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|Newsletters: Tips for Dealing with Skin and Stoma Issues|
Tips for Dealing with Skin and Stoma Issues
Dane De Luca, RN, BSN, WOCN, CWON
The society for Wound, Ostomy and Continence Nurses was initially a resource for ostomy patients; it later grew to include wound and continence care. A WOC nurse can help you if you are experiencing skin issues because of diarrhea or feeding-tube leakage. The purpose of this article is to discuss some of the products and techniques that are used by a WOC nurse which can also be used in the home.
The most challenging skin issues result from diarrhea, frequent stooling, or the combination of both. Some common causes of diarrhea are atrophy of the intestinal lining; ischemic bowel; short bowel syndrome (SBS); Crohn’s disease or colitis; pseudomembranous colitis; and infection. Individuals who receive tube feedings may experience diarrhea if the feeds are too concentrated or delivered too rapidly.
Incontinence-associated dermatitis (IAD) is an inflammation of the skin in the genital, buttock, or inner thigh areas that occurs when urine and/or stool comes in contact with the skin. With IAD, the skin can become red, painful, weepy, eroded (the top layer of skin is lost), edematous (swollen), and itchy. Often it is associated with a fungal infection.
The management of an unstable G- or J-tube that leaks effluent around the insertion site also presents significant challenges to doctors and nurses, patients and family members. Skin issues that occur with tubes include: stomal enlargement; leakage; skin breakdown; and hypergranulation tissue. Site leakage is the most common problem with feeding tubes, and skin that is in frequent contact with gastric secretions can become painful, weepy, and eroded, much as with IAD. Some of the same products and techniques are used to treat the skin in both situations.
Treating Skin Breakdown
The role of the WOC nurse—and your goal as a home nutrition support consumer or caregiver—is to prevent skin breakdown; minimize skin exposure to stool, urine, or gastric contents; and promote healing to prevent infection. Key to preventing skin breakdown is a skin care regimen that includes gently cleansing and moisturizing the skin, and applying a skin protectant or barrier ointment.
Cleansing with soap and water is very appropriate if you are not experiencing any skin issues. To minimize skin exposure to irritants, cleanse as soon as possible to keep stool or gastric contents from sitting on your skin.
If there are skin issues, cleansing with a perineal cleanser (for bottoms) or wound cleanser (around a G- or J-tube site) is really beneficial. These products have a pH range that reflects the acid mantle of good, healthy skin (5.4 to 5.9), which helps prevent bacterial or fungal infection. Exposure to stool, urine, or gastric contents can increase the skin pH, which increases the risk of skin colonization by microorganisms and of infection.
Cleansers work by converting dirt and microorganisms on the skin surface into an emulsion so that they can be easily removed with rinsing. No-rinse cleansers use a combination of detergents and surfactants to help loosen and remove dirt or irritants. Many cleansers also contain a moisturizer. Products that contain both a cleanser and moisturizer (which can counteract the effect of dry skin) can save time and money. Cleansers are available as liquids, emulsions, or foams; you can also buy towelettes that already contain the cleanser.
Friction (rubbing too hard to cleanse the skin) can also contribute to skin breakdown. It is important to be gentle when cleansing to reduce friction on the skin, such as around a tube site.
Protecting the Skin
Skin protectants provide a barrier on the skin to protect it from water and the irritants found in stool, urine, or gastric secretions. This type of product includes petrolatum-based ointments, dimethicone-based ointments, zinc oxide creams, and oils. Some brands combine all of these ingredients, and others have just one of them as the main component. Skin protectants can come in the form of a cream, paste, or ointment. Pastes and ointments are thicker and stay in place longer. Skin protectants are also available as lotions, but these are intended for healthy skin.
If the skin is weepy, you can dust a protective powder on the compromised skin and seal it with a skin sealant or liquid barrier film product (composed of polymers and a solvent). With a liquid barrier film, the solvent evaporates after application, leaving the polymers to dry and form a protective film on the skin. Then you can place the ointment on top of the treated skin.
Recently I saw a little baby whose skin was very red and weepy around the perineal area. She was crying from the pain of the IAD. Because the skin was actually eroded, I applied a protective powder for moisture absorption and dusted that off, then put a liquid barrier film product over it. I did that twice to give it a dry surface, then covered it with a skin protectant.
Sometimes ointments can end up on the sheets or in the diaper. On the buttocks, our trick to avoid this is plastic wrap. After we put a barrier ointment in place, we cover it with a piece of plastic wrap. If necessary, we’ll cut two sheets of plastic wrap and put one on each buttocks cheek. The plastic wrap helps the ointment to be absorbed and keeps it on the compromised skin.
With skin that is significantly irritated by leakage around a feeding tube, I might put a special dressing on it to help absorb the drainage around the tube. (See “Product Examples.”) Or we might pouch the site to help it heal (see “Pouching”).
Antifungal powders are used similarly to protective powders (to help dry up a weepy area) except that they contain an antifungal agent. In these cases, when we want the powder to stay in place, we sprinkle the powder down, then cover with a liquid barrier film product.
Hypergranulation tissue is beefy red, raised, spongy tissue that forms around the tube insertion site. The most common cause of hypergranulation tissue is chronic leakage around the tube; excessive tube motion can also cause or increase the tissue formation. Hypergranulation tissue can bleed easily and secrete a yellowish ooze.
Treatment includes silver nitrate, where the tissue is cauterized and the hypergranulation tissue is brought down to skin level. This promotes healing. Silver nitrate application should initially be done and taught in the doctor’s office; after the initial demonstration it can be done at home. Your skin may burn or sting for a few minutes after silver nitrate is applied, and it may look discolored. [More on hypergranulation tissue on our Tube Feeding Tips pages.]
After treatment, preventing the tube from moving is beneficial. To secure a tube, you could use a protective barrier sheet. We use this in ostomy care as well. If you have to put some sort of a dressing around an ulcer near a G- or J-tube, you could put the dressing down, then put a barrier sheet on top of it to seal the dressing. The collar of the tube would sit on top of the barrier sheet. (See “Product Examples” and Tube Feeding Tips.)
Sometimes you can get what I’m going to call a “gastric stoma.” This is when the actual stomach lining migrates up around the tube and matures at the skin level. It can cause major leakage problems and it becomes very challenging to keep the tube in place because the stoma has a wet mucosa that is constantly making the tube move in and out.
Treatment options include tube holders; pouching of tube site with or without the tube in place; taking the tube out; cauterization; or surgical relocation of the tube.
If the tube site is terribly enlarged or painful, we may have to take the tube out and the WOC nurse could apply an ostomy pouch to contain the drainage. “Pouching” the site allows the skin and tract to heal. In such a case, replacing the tube with a larger tube may also be appropriate.
If we have to keep the tube in, we can still apply an ostomy pouch to the site, but this is more complicated and would be a temporary solution. It would require the skill of a nurse to initiate and manage.
There are many great over-the-counter ointments and skin protectants available. Pharmacies and hospital supply companies carry skin care product lines by many manufacturers. We mention a few products on the right to give you an idea of what is available, and we found the Web site www.ostomycaresupply.com had an extensive list of products. Some manufacturers will provide samples upon request. Reimbursement for skin care products is dependent on your insurance and home care coverage; it may be worth asking if something is covered.
When applied with some of the techniques WOC nurses use routinely, these products can help you prevent or care for skin breakdown associated with IAD or G- or J-tube problems.
The products listed here are representative of hundreds of skin care products available. These were highlighted in a presentation the author gave at a recent Oley Foundation conference as products with which she is familiar. There are many manufacturers with complete skin care lines from which to choose. Listing does not imply endorsement.
Baza Cleanse and Protect® by Coloplast—“all
in one” product; most active ingredient is dimethicone.
Skin Protectants and Barriers
Critic-Aid® Clear by Coloplast—petrolatum-based with dimethicone.
Sensi-Care® by ConvaTec—zinc oxide–based.
Calmoseptine®—an ointment containing zinc oxide, calamine, lanolin, and menthol (for a little bit of a cooling effect).
Ilex® by Medcon Biolab Technologies—a white petrolatum-based paste. (It is helpful to apply a layer of petrolatum over Ilex to prevent it from sticking to gauze or a cover dressing.)
Cavilon™ No Sting Spray Barrier by 3M—alcohol-free formula.
Protective Sheet by Coloplast—a protective barrier sheet that is sticky on one side; it acts like a thick, outer skin.
Stomahesive® by ConvaTec—powder helps form protective barrier.
Wound Care Products
Triad™ by Coloplast—considered a wound dressing, it’s hydrophilic (it’ll absorb the moisture away from eroded or weepy skin); zinc oxide–based.
Aquacel® Ag (Silver) by ConvaTec—goes into the wound bed dry and absorbs drainage; used on areas that are so weepy, nothing will stick. The silver component of it is antimicrobial so it cuts down on infection.
Mepilex® by Molnlycke—a multilayered foam pad; the layer against the skin conforms to uneven surfaces and adheres without additional tape. You can put a slit in it and wrap it around the tube to help draw up drainage like a sponge would.
PolyMem® by Ferris Mfg. Corp.—a pink foam dressing with a surfactant and glycerin. It will absorb drainage and interact with the wound bed. Also comes in a silver form and in a shape that’s made to go around tubes. It does not have an adhesive back, so you have to secure it with tape. (You’re not supposed to clean between dressing changes when you use this product.)
Flexi-Trak® anchoring device by ConvaTec—can be opened and closed several times for adjustments; not a “one and done” type of holder.
Tube holder by Hollister—tighten a loop around the tube and the tube is held in place; adjust the loop to make it tighter or looser. Can be left on for several days.
LifelineLetter, May/June 2013