Janice C. Colwell

Moisture-associated skin damage: Overview and pathophysiology

Moisture-associated skin damage (MASD) is caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection. Multiple conditions may result in MASD; 4 of the most common forms are incontinence-associated dermatitis, intertriginous dermatitis, periwound moisture-associated dermatitis, and peristomal moisture-associated dermatitis. Although evidence is lacking, clinical experience suggests that MASD requires more than moisture alone. Instead, skin damage is attributable to multiple factors, including chemical irritants within the moisture source, its pH, mechanical factors such as friction, and associated microorganisms. To prevent MASD, clinicians need to be vigilant both in maintaining optimal skin conditions and in diagnosing and treating minor cases of MASD prior to progression and skin breakdown.

MASD part 2: Incontinence-associated dermatitis and intertriginous dermatitis: A consensus

A consensus panel was convened to review current knowledge of moisture-associated skin damage (MASD) and to provide recommendations for prevention and management. This article provides a summary of the discussion and the recommendations in regards to 2 types of MASD: incontinence-associated dermatitis (IAD) and intertriginous dermatitis (ITD). A focused history and physical assessment are essential for diagnosing IAD or ITD and distinguishing these forms of skin damage from other types of skin damage. Panel members recommend cleansing, moisturizing, and applying a skin protectant to skin affected by IAD and to the perineal skin of persons with urinary or fecal incontinence deemed at risk for IAD. Prevention and treatment of ITD includes measures to ensure that skin folds are dry and free from friction; however, panel members do not recommend use of bed linens, paper towels, or dressings for separating skin folds. Individuals with ITD are at risk for fungal and bacterial infections and these infections should be treated appropriately; for example, candidal infections should be treated with antifungal therapies.

MASD Part 3: Peristomal moisture-associated dermatitis and periwound moisture-associated dermatitis: A consensus

Moisture-associated skin damage (MASD) occurs when excessive moisture in urine, stool, and wound exudate leads to inflammation of the skin, with or without erosion or secondary cutaneous infection. This article, produced by a panel of clinical experts who met to discuss moisture as an etiologic factor in skin damage, focuses on peristomal moisture-associated dermatitis and periwound moisture-associated dermatitis. The principles outlined here address assessment, prevention, and treatment of MASD affecting the peristomal or periwound skin.

Peristomal moisture-associated skin damage in adults with fecal ostomies: a comprehensive review and consensus.

Approximately 1 million persons living in North America have an ostomy, and approximately 70% will experience stomal or peristomal complications. The most prevalent of these complications is peristomal skin damage, and the most common form of peristomal skin damage occurs when the skin is exposed to effluent from the ostomy, resulting in inflammation and erosion of the skin. Despite its prevalence, research-based evidence related to the assessment, prevention, and management of peristomal moisture-associated skin damage is sparse, and current practice is largely based on expert opinion. In order to address current gaps in clinical evidence and knowledge of this condition, a group of WOC and enterostomal therapy nurses with expertise in ostomy care was convened in 2012. This article summarizes results from the panels literature review and summarizes consensus-based statements outlining best practices for the assessment, prevention, and management of peristomal moisture-associated dermatitis among patients with fecal ostomies.

Parastomal hernia repair with acellular dermal matrix.

Purpose Treatment of parastomal hernia is often complicated by a high recurrence rate and likelihood of wound contamination. We reported an initial series of parastomal hernia repairs performed with acellular dermal matrix. Methods We reviewed a series of 11 patients who had parastomal hernia repairs with acellular dermal matrix and recorded the type of ostomy, previous repair, associated intestinal pathology, type of repair performed, perioperative complications, and rate of recurrence. Results Between 2004 and 2006, 11 patients underwent parastomal hernia repair with acellular dermal matrix by the senior author. Nine of 11 patients had associated Crohns disease or ulcerative colitis and 3 had recurrent parastomal hernias that had failed initial repair. Mean follow-up was 8.7 months (range: 1–21 months). Two patients developed wound infections that did not require implant removal and healed with local wound care. Three patients developed recurrent hernias. Conclusions Parastomal hernia with acellular dermal matrix results in recurrence rates comparable to those reported in the literature for synthetic mesh repair. It offers the advantages of avoiding stoma relocation and of not requiring implant removal in cases of wound infection.

Care of the obese patient with an ostomy.

Obesity has become the number one health problem in the United States. The patients who is obese and undergoing a surgical procedure that results in the formation of fecal or urinary diversion requires advanced skills of a multidisciplinary healthcare team. Patients who are obese carry a high risk of wound and cardiopulmonary complications and often present a serious challenge in terms of stoma creation and management. The purpose of this article is to examine the risk factors that face the patient who is obese and undergoing stoma surgery, the challenges of stoma creation, and the resultant stoma management problems.

A review of radiation proctitis in the treatment of prostate cancer

Pelvic radiation is a common therapy for the treatment of prostate cancer. A complication of this therapy, radiation proctitis, may be limited to the direct posttreatment period or it may appear as serious complications that occur months to years after therapy has been completed. Mucosal damage, present with both acute and chronic radiation proctitis, produces a variety of symptoms including mucoid diarrhea, pain upon defecation, serious rectal bleeding, stenosis, and fistula formation. The treatment of radiation proctitis is symptom related, and the goals of therapy include the prevention or correction of mucosal changes and eradication of rectal bleeding. This article will review the pathophysiology of radiation proctitis and its treatment.

Complications of peristomal recurrence of Crohn's disease: a case report and a review of literature.

Patients with Crohns disease and colonic inflammation that proves refractory to medical therapy often require a proctocolectomy and end ileostomy. Disease recurrence can occur despite creation of an end ileostomy and may lead to peristomal complications such as fistula formation, abscesses, stoma retraction, or strictures. We present the case of a 51-year-old man with medically refractory ileocolonic Crohns disease who underwent a proctocolectomy with end ileostomy. The disease course was complicated by recurrence of ileal Crohns disease despite biological therapy. The patient presented with peristomal complications including an enterocutaneous fistula, stoma retraction, and an ileal stricture necessitating surgical revision of the ileostomy. Review of literature confirms an approximately 30% risk of recurrence of Crohns disease after an end ileostomy. A penetrating phenotype and preexisting ileal disease are risk factors for disease recurrence. A thorough evaluation of the stoma/peristomal area and evaluation of the small bowel by ileoscopy and small bowel imaging are required to assess the extent of disease and extraluminal complications such as stomal retraction and fistulas that require further surgical intervention. While postoperative medical treatment with immunosuppression or biological therapy is often employed, these therapies are unproven to prevent postoperative recurrence in the setting of a stoma.

What treatments are effective for the management of peristomal hernia

A hernia is defined as the protrusion of a loop of an organ through an abnormal opening. The more specific hernia that is the focus of this Evidence-Based Report Card, peristomal herniation, is defined as protrusion of bowel through an abnormal opening created by a weakness or interruption of the abdominal wall fascia adjacent to the stoma.1 Clinical manifestations include an unsightly or bothersome bulge adjacent to the stoma, difficulty pouching, difficulty maintaining a seal when a new pouch is applied, pressure or discomfort associated with stretching of the hernia ring, and intermittent bowel obstructions or acute abdominal pain associated with incarceration of the bowel within the hernia sac. The clinical diagnosis of a peristomal hernia requires assessment of the patient in a prone, standing, and sitting position. Attention is paid to the peristomal area, noting a bulging area in the area immediately around the stoma. This bulge should disappear when the patient is prone, because the intraabdominal pressure is lessened. A digital examination done with the patient performing a Valsalva maneuver will reveal an enlarged fascial ring.1 Although the physical assessment of the patient will provide evidence of a peristomal hernia, a computed tomography (CT) scan will provide the definite diagnosis.1 An in-depth bowel history should be taken to establish normal function and compare to the present function now that the patient has noted the bulge around the stoma. Evaluation for the presence of intermittent obstructive symptoms is important. A history typical of a patient with fecal stoma and a peristomal hernia will include periods of non-bowel activity during physically active times, followed by high output during times of a prone position (such as sleeping). An analysis of 16,470 patients in the United Ostomy Association’s patient registry reveals that the prevalence of peristomal herniations is approximately 30%.2 Reports of the incidence of peristomal hernias vary from 6.5% to as high as 62.5%.1-12 Variability in these reports can be attributed to many factors, including sampling differences (some studies were limited to urinary diversions, whereas others were limited to fecal diversions or a particular type of fecal diversion), to the underlying definition of what constitutes a hernia (some include any herniation, whereas others include only symptomatic hernias or those deemed appropriate for surgical repair), or to reporting methods (some relied on self-report, whereas others were based on physical or imaging studies).1,11,12 Cheung reviewed 322 stomas and found that half of the peristomal hernias occurred within 2 years of initial ostomy surgery.13 The median time for peristomal hernias to appear in end sigmoid colostomies was 15.3 months, and the median time for herniation in patients with ileal conduits was 22.4 months. When all diversions were combined, 24% occurred in the first year after surgery and 50% after the first 2 years after surgery.

Discharge planning for a patient with a new ostomy: best practice for clinicians.

A comprehensive discharge plan for a patient with a new stoma is needed to ensure the individual receives the necessary ostomy education prior to discharge. The plan should include teaching basic skills and providing information about how to manage the ostomy (ie, emptying and changing the pouch, how to order supplies, available manufacturers, dietary/fluid guidelines, potential complications, medications, and managing gas and odor), assisting with transitions in care, and providing information about resources for support and assistance. The purpose of this best practice guideline is to provide clinicians with a brief overview of the essential elements that should be included in the discharge plan to facilitate patient education and the transition of care from hospital to home.