven days.  If you have trouble getting your skin barrier to stay in place, you may need to get help with fitting and product selection.  The best source of help is a certified wound ostomy continence nurse—an ET nurse.

 

Q  What is the skin barrier?

A  The skin barrier is the waxy part of your pouching system that sticks to your skin.  The skin barrier is primarily responsible for holding your pouch to your body.  Tape may be used as an additional support, but if the skin barrier doesn’t hold the tape alone won’t be enough.

 

Q  Is that the only purpose of the skin barrier?

A  Holding your pouch on is a pretty important, but the skin barrier also helps to protect your skin.  Without the skin barrier, your skin would be exposed to the harmful affects of the urine or stool.

 

Q  What size should my skin barrier be?

A  The opening in the skin barrier should be the same size as your stoma.  This is not something about which you want to guess.  Sizing guides are available free from Hollister Incorporated.  If you are not sure that you have the right size opening or you want to try a skin barrier that is already pre-cut, you need to measure.  Size does matter!

     An additional note:  Some skin barrier work best if they are cut 1/8^th  to 1/16^th of an inch larger that the stoma with the gap filled-in with paste.  Extended wear barriers—like the Flextend—may be sized to actually touch the stoma.  These barrier are especially designed for individuals with more liquid stool—like ileostomates and transverse colostomates—and for urostomates.  Urostomates should not use paste products to fill in gaps but should use convex barriers. 

 

Basics of Good Skin Care

By Barb Barrickman, RN/ET 

 

     Caring for the skin around the stoma is an important part of basic ostomy care.  Good skin care around the stoma is not very different from caring for the rest of your skin.  Healthy skin protects us from the environment; produces vitamin D; provides a tough, flexible foundation to hold the rest of our body; regulates body temperature; insulates the body from cold and trauma; and provides an avenue for sensation and grip.

     Normally the skin is acidic in pH, approximately 5.5.  This natural acidity discourages bacterial growth, helps to absorb moisture and keeps the cells closer together to prevent cracks in our protective layer.  

     As we age, our skin changes.  It becomes thinner, making it more susceptible to injury and changing the way our body reacts to temperature, pain, pressure and chemicals.  It becomes less flexible and often sags.  It heals half as quickly as before and becomes drier with visible cracks which harbor bacterial growth.

     Good skin care can delay many of these natural aging processes and aid in keeping the skin healthy. The basics of good skin care include:

Ø      Cleaning the skin with a good cleanser with a pH less than 4.5.  Normal skin can handle this well, with the skin regaining its normal acidic pH within 20-30 minutes.

Ø      Beware:  Frequent washing irritates skin.  Soap and a washcloth are the worst enemies of fragile and/or damaged skin.  Washing with just plain water and gentle friction is all that is needed. 

Ø      Washing peristomal skin with only water.  Usually the skin under a barrier is clean.  When you change, it only needs gentle rinsing with water and your hand to achieve satisfactory results.

Ø      Air drying is beneficial if time permits.

Ø      Appling moisturizer to your skin—except under pouching adhesives—after bathing to take advantage of open pores.  Look for moisturizers that contain one or more of the following ingredients: liquid paraffin, lanolin, caster oil, cetostearyl alcohols, glycereal stearate.

Ø      Checking the ingredients in your skin care products and know why they are there.  Active ingredients should be listed in descending order of percentages contained in the product.

Purposes of Ingredients and examples:

 

§         Emollients soothe and soften the skin, e.g.; almond oil, aloe vera, lanolin, dimethicone copolyl, mineral oil.

§         Antimicrobials eliminate microbes and reduce skin infections; kill normal skin flora as well as unwanted bacteria. The normal skin flora re-colonize one to two hours after the use of an antimicrobial. Examples: hexy1resorcinol, tricolsan, benzethonium chloride. Emulsifying surfactants sisolve human excreta, e.g.; polyaxamar 188, potassium palmitate, polysorbate.

§         Humectants prevent drying; soften and moisturize damaged skin by binding moisture to the skin, e.g.; d-panthenol, propylene glycol, sodium PCA, glycerin.

The peristomal. skin may need special protection from the adhesives on the pouching equipment and/or the output from the stoma.

     Barrier products are designed to protect the skin from contact with moisture and prevent friction. Skin films actually plasticize the skin by placing a co-polymer film on the skin.  Product examples that provide this barrier film include:

§         Bard Protective Barrier Film

§         ConvaTec AllKare Protective Barrier Wipes

§         Hollister Skin Protectant Barriers

§         Smith & Nephew/United Skin Prep

§         3M No Sting Skin Protectant

 

     These products may be helpful in preventing and/or treating skin breakdown problems in the peristomal skin area.  They should be used only as directed and after consulting with an ET nurse or ostomy supplier. 

     Barrier wipes are not designed to be used with the new extended wear barriers like ConvaTec’s Durahesive or Hollister’s Flextend.  These barriers gently melt onto the skin providing a tight seal.  Barrier wipes work to defeat this action in these products. 

     However, there are many products your ET nurse or dermatologist are able to introduce you to that may solve skin itching and irritation problems under the barrier.  Never settle for anything less than complete satisfaction from your ostomy system.

 

Product Complacency

By Linda Allen, RN/ET  

 

     If you have an established ostomy, i.e.; over one-year old, you might be a victim of the "complacency syndrome".  Complacency can be defined as a feeling of quiet security, often while unaware of some potential danger, defect or the like.

     Initially after surgery, it takes time to develop a security with management of your ostomy.  After a period of time, it normally becomes like a second nature.  We are creatures of habit and we sometimes accept a situation even if it's not as effective as it should be, because it is what we are accustomed.

     Here's a classic example:  About ten years ago, I worked with a young woman whose ileostomy stoma was about ten-years old.  Following her surgery, she was fitted with improper products, a one-piece closed-end pouch for an ileostomy stoma.  Editor’s note:  There are those of us in the Chapter that do use closed-end pouches to manage ileostomies successfully.  We use a two-piece system and when we’re ready to empty it, snap off the pouch, empty it, and then snap it back on ... life is good.   

     Since the pouch could not be emptied, she had to change it each time it became full ... six to ten times a day.  Just imagine, her entire life revolved around care of her stoma leaving little time for anything else.  She had adapted by purchasing special clothes; carrying special equipment in her purse; and setting up a special bed, one with a hole in the mattress!  This was done to allow her skin to breathe, since its tendency was to become irritated because of the frequency of pouch changes during the day.  

     Not surprisingly, she also spent a near fortune on purchasing ostomy products and the special accessory items she needed for her care, many hundreds a month.  She had adapted to this routine and did not think to question that there could be a better way.  

     Do you have a problem that you may not have realized?  After a period of time, stomas and the surrounding skin may change.  We may gain or lose weight or develop a hernia.  All of these factors affect the way a product works.

     Maybe it's time for a reality check.  Answer the following questions for yourself:

Ø      Is your current product secure or does it leak frequently?  Leaks should never be tolerated.

Ø      Are you satisfied with your length of wear time? Never less than one day or over seven.

Ø      Is it adequately protecting your skin?  The skin under your wafer should look like your skin on the other side of your abdomen. 

Ø      Does it fit snugly around your stoma?  There should be no redness, whiteness, rash or broken areas.

Ø      Is your ostomy system odor proof? If not, investigate why.  Most current pouches are made with odor-proof plastics and if used correctly will not let odor escape.

Ø      Is your ostomy system low profile and discreet? Gone are the days when big, bulky products were our only choice.  Choose a product that will not be visible under clothing.

Ø      Is it easy to apply?  

Ø      Is it time saving and simple to use?  Ostomy care should take no longer than 10 to 15 minutes and many times ... even less than that.

Ø      Can you easily afford your ostomy system? There are a wide variety of products designed for every budget.  The price of an ostomy change is around $3 to $15, depending on the system that most suits your needs.  The annual cost of supplies is directly related to the frequency of changes as well as the products themselves.  If cost is an issue, utilize your products carefully, look into low-cost alternatives and eliminate unnecessary items.

Ø      Are your products readily available?  If the products you want are hard to find, ask your retailer the best way to obtain them.  They want to serve you and meet your needs.

 

Adhesions and Other Pains

Forward By ReRoute, Evansville, IN Chapter

 

     Adhesions are tough, string-like fibrous bands, often in the small intestine.  They may form spontaneously but are more common after surgery, where disturbances caused by tissue manipulation may lead to healing in the form of fibrous tissue ...  hence adhesions.

     Some people form them more easily than others. Adhesions may grow to interfere with the normal motion of the intestine causing a blockage or obstruction with food, liquid or even air unable to pass the blocked area.  Severe bloating, abdominal pain, vomiting and constipation are symptoms of blockage and present a serious situation requiring medical attention and possible immediate surgery to cut the obstructive adhesive bands.

     Abdominal pain, though, doesn’t always mean adhesions are blocking the intestines.  A frequent cause for such pain is a spasm of muscles responsible for peristalsis—the rhythmic muscular contractions that propel the bolus through the intestines.  Muscle spasms in the calf are referred to as a “charley horse”; spasms in the intestines are essentially the same thing but assume the name “irritable intestine” or “irritable bowel”.

     Even ostomates who function without colons are not immune from painful intestinal spasms—in the small intestine. An ileostomate may sometimes suffer from pain that can’t be traced to blockage and may be told that adhesions are responsible; the actual cause may instead be a spasm.

 

Stoma Bumps

What Are They? - What To Do?

By Liz O'Connor RN, CETN

 

ET nurses are often asked about small bumps or ulcers which appear on a formerly smooth stoma.  They may be on the surface or around the edge where the stoma meets the skin.  They may occur in a single area or around the whole circumference.

 

Most of the time these are granulomas, which are of a benign nature.  Granulation tissue is a normal defense reaction of the body to injury.  Those at the edge may be due to a reaction to the suture being sewn though the stoma to the skin.  It may also be caused by a too rigid or too tight faceplate rubbing against the stoma.  A faceplate with a hard barrier must never touch the stoma.  

 

Those on the top or side of the stoma may be caused by an allergic reaction to the plastic or other material manufacturing the barrier.   This may be true even after using the same equipment for a long time.  They may also be caused from stomal drainage constantly pointing to one area of the stoma.  This may occur when the stoma opening points down.

 

What should you do?   Most of the time these are nothing to worry about.  Don't second-guess or self-diagnose yourself.  See your ET nurse, and if necessary your doctor.  Occasionally, these bumps may be a manifestation of another condition, like the recurrence of Crohn's disease.  Often, they can be treated with silver nitrate sticks.   These are available by prescription.  Occasionally,  they need to be biopsied, to eliminate the possibility of other conditions.  Quite often, a change in the barrier or faceplate will resolve the issue.

 

Fungal Rashes

By Lyn Kramer, RN,CETN

 

Fungal rashes are more prevalent in late spring and summer.  This rash is the same as the one you can get on your feet, groin, or in any dark moist skin fold.  This is the perfect place for this natural body organism to flourish.  It is called Candidiasis Albicans, athletes foot, or a yeast infection.          

People who have high blood sugars or eat higher quantities of sweets than normal, those with diabetes, or people who take prednisone type medications are more prone to this rash.  Persons with an ostomy who wear a plastic pouch on their side—like most do—are also more prone to this.  The plastic ostomy pouch plus the contents of the pouch increase the body heat and perspiration in this area during the warmer months. 

 

The old adage of, "An once of prevention is worth a pound of cure" comes to mind.  If you know you fit into the above-mentioned group of people with these indications, then take action before you get the rash.

 

Simple things for prevention are:

 

·              Make sure the barrier that sticks to your body is kept dry after showers and baths (showers are best).  You may use a hair dryer set to cool or dry this area very well with a towel.

 

·              Use a micro-granulated, anti-fungal powder around the intact barrier area as well as under the pouch area.  The area under the pouch may be applied daily.  There are many over-the-counter brands available.  The main or active ingredients to look for are miconazole nitrate 2% or zinc oxide.  These items are available in the foot care and body care areas of most stores or pharmacies.  These are not prescription items, and they are less expensive than Mycostatin powder that is often prescribed by a doctor for treating fungus.

 

·              Use a pouch cover between you and your pouch.  I have said this before many times, but I think it helps all year long.  Some newer style pouches have an extra layer of material on the back that is being called a pouch cover, but this is still made of plastic.  You need a cloth or a very good quality, thick and absorbent towel cut-to-fit under the pouch area.  You need to change the cover when it becomes moist or it can also grow the fungus.

 

·              If you do develop a rash, do not use a cream on your skin area that is under your barrier.  The barrier will stick to the cream and not your body, thereby falling off.  You only need to use the miconazole nitrate powder on the infected area.  If the manufacturer's instructions on your barrier allows it, you may seal the powder in with a skin seal; i.e. Skin Prep, AllKare, etc.  You may need to change your pouch more frequently until the rash clears.  It should clear in one or two changes.  

 

Skin Care
--Re-Route, Huntsville, Alabama

Soap and water do not hurt the stoma, so you can bathe and shower without your appliance just as you always have.  However, it’s a good idea to choose a soap that is residue free. Soaps containing moisturizers and oils such as cream soaps, liquid wipes and baby wipes leave a residue that can interfere with how well the skin barrier adheres to your skin.  It is not recommended that soap is used to actually clean around the stoma.  The skin is not dirty there, and gently rubbing the area with plain water on it will give the best results.  Soap will excessively dry the skin which may make it raw or itchy.

 

Remember: it’s important to avoid excessive adhesive buildup.  Adhesive removers can help you wash away adhesive residue easily, without traumatizing sensitive skin.  Rubbing the adhesive off may damage the delicate top layer of your skin.  It is best not to do this.  Also, only use removers when needed.

 

Skin irritations, including changes, rashes or breakdown of the skin around the stoma, may be caused by leakage from around the skin barrier or pouch, or by irritation from an improperly fitting pouching systems.  It is necessary for all of us to use good judgment evolving our ostomy management system when an adjustment seems prudent.

 

Skin infections can also be caused by a combination of events, such as moisture accumulation and buildup of normal fungi on the skin, leading to a yeast infection called candida albicans.  Cutting the wafer to the correct size, correctly applying your pouch, and carefully cleaning and drying the skin around the stoma with every pouch change are the best ways of preventing skin irritation.  If redness, swelling or a rash persists, call your healthcare professional.

 

More Skin Care

By Nita Matz, ET, Philadelphia Journal

 

Our skin is a vital organ and a major unit of the intergumentary system.  It has several different layers and many important functions.  It acts as a barrier between us and our environment—it is never static and undergoes frequent changes and adapts, often very quickly to our needs.  The skin is alive.

 

Made up of two layers—the epidermis and dermis (corium)—the skin functions in several ways as:

 

·              Covering the body

·              Protection of deeper tissues both from injury and germs

·              Regulator of body temperature

·              A preceptor of touch, pressure and temperature sensation.

 

Proper care of the peristomal skin of the ostomate is very important to both health and comfort.  As many of you are aware—even the most experienced—skin irritation can develop from time to time.  To keep peristomal skin in good condition is a daily goal and requires constant vigilance.

 

Care must be taken in the removal of adhesives and appliance seals to prevent trauma—injury—to the skin.  To aid in the removal, "walk" the adhesive off gently with one hand as you press against the body with the other using a moist cloth or gauze.  Push, don't pull, the barrier off your skin.

 

Cleanse the skin with a mild soap, if needed.  Make sure you rinse with much clear water and dry thoroughly.  Most people will find that even mild soap is too drying to the skin and should only use clear water to clean the peristomal skin.  If a solvent is used, make extra sure the skin is rinsed carefully and completely.

 

Caution must be used if the trimming peristomal hair is necessary.  Shaving is not recommended because of the possibility of accidental abrasion to the skin or stoma; that is, the razor may cut the skin.  Use blunt-tipped scissors or an electric razor.

 

Measure your stoma periodically to be sure your appliance is not leaving too much skin unprotected.  If you stoma is oval shaped or slightly irregular in shape, use a good skin barrier, one of the many pastes that are on the market to fill-in the unprotected area between the stoma and your barrier.  Barriers should be cut a little larger rather than a little smaller.  But, this leaves a gap between the barrier and the stoma.  Paste is used like a caulk to fill-in this space.  Remember, stomas change in size and the cut-out in the barrier may need to be adjusted accordingly.

 

If your skin begins to itch or burn beneath your appliance, change it as soon as feasible because it is probably leaking.  Skin irritation and breakdowns can result if these warnings are ignored.  Do not try to get that extra day wear time between appliance changes. 

 

There are many good skin care products on the market and you may wish to try some of them.  If you have allergies, try any new product on another area—other than the peristomal skin—to determine if your are sensitive to any of the ingredients.

 

A good skin care routine makes a difference in your physical and emotional well-being.  So, remember a few basic rules in caring for your stoma and peristomal skin:

 

·        Remove the barrier and tape carefully

·        Cleanse your skin thoroughly

·        Allow your skin to dry completely before applying a fresh barrier

·        Change your appliance regularly

 

Do not postpone an appliance change if you suspect any leakage, including symptoms such as itching or burning under the barrier.  A good saying for all ostomates when caring for their skin is, "An ounce of prevention is worth a pound of cure."

 

Skin—The Forgotten Organ

By  Myra Robbins

 

Which is the body's largest organ?  Most people will guess the liver or the lungs, but if you voted for the skin, you were right.  Seldom recognized as an organ at all, the skin has some interesting characteristics.  For an average adult, the skin's area measures approximately 20 sq. ft. and makes up 15% of the body's weight.

 

The skin receives 1/3 of the circulating blood, allowing nutrients to be delivered and wastes to be removed.  It regulates the body's temperature by perspiring to cool the body, and constricting the blood vessels to conserve the body's heat.

 

Although all functions of the skin are important, some are particularly significant to the ostomate:  Perspiration may become a problem in warmer climates where excessive moisture may affect appliance wear.  The skin's ability to maintain a barrier against threatening elements, such as germs, and to repair itself when damaged, plays a vital role for the ostomate.

 

As a barrier, the skin provides a protective acidic mantle often mentioned in soap and shampoo commercials.  The pH range of this mantle is between 4.0 and 5.6.  Cleaning the peristomal skin only with water will help prevent disturbing this range.

 

Skin flora consists of micro-organisms such as yeast and bacteria.  There is a delicate balance that is often disturbed by immuno-suppressive agents, i.e. steroids, disease states and antibiotics.  Often ostomates get introduced to a yeast infection shortly after their surgery, since antibiotics are routinely used in such settings.

 

Urostomates experience a rather common problem when urine is allowed to stay on the skin and changes its pH from acid to alkaline.  In babies this causes diaper rash.

 

Some simple remedies are available to restore the pH balance and to reduce the effects of exposure to moisture.  Half strength vinegar applied with each appliance change will help restore the skin, but does not address the cause of the problem, which is usually an improperly fitting appliance.

 

Liquid barrier solutions are available in many forms, the most common being the wipe or square which resembles an alcohol wipe.  Most appliances have a solid inner barrier of material that is often used in wound care to help heal broken skin.  Where the liquid barrier works best is at the outer tape edges where moisture penetrates and accumulates to cause problems.  Caution:  Barrier wipes are not recommended on the new extended wear barriers, e.g. ConvaTec Durahesive or Hollister Flextend.  These barriers are made to be used without barrier wipes, and sealants may affect their adhesion.

 

If a yeast or monila infection is present around the stoma, see your ET nurse, doctor or pharmacist for some micro-granulated anti-fungal powder usually available without prescription.

 

Skin Protectors

--Corpus Christi Ostomy News

 

Skin protectors are products designed to protect the skin around the stoma from damage resulting from appliance leakage, or pulling off barriers and tapes too aggressively.

 

A thin film of these products can be thought of as an artificial layer of skin.  It should be noted that these products do not—they do not—make appliances stick better; they do not heal irritated skin; nor do they replace a skin barrier.  Examples of skin protectors include Kin Prep by United; Skin Gel by Hollister; All-Care Wipes by ConvaTec; protective Film Barrier by Bard.  They all contain alcohol and may cause sensitive reactions in some individuals.

 

If powders, such as Micostatin—a micro granulated anti-fungal—Stomahesive or Karaya are used for treatment of irritated skin, the affected area is first cleansed.  The powder is then lightly sprinkled on the area leaving no heavy residue.  Then, It is covered—sealed in—with the skin protector.  Finally the appliance is put in place.

 

Protectors are available in wipes, sprays and dabbers.  If porous paper is used to hold the appliance in place, spraying skin protector on the tape will make it waterproof and more durable when showering frequently or when swimming. 

 

Skin protectors are not recommended on any of the newer extended wear barriers.  These barriers work best when allowed to "melt" onto the skin.  Skin protectors frustrate this effort resulting in less than satisfactory performance.

 

The Perineal Wound

--Orange Oasis

 

I you had your rectum and anus removed as part of your ostomy surgery, you have what is called a perineal wound, a gap in you perineum.  This wound is often neglected in the care and management of patients with colostomies and ileostomies, since most of the attention is devoted to the stoma.

 

As a result, many ostomates are not prepared to deal with the perineal wound.  Doctors and ET nurses tend to explain the ostomy and the need to remove the rectum, but rarely mention the "hole" left after the rectum and anus have been removed, and what to do with it and how to take care of it.

 

The perineal wound is bounded by the pelvic bones.  It is different from other wounds which just simply grow together—often after having been stitched, since it is important that the wound heal from the inside out and thus be filled with tissue.  Healing may take considerably longer than normal.  The healing time may range from a month to a year.

 

While you are waiting for the wound to heal, it may be more comfortable to sit on a soft cushion.  But, do not use a donut cushion.  It has the tendency to pull the skin outward, putting more strain on the area, causing pain and slowing down the healing process.

 

Sitting in a warm bath can be both soothing and helpful.  It may ease the discomfort and at the same time stimulate the blood circulation in the area.

 

Ostomates may experience a need to evacuate the rectum, even though it has been removed.  Some ostomates experience such urge while irrigating.  Such phantom sensations are the result of nerves that have enervated the rectum; were responsible for rectal continence.  They continue to function even after removal of the rectum.

 

Usually this pain is really just an awareness of the need to go to the toilet.  Your body remembers this from all the years you used your rectum.  It may never completely go away.  But, often changing positions, distracting yourself with other activities, or even sitting on the toilet for a short period of time will allow the feeling to quickly pass.  Remember:  Without a rectum or anus and with a colostomy or ileostomy the urge to go to the toilet is not real.  Don't panic.  Your fine.  This is a normal part of being an ostomate.

 

Although an occasional awareness is normal, and there may be some minor pain immediately just after surgery because of the wound, chronic pain is not.  Pain in the perineal wound area during the first year after surgery may be significant.  It could indicate an infection of the wound.  There may be healing at the skin level, but abscesses may be forming below.  There may also be other complications depending on the reason for the surgery; i.e., a lingering fistula.  Ostomates with persistent pain should see their physician. 

    

Allergic Reactions

By Kathryn Hoyman, RNET—Minneapolis Chapter

 

Many times I hear that people are allergic to adhesive tape or paper tape or skin prep or any number of different products that are used in ostomy care.  Allergies may occur with any product.  They may occur with the first use of a product or after years of using a product without problems.

 

Actual allergic reactions to ostomy products are not common.  But, some people do have issues relating to an allergic reaction to certain products at certain times.  And many people have sensitivities at one time or another.

 

Many conditions appear to be an allergic reaction but are actually another problem.  It is important to know whether or not your are truly allergic to a product, because eliminating products reduces your options.  Believing you are allergic may cause you not to try a pouch that might be perfect for you.

 

Allergic reactions are usually severe.  They will cause blistering and wet, weeping skin wherever the products touch you.  Two situations are frequently labeled as allergic by mistake:

 

First, if a skin sealant wipe is used, it needs to dry completely to allow the solvents to evaporate.  If the pouch is applied while the solvents are still on the skin, sore skin can easily occur.  Since the solvents can't evaporate through the skin barrier as they can through the paper tape collar, this will look like an allergy to the skin barrier.

 

Second, each time you remove a pouch, the adhesive takes with it the top layer of dead skin cells.  However, if you are removing a pouch more frequently than it was manufactured to perform, cells can be removed faster than they are replaced  [Some barriers are made to be removed daily while some should not be removed more often than every three days.  Your ET and the manufacturers will help you determine the barrier that's best for your needs.]

 

This is called "skin stripping".  Everyone's skin reacts differently to having tape removed.  But it's important to be gentle and not remove a pouch more frequently than necessary.  Skin that is stripped will be sore in some spots and not in others.  Sometimes skin around the stoma becomes fragile and strips easily.  A barrier, tape and pouch with a very gentle adhesive must be found.

 

To test whether you are really allergic:  Take a small piece of the test material and place it on any convenient part of your skin far away from your stoma.  After 48 hours, take it off and see whether you are reacting.  If pain, itching or blistering occurs, take it off immediately. 

 

If it's an allergy you will react.  If you have a history of allergies, test in this manner before trying on any new ostomy product.  It is better to have half an inch of sore skin on your leg than around your stoma.  You need healthy skin around the stoma for a good seal and satisfactory performance from an ostomy system.

 

If you develop an allergy to a product you have used for a long time, you can call the manufacturer.  They may have made changes in the manufacturing process.  Calls from users are sometimes their first notice that the new improvements are or are not working.

 

Skin Sealant

--The Pouch

 

Skin Sealants; such as: Skin Prep by Smith & Nephew, Skin Gel Wipes by Hollister, Allkare by ConvaTec and Bard Skinare Protective Film, are available in different forms:  small wipes, sprays or applicator bottles.  These products contain a plastering agent as their main ingredient and are used to provide a thin protective film on the skin surface.

 

This film helps prevent injury to the surface layer of the skin during appliance removal.  It also acts as a moisture barrier.  For people with dry skin, the film actually improves appliance adhesion.

 

Skin sealants also contain variable amounts of isopropyl alcohol.  Because of the alcohol content, some minor burning and stinging often occur when the sealant is applied to damaged skin.  Therefore, ski barrier powder should be used rather than a skin sealant on irritated skin.

 

It is also important to know that skin sealants are not be recommended for use under certain skin barriers.  Those using ConvaTec's Durahesive or Hollister's Flextend barriers are advised not to use any skin prep.  These barriers are made to "melt" on top of your skin.  The use of a skin sealant will reduce the adherence of the barrier and provide less than satisfactory performance.  

    

Push the Skin

--Green Bay News Review

 

Damaging the skin around a stoma—or anywhere else—is asking for infection.  Don't peel your pouch away from your body.  Take hold of an edge of an adhesive section—the tape or barrier—and push the skin away from the adhesive.

 

In older people and babies with thin skins, you can peel their skin off by pulling on tape.  Take a good look at what is happening when you pull tape.  The tape is pulled upwards, dragging the skin with it until it is pulling hard enough to break loose.  It even look painful.

 

Now look at what happens when you push the skin away from the tape.  It doesn't hurt, and the outer layer of skin is not torn off, which sometimes happens with pulling.  To those people who think yanking it off fast is best ought to take a good look at the skin afterwards.  By the way, never yank the tape off fast.

 

If you have a leak, digestive enzymes in the discharge will excoriate your damaged skin quicker and deeper than if your skin is in good condition or protected with some sort of skin preparation.  The farther away from the rectal area the stoma is located, the stronger the digestive enzymes in the discharge, and the sooner your skin can become excoriated.  Learn to treat skin very gently.

 

Stomal Prolapse

By Diane Kranser, RN, MS, ET Oshawa Ostomy News

 

Prolapse is a relatively frequent stomal complication—it affects up to 14% of all ostomates.  It is defined as the excessive protruding of the bowel out of the abdomen. 

 

The piece of bowel that protrudes may often be as long as six inches in length; up to three inches in width; and will bleed easily.  If your stoma prolapses, you should remove your pouch, or make sure the bowel has room to swell without being constricted within the pouch.  Apply a cool compress or fill the pouch with cool water.  This should help reduce it. 

 

If this is the first time your stoma has prolapsed, make an appointment to see your ET nurse.  If you cannot get in touch with him/her immediately, it is OK to wait unless there are other complications; like, if your drainage has stopped.  Then, it would be wise to go to the emergency room of your local hospital.

 

It your stoma has prolapsed before, you may have been taught by your physician or ET to "reduce" your stoma.  You should try to do so.  It usually works fine.  Surgical repair is often required for a stomal prolapse.

 

Wonders of Milk of Magnesia

Forward By It’s in the Bag

 

     Because of its alkaline properties, Milk of Magnesia (MM) is beneficial to skin which has been burned by hydrochloric acids and/or enzymes from intestinal secretions.  Hygienic care of the skin for all types of ostomies is very important.  We have included a sample method of treatment if you ever have these symptoms.

     Use one of the many specially designed adhesive removers available on the market to remove all residue remaining after removing the barrier.  Also, these removers will kill any latent intestinal bacteria which can multiply under the faceplate.  The problem comes in because it is possible for enzymes to penetrate so deeply into the skin that neither soap nor the alcohol on the adhesive remover can remove them, but MM will neutralize them.

     Rub it gently into the skin.  If the enzymes are there, MM will curdle like cottage cheese.  In that case, rinse it off with warm water, pat the skin dry and apply a new film of MM.  Let this dry completely and, if you use one, then apply your usual skin preparation; like, Hollihesive, karaya or  Stomahesive powder.  A very thin paste made of MM and a  powder is healing to the damaged skin.  After the paste is dry, the barrier may be applied.

 

Skin Care Basics

By Barb Barrickman, RN, CETN 

     Caring for the skin around the stoma is an important part of basic ostomy care. Good skin care around the stoma—the personal area—is not very different from caring for the rest of your skin. Healthy skin protects us from the environment; produces vitamin D; provides a tough, flexible foundation to hold the rest of your body; regulates body temperature; insulates the body from cold and trauma; provides an avenue for sensation and grip.

     Normally the skin is acidic in pH, approximately 5.5. This natural acidity discourages bacterial growth, helps to absorb moisture, and keeps the cells closer together to prevent cracks in our protective layer. As we age, the skin changes.

     It becomes thinner, making it more susceptible to injury and changing the way our body reacts to temperature, pain, pressure and chemicals.  It becomes less flexible and often sags. It heals half as quickly as before and becomes drier with visible cracks which harbor bacterial growth.  Good skin care can delay many of these natural aging processes and aid in keeping the skin healthy.  The basics of good skin care include:

1. Clean the skin with a good cleanser with a pH between 4.5 & 0. Normal skin can handle this well, with the skin regaining its normal acidic pH within 20-30 minutes.

2. Frequent washing irritates skin.  Soap and a washcloth are the worst enemies of fragile and/or damaged skin.  Washing with just plain water and gentle friction is all that is needed.

3. Air drying is beneficial if time permits.

 4. Apply moisturizer to skin—except under the barrier—after bathing to take advantage of open pores.  Look for moisturizers that contain one or more of the following ingredients: liquid paraffin, lanolin, caster oil, cetostearyl alcohols, glycereal stearate.

5. Check the Ingredients In your skin care products and know what they are for. Active ingredients should be listed in descending order of percentages contained in the product.  The purposes of ingredients and examples:

·        Emollients soothe and soften the skin. Examples: almond oil, aloe vera, lanolin, dimethicone copolyl, mineral oil.

·        Antimicrobials eliminate microbes and reduce skin infections; kill normal skin flora as well as unwanted bacteria. The normal skin flora re-colonize one to two hours after the use of an antimicrobial. Examples: hexy1resorcinol, tricolsan, benzethonium chloride. Emulsifying surfactants sisolve human excreta. Examples: polyaxamar 188, potassium palmitate, polysorbate.

·        Humectants prevent drying; soften and moisturize damaged skin by binding moisture to the skin. Examples: d-panthenol, propylene glycol, sodium PCA, glycerin.

     The peristomal. skin may need special protection from the adhesives on the pouching equipment and/or the output from the stoma. Barrier products are designed to protect the skin from contact with moisture and prevent friction. Skin films, actually plasticize the skin by placing a co-polymer film on the skin. Product examples that provide this barrier film include:

·        Smith & Nephew/ United Skin Prep,

·        ConvaTec AllKare Barrier Wipe,

·        3M No Sting Skin Protectant,

·        Bard Protective Barrier Film,

·        Hollister Skin Protectant Barrier.

     These products may be helpful in preventing and/or treating skin breakdown problems in the peristomal skin area.  They should be used only as directed and after consulting with an ET nurse or ostomy supplier.  Some ostomy barriers; i.e., the new extended wear barriers like ConvaTec’s Durahesive or Hollister’s Flextend, are not recommended to be used in conjunction with these film protectants.  These barriers actually melt into the skin and a protectant would frustrate this effort.

 

Reasons for Skin Breakdown

By Marvin M. Schuster, M.D.

 

     Skin breakdown is one of the most common problems ostomates encounter, but can be avoided by proper care and management. Different problems arise for ileostomates, colostomates, and urinary diversions, but no matter what the disorder or whom it affects, prevention is always much easier than treatment at late stages.

     For this reason, the ostomate should give particular attention to the state of the skin and take immediate steps if he or she notices anything unusual.  This is especially important because good, healthy skin makes for a better fitting appliance which, in turn, makes for a good, healthy skin.  Skin breakdown may be due to one of three causes:

Allergy:

     An allergy may be due to the adhesives, cement, or the material of which the appliance is made.  Fortunately, Karaya—used in many barriers and paste—itself is so inert, that it is extremely rare for a person to be allergic to it.  Other skin barriers, like ConvaTec’s Stomahesive or Durahesive and Hollister’s SoftFlex or Flextend, are specifically designed for skin comfort.  In addition, many suspected cases of allergy in fact are simply skin sensitivities to certain products.  For example, many people do not wear a wool sweater directly on their skin because it is itchy, yet, they are not allergic to wool, just sensitive.

     If there is any suspicion of allergy, the ostomate should test whatever material he/she seems to be allergic to on a part of the body remote from the stoma, say the chest or arm for example.  One can do this by putting a small amount of tape or cement or suspected material in a patch in the test area and observe for further effects.   Should the skin break down on the test area, obviously, it will not interfere with adherence of the appliance. 

     Sometimes one can eliminate allergic response simply by switching to another brand of ostomy supplies.  Becoming sensitive to one type of barrier happens to many people even after years of using a product with excellent results.  But again, this is best determined by trial, using the patch test as suggested.

Exposure of Skin to Digestive Enzymes:

     This problem is more common to ileostomates than to colostomates or to people with urinary diversions, since the ilea excretions are rich in digestive enzymes whereas the other two fluids are not.  Prevention also begins with a sufficiently protruding stoma for the ileostomate—which may be achieved by using a convex barrier.  If skin breakdown is present, there are a number of substances which can be used to promote healing and an enlightened physician or ET can handle this problem.  ConvaTec and Hollister both have barrier rings, strips and pastes designed specifically to protect the skin against digestive enzymes. 

Infection with Bacteria or Fungus:

     This problem often gets started from one of the other two problems, especially when there is a poor fit to the appliance, and leakage occurs.  If you have little red raised bumps under your barrier, there is a good chance you have a fungal—also called a yeast infection.  Two very good agents for handling this situation are a micro-granulated fungal powders like Mitrazole or Mycostatin powder—which may be purchased without a prescription in Illinois. 

     A steroidal skin prep, like Desonide lotion or Kenalog spray—which removes itching like magic but requires your doctors prescription—will help with the healing of certain types of infection.   Lotions and sprays may interfere with the adherence of an ostomy appliance on depending on one’s skin type and the ostomy system used—so be careful. 

 

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