Management of Peristomal Skin Complications

Diagnosis and Assessment

The American Gastroenterological Association recommends inspecting for fungal infection characteristics, such as itchy maculopapular rash with satellite borders, typically caused by prolonged moisture and heat under the appliance 1
Swabbing the area for both bacterial and fungal culture is necessary to guide targeted therapy, especially in immunocompromised patients 2
Assessing for effluent leakage is crucial, as it is the most common cause of peristomal skin damage and creates an environment conducive to fungal overgrowth 1, 3
Identifying high-risk features, such as diabetes, obesity, poor nutritional status, and chronic corticosteroid or immunosuppressive therapy, is important, as they significantly increase infection risk 2, 4

The American College of Gastroenterology recommends cleaning the affected area thoroughly with soap and water, ensuring complete drying, and then sprinkling antifungal powder directly onto the peristomal skin 1, 4
Applying skin sealant over the powder is necessary to create a protective barrier that allows the antifungal to work while preventing further moisture accumulation 1
Reassessing at 2 weeks is crucial, and if no improvement occurs, the patient requires further evaluation by a surgeon or enterostomal therapist for possible systemic antifungal therapy 1
Using stoma adhesive powder or zinc oxide can help prevent local skin irritation 2
Considering temporary steroid spray is necessary if allergic contact dermatitis is suspected, which presents with itching and redness in the shape of the appliance 1

Ensuring proper appliance fit, by cutting the opening one-eighth inch larger than the stoma, can help prevent mucosal irritation while limiting skin exposure 5
Optimizing pouching techniques, such as using convex appliances, ostomy belts, paste, or barrier rings, can help bolster stoma height off the peristomal skin 5
Heating the appliance with a hair dryer before application and lying flat for several minutes after application can improve the seal 5
Ensuring peristomal skin is completely dry before application, using a fine dusting of stomal powder followed by skin sealant if needed, is crucial 5

Immunocompromised patients require a lower threshold for systemic antifungal therapy and daily monitoring for improvement or worsening 2, 4
Considering earlier surgical consultation is necessary if infection persists despite appropriate topical treatment 2
Maintaining good hygiene with daily cleaning using antimicrobial cleanser is essential 2

Adding systemic antifungal agents based on culture results is necessary if topical antifungal treatment fails after 2 weeks 4
Considering tube/appliance removal and replacement is necessary if infection persists despite combined topical and systemic therapy 4
Evaluating for complications, such as stoma tract disruption, peristomal infection, or severe skin excoriation, is crucial, as they may necessitate surgical intervention 2, 4