Dermatologic Complications
Peristomal dermatologic conditions can have chemical (irritant contact dermatitis, pseudoverrucous lesions), mechanical (mechanical dermatitis, mucocutaneous separation, stripping injury), infectious and bacterial (candidiasis, folliculitis), immunologic (allergic contact dermatitis), or disease-related (pyoderma gangrenosum, malignancy, Crohn's disease) etiologies.[7] This review focuses on the different types of dermatitis that can occur around stomas.
Irritant contact dermatitis is caused by the contact of substances with the skin or by the improper placement of stoma equipment.[7] Chemical irritant dermatitis arises from the patient's reactions to substances that come into contact with the peristomal skin; these include gastric secretions, mucus, solvents, or cleansing materials. Fecal or urine irritant contact dermatitis is common with ostomies because of leakage that can occur around the stoma. The majority of irritant dermatitis cases involve the inappropriate placement and sizing of the ostomy equipment, resulting in constant exposure to the irritant.
Mechanical dermatitis results from the physical abrasion that can occur because of the movement of stoma support belts or the hard plastic components of the ostomy pouch system across the skin.[7] The affected skin is often characterized by erythema and possible abrasion. Stripping injuries, which occur when adhesives are forcibly removed from the skin, constitute another form of mechanical injury.
Allergic contact dermatitis can be attributed to a patient's sensitivity to the components of the equipment (such as sealing rings or the ostomy pouch itself), topical ointments, deodorizers, adhesives, and skin cleansers (Figure 1). Patch testing is often used to determine the cause of the allergy.[5] Although several allergens known to cause peristomal allergic contact dermatitis may also be linked to contact urticaria, the literature includes no reports associating contact urticaria with stoma dermatitis.
Figure 1.
An example of peristomal allergic contact dermatitis.
Other less frequent types of dermatitis are chronic papillomatous dermatitis (CPD) and seborrheic dermatitis.[5] CPD is thought to be an acanthomatous reaction due to chronic urine exposure. CPD is most frequently found in urostomies but also occurs (rarely) in ileostomies.[8] CPD can be due to mechanical or chemical irritation and may be human papillomavirus (HPV) positive. Urologic literature refers to lesions that are descriptively similar to CPD as hypertrophic scarring, hyperkeratotic stenosis, stomal keratinization, and reactive acanthosis. Williams and colleagues described the case of a 63-year-old man who presented with a 4 cm verrucous lesion surrounding his ileostoma. Although the clinical findings and histology resembled those of a verrucous lesion consistent with those seen in manifestations of HPV, immunohistochemistry revealed the lesion as HPV negative. The authors postulated that the patient's medical history, consisting of familial adenomatous polyposis (FAP) and advanced colorectal adenoma, may have predisposed him to CPD. They stated that the feces of FAP patients contain more undegraded cholesterol and bile acids than those of normal patients, which could contribute to CPD.[8]
Wieland and colleagues described the case of a 55-year-old woman who presented with grayish white papillomatous lesions around her ileostoma.[9] Endoscopic examination revealed minor superficial ulcerations around the terminal ileum. Biopsies of the skin, skin-mucosa transition, and intestines were performed. The skin biopsy specimens showed hyperplasia, hyperorthokeratosis, hyperparakeratosis, hypergranulosis, and papillomatosis. Histologically, the diagnosis was acanthosis without any koilocytosis. Because of the recurrence of the lesions after treatment with podophyllotoxin solution, carbon-dioxide laser removal, neodymium:yttrium-aluminum-garnet laser treatment, and toluidine photodynamic therapy combined with carbon-dioxide laser evaporation, samples of the tissue were taken and further analyzed through polymerase chain reaction. Each sample was analyzed for the presence of genital, mucocutaneous, or epidermodysplasia verruciformis (EV) HPV. Deoxyribonucleic acid sequences of the EV-HPV type were found in all biopsy specimens taken from the irritated site, whereas the genital and mucocutaneous HPV types were not found. The strains of HPV that were detected included HPV 20, HPV 23, HPV 38, and four novel HPV strains that make up different clusters of the group EV-HPV B1. Specifically, HPV 23 was found in both the skin-mucosa transition biopsy specimen and the intestinal mucosa biopsy specimen. Because the patient regularly flushed out her ileostoma, the virus (or cells containing the virus) could have been transferred from the infected stomal area to the intestinal mucosa. This case indicates that it is possible for cutaneous HPV to be transferred to mucosal areas of the intestine; thus, it is important to treat dermatologic stoma complications so that they do not result in more serious complications.
Seborrheic dermatitis can be a preexisting condition involving the scalp, neck, and chest, along with the peristomal skin.
A summary of the possible differential diagnoses or peristomal dermatoses is presented in Table 1.
The relative incidence of each type of dermatitis was documented by Lyon and colleagues in a study in which 525 patients received a postal questionnaire about the development of peristomal skin disease following their ostomies;[5] 325 (62%) of the patients responded to the questionnaire, and those who reported skin problems were sent to the hospital's regular stoma care and dermatology clinic for further examination. This clinic was staffed by a dermatologist and a stoma care specialist nurse. One hundred forty-two patients attended the clinic, and a diagnosis of irritant dermatitis (including that secondary to fecal or urine leakage) was most common (50 patients), followed by mechanical dermatitis (15 patients), nonspecific dermatitis (22 patients), and seborrheic dermatitis (12 patients). The remainder of the patients were diagnosed with overgranulation, bacterial infections, folliculitis, psoriasis, eczema, cutaneous Crohn's disease, pyoderma gangrenosum, allergic contact dermatitis, or dermatitis artefacta.
Lyon and colleagues also investigated the possible etiologies of the different cases of dermatitis.[5] They stated that 6 months after a surgery, the abdominal stomas remodel and become smaller, leaving a portion of skin that is constantly exposed to stoma effluent, thus causing irritation. Lyon and colleagues also noted three cases of irritant dermatitis in which a buried stoma caused by postsurgical weight gain resulted in a large area of skin irritation due to stoma effluent trailing under the stoma bag and pouching equipment. The nonspecific dermatitis cases were defined as recurrent or persistent dermatitis for which patch testing, microbiologic swabs, and usage tests all had negative results. According to the authors, areas of seborrheic dermatitis are often colonized by Pityrosporum yeasts in the occluded skin, which could contribute to the disease process. Finally, in this particular study, 65 patients with persistent or recurrent dermatitis underwent patch testing, but only one had a relevant positive reaction. This allergic contact dermatitis case was attributed to sensitivity to a fragranced stoma bag deodorizer.
Dermatitis. 2010;21(3):138-147. © 2010 American Contact Dermatitis Society
Cite this: Stoma Dermatitis: Prevalent but Often Overlooked - Medscape - Jun 01, 2010.
