Peristomal skin breakdown (PBSD) is a frequent complication for individuals with an ostomy. The peristomal area is the skin surrounding the stoma where the pouching system is applied. When this skin becomes irritated or damaged, it causes pain, discomfort, and difficulty maintaining a secure seal for the appliance. Timely treatment is important to prevent worsening and potential infection.
Recognizing the Signs and Underlying Causes
Identifying the signs of skin breakdown is the first step toward effective treatment. Common visual signs include redness, irritation, or a rash beneath the adhesive barrier. Patients often report a burning, stinging, or persistent itching sensation around the stoma. If the breakdown is advanced, the skin may appear eroded, raw, or weeping fluid.
The most common cause is irritant contact dermatitis, occurring when effluent (urine or stool) leaks onto the skin. Ileostomy output, rich in digestive enzymes, is particularly caustic and can cause rapid skin erosion. Mechanical trauma, often called “skin stripping,” is another frequent issue. This happens when the adhesive barrier is removed too quickly, pulling away the top layers of healthy skin.
Infection, specifically candidiasis, is another common underlying cause. The peristomal area provides a warm and moist environment ideal for yeast growth. Fungal infections typically present as a red, bumpy, or patchy rash with small, separate red spots (satellite lesions) extending outward. Determining the cause (chemical irritation, physical trauma, or fungal infection) directs the choice of specialized treatment products.
Immediate First Aid and Cleaning Protocols
When skin breakdown is discovered, the first priority is to gently manage the affected skin. Immediately clean the peristomal skin using only warm water and a soft cloth or wipe. Avoid using standard soaps, especially those with oils, perfumes, or moisturizers, as they leave a residue that prevents the new appliance from adhering properly.
If an adhesive remover is used, any oily residue must be thoroughly washed away with water. After cleansing, the skin must be dried completely using a soft patting motion, rather than rubbing, to avoid further mechanical trauma. The skin surface must be meticulously dry, as moisture compromises the adhesion of the new barrier and is conducive to fungal growth.
Before applying the new barrier, the stoma should be measured carefully to ensure a precise fit. The opening in the adhesive barrier should be cut to fit snugly around the stoma, leaving only one to two millimeters of healthy skin exposed. Cutting the barrier too large is a primary cause of leakage and recurrence of skin breakdown. Apply the new barrier system by gently pressing it onto the skin, holding pressure to warm the adhesive and achieve a secure seal.
Specialized Topical Treatments for Healing
For actively weeping, raw, or eroded skin, specialized topical agents are necessary to absorb moisture and create a surface the adhesive can stick to. Ostomy barrier powder, a non-medicated hydrocolloid powder, is dusted lightly over raw areas to absorb exudate and convert the moist surface into a dry, protective layer.
This powder must then be sealed onto the skin using a no-sting skin barrier wipe or spray, a technique called “crusting.” The barrier film is dabbed or sprayed over the powder, fixing it in place to create an artificial scab. This process can be repeated two or three times to build a thin, protective crust over the compromised skin before the full adhesive barrier is applied.
If the breakdown is diagnosed as a fungal infection, an antifungal powder, such as one containing miconazole, should be used instead of the standard barrier powder. This medicated powder is applied directly to the rash and then sealed with the no-sting barrier film using the crusting technique. If the skin breakdown is severe, worsens, or persists for more than 72 hours, or if the skin turns purple or black, contact a Wound, Ostomy, and Continence Nurse (WOCN) or healthcare provider immediately.
Long-Term Strategies for Peristomal Skin Health
Preventing the recurrence of peristomal skin breakdown requires consistent attention to the pouching system and skin health. Routine monitoring of the peristomal skin during every appliance change allows for the early detection of minor irritation before it escalates to a severe breakdown.
Maintaining an appropriate pouch wear time schedule is important to prevent the adhesive from eroding and compromising the seal. A well-fitting system should provide a consistent seal for several days; changing it before it leaks minimizes skin exposure to effluent. The stoma should be measured periodically, especially in the first few months after surgery, as the size and shape can change significantly, requiring adjustment to the barrier template.
To protect healthy skin from the trauma of repeated adhesive removal, incorporate a non-alcohol-based skin barrier film or wipe into the routine. This product creates a thin, protective layer that shields the skin from the adhesive and reduces the risk of mechanical stripping. If the ostomy output is very liquid and contributes to frequent leakage, consult a healthcare provider about bulking agents or dietary adjustments to create thicker output, reducing chemical irritation.