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Sarah Gu├ęgan, MD, PhD

Cutaneous Reactions Associated With Abdominal Stomas

Sarab Guegan

Wednesday, November 10, 2010

Skin impermeability is crucial in order to maintain its integrity. However, use of stomal appliances may lead to various degrees of barrier abnormalities that can themselves induce secondary disorders. Dermatoses around abdominal stomas are therefore common and may occur in as many as 73% of cases, with patients with high-output stomas (ileostomy, urostomy) being more at risk than those with colostomy.1 Appropriate diagnosis and management of peristomal skin reactions are therefore critical components of stomy care.

Mechanical Trauma

Ill-fitting appliances and frequent pouch changes are a common cause of epidermal damage secondary to mechanical stripping. Appliance reassessment, as well as stomal powder, skin sealant and barrier preparation, is needed to correct any problems encountered. Belts or convex flanges may be responsible for pressure ulcers that require topical care and sometimes lead to the use of an alternate disposal. Mucocutaneous separation occurs in the early post-operative period. Surgical intervention is usually not necessary; nevertheless, wound care interventions and pouching will be required.

Irritant Contact Dermatitis

Irritant reactions are usually a consequence of leakage onto the skin of stoma effluent, faeces or urine, especially in cases of inappropriate appliance or postsurgical modifications, e.g. physiological stoma remodelling in the 6 months following surgery, stoma herniation or prolapse, stoma burying, fistulae, and scarring. For high-output stomas (jejunostomy, ileostomy), the nature of the enzyme-rich output may explain the ineffectiveness of normal skin protection measures because it will rapidly digest hydrocolloids.

In retrospective studies, irritant contact dermatitis is always listed as the most common peristomal complication, and has been reported in 15-42% of stoma patients.1,2

Education in proper pouching techniques and adequate peristomal skin protection should be emphasized in order to prevent irritant contact dermatitis. Various types of protective films, filler pastes, barrier preparations, and hydrocolloids can be used in such situations.

Allergic Contact Dermatitis

Although a high percentage of patients will feel that their skin disorder is the result of an allergy, true allergic contact dermatitis is actually a rare cause of peristomal cutaneaous reactions.1,3 It does occur in a few cases, and must therefore be investigated with appropriate patch testing. In particular, the patient's stomal components should be tested.

Infectious Dermatitis

Fungal Infection - Candidiasis

Candida albicans frequently colonizes the peristomal cutaneous area, as revealed by routine swabs, and may be responsible for superficial cutaneous infections characterized by erythematous patches with satellite papules and pustules. Trichophyton and Pityrosporum agents have more rarely been implicated in the development of peristomal rash. Topical miconazole, clotrimazole or terbinafine, and oral fluconazole or itraconazole in cases of resistant or recurring fungal infection, are of use in the resolution of such dermatitis.

Bacterial Infection - Folliculitis

Staphylococcal infection may be responsible for superficial erythematous lesions associated with the characteristic honey-colored crusting, superficial erosions and folliculitis. In turn, folliculitis, characterized by an erythematous pustular area, has been frequently associated with skin shaving performed in order to improve pouch adhesion. Swabs taken for microbiological examination help to distinguish such infections from cutaneous candidiasis. Adequate topical antibiotics will clear such dermatitis.

Inflammatory Conditions

Hyperplastic Granulation and Chronic Papillomatous Dermatitis

Hyperplastic granulation usually occurs at, or just beyond, the mucocutaneous junction. Histology shows granulation tissue, bowel metaplasia, and acute-on-chronic metaplasia. The condition is considered to be the result of irritation and, in most cases reported, short colostomies were responsible.1

Chronic papillomatous dermatitis, with a specific appearance of coalescent and warty papules, has been reported in urostomies in response to chronic urine exposure. The histology shows an acanthomatous reaction or a pseudo-epitheliomatous hyperplasia.1

Pyoderma Gangrenosum

Pyoderma gangrenosum (PG) is a painful neutrophilic dermatosis characterized by rapidly evolving ulceration with an undermined overhanging inflammatory edge. The diagnosis is usually clinical, as performing a biopsy may pejoratively affect lesion evolution. In the case of peristomal PG (Figure 1), minor trauma from the stomal appliance is thought to be a contributing factor, and may explain its particularly difficult management.

 

Figure 1. Peristomal pyoderma gangrenosum

In retrospective studies, PG was reported in 1-5% of patients with inflammatory bowel disease (IBD),4 and peristomal PG in 0.6% of such patients.5 In a recent prospective study, 0.75% of 2402 IBD patients presented with PG, with only two cases of peristomal PG among 11.6 However, peristomal PG does not occur exclusively in patients with IBD.

A wide range of treatment options exists. A small open study reported superiority of topical tacrolimus over topical steroids,7 whereas a randomized double-blind study validated the use of anti-tumor necrosis factor therapy (infliximab) as first-line therapy for use in IBD patients presenting with PG, rather than long-established systemic therapies such as oral corticosteroids or cyclosporine.8

Psoriasis, Seborrheic Dermatitis and Eczema

Pre-existing skin disorders, such as psoriasis (Figure 2), eczema and seborrheic dermatitis, may localize around stomas and account for 20% of peristomal skin conditions.1 Short-term topical cortisteroids are most effective in the resolution of such dermatoses.

 

Figure 2. Peristomal psoriasis.

Cutaneous Crohn's Disease

Crohn's disease can affect the stomal region; indeed, histologically confirmed cutaneous Crohn's disease, peristomal fistulae or mucosal Crohn's disease with typical aphthous ulcers of the protruding bowel mucosae in the context of active intestinal Crohn's disease have all been reported.1

Malignancy

In patients previously treated for colorectal cancer, the stomal region can very rarely be subject either to a true metachronous cancer with local peristomal spread or to cutaneous metastasis. More than 10 cases of metachronous tumor in this area have been reported in the literature,9,10 whereas cutaneous metastasis following excision of the primary tumor is known to arise in less than 5% of patients.11 Any atypical skin lesion, such as a rash, ulceration, induration or nodule, should therefore be biopsied to rule out such a possibility. Once isolated, wide local excision of the lesion followed by adequate adjuvant chemotherapy is usually the preferred treatment option.

Conclusions

Several cutaneous conditions can affect the peristomal area and thus be a source of inconvenience. Adequate ostomy care and prevention of such cutaneous reactions should be emphasized, and self-care programs promoted. Importantly, early diagnosis of peristomal dermatoses and appropriate treatment choices are crucial to patients' quality of life.

References

  1. Lyon CC, Smith AJ, Griffiths CE, Beck MH. The spectrum of skin disorders in abdominal stoma patients. Br J Dermatol 2000;143:1248-1260.
  2. Sung YH, Kwon I, Jo S, Park S. Factors affecting ostomy-related complications in Korea. J Wound Ostomy Continence Nurs 2010;37:166-172.
  3. Martin JA, Hughes TM, Stone NM. Peristomal allergic contact dermatitis--case report and review of the literature. Contact Dermatitis 2005;52:273-275.
  4. Callen JP. Pyoderma gangrenosum. Lancet 1998;351:581-585.
  5. Lyon CC, Smith AJ, Beck MH, Wong GA, Griffiths CE. Parastomal pyoderma gangrenosum: clinical features and management. J Am Acad Dermatol 2000;42:992-1002.
  6. Farhi D, Cosnes J, Zizi N, et al. Significance of erythema nodosum and pyoderma gangrenosum in inflammatory bowel diseases: a cohort study of 2402 patients. Medicine 2008;87:281-293.
  7. Lyon CC, Stapleton M, Smith AJ, et al. Topical tacrolimus in the management of peristomal pyoderma gangrenosum. J Dermatolog Treat 2001;12:13-17.
  8. Brooklyn TN, Dunnill MG, Shetty A, et al. Infliximab for the treatment of pyoderma gangrenosum: a randomised, double blind, placebo controlled trial. Gut 2006;55:505-509.
  9. Vijayasekar C, Noormohamed S, Cheetham MJ. Late recurrence of large peri-stomal metastasis following abdomino-perineal resection of rectal cancer. World J Surg Oncol 2008;6:96.
  10. Shibuya T, Uchiyama K, Kokuma M, et al. Metachronous adenocarcinoma occurring at a colostomy site after abdominoperineal resection for rectal carcinoma. J Gastroenterol 2002;37:387-390.
  11. Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma: a retrospective study of 4020 patients. J Am Acad Dermatol 1993;29:228-236.
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