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WCET TM JournalVolume 38 Number 1 Supplement to the WCET Journal
Official Journal of The World Council of Enterostomal Therapists
and International Inter-professional Wound Care Group
a world of exper t professional nursing care for people with ostomy, wound or continence needs
In this issueForeword: Maintaining peristomal skin health and quality of life
Peristomal moisture-associated skin damage and the significant role of pH
Maintaining peristomal skin health with ceramide-infused hydrocolloid skin barrier
The burden of peristomal skin complications on health utility and quality of life
Conclusion: Time to consider prevention in ostomy care
Dansac TRE seal is more than just a seal – with three levels of protection, the Dansac TRE seal has been designed to help keep skin naturally healthy.
AdhesionDesigned to provide a
secure, flexible seal to protect the skin from stoma fluid and
to be easy to remove.
AbsorptionHelps absorb excess moisture
to maintain skin’s natural balance without the seal losing internal or
external strength.
pH balanceDesigned to help
manage the skin-damaging effects of digestive
enzyme activity.
SEALING IN SKIN HEALTH
The Dansac logo and Dansac TRE are trademarks of Dansac A/S©2017 Dansac A/S
P12o
f-74
-300
© 20
17 D
ansa
c A/S
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Foreword
Maintaining peristomal skin health and quality of life
Peristomal skin health is often overlooked in the management of the person with an ostomy. Ostomy skin barriers by their very nature are occlusive, adhesive, and moisture absorbent.
Peristomal skin has been demonstrated to change histologically over time due to the ongoing assaults from the occlusive nature of these skin barriers1. The exposure to digestive enzymes and moisture, as well as repeated skin stripping from frequent barrier removal may also impact the health of peristomal skin. Many clinicians would agree that peristomal skin complications (PSCs), could be averted or managed with the successful management of leakage, and while manufacturers have introduced an array of solutions to address this challenge, this does not necessarily translate into optimised peristomal skin health. Some solutions are also quite costly, requiring multiple devices and accessories to be employed to manage these PSCs. This supplement explores the use of new barrier formulations in proactively managing PSCs and their impact on peristomal skin health and quality of life (QoL).
The skin has a natural moisture barrier to help maintain good peristomal skin health. However, in one study, nurses recall that patients experience peristomal itching without any visible signs of peristomal skin damage2. It is also known that there is a increase in transepidermal water loss (TEWL) from damaged or eroded skin. Ceramides are a naturally occurring lipid in the skin, which helps protect against dryness by regulating moisture content in the skin. Their role in peristomal skin health is discussed in detail in this supplement.
The surface of human skin is naturally acidic. In ostomy care, digestive enzymes play a pivotal role in the development of PSCs. When a stoma is formed, these enzyme-rich intestinal fluids are brought to the skin surface and can come into direct contact with the skin surface. This supplement illustrates how these enzymes are normally active in pH-neutral to alkaline environments, and how they can cause significant PSCs once
in contact with skin. The use of a pH-buffering skin barrier can address this challenge, thus helping to preserve skin health. This will be further discussed in the supplement.
Lastly, peristomal skin conditions can have an impact on the QoL, health utility, quality of life years (QALYs), as well as socio-economic and physical well-being of the person with an ostomy3-6. Higher levels of PSCs have negative effects on health utility while conversely fewer or no PSCs can have a positive effect on health utility. Stoma care nurses play an important role in maintaining peristomal skin health, which affects the QoL of those they care for.
This supplement explores all these issues in detail, how ostomy skin barrier formulations may assist in reducing the rate and incidence of peristomal skin complications, as well as providing supportive evidence for integrating new barriers into ostomy care.
REFERENCES
1. Otsuka M, Ikeuchi K & Anazawa S. Histological study of skin surrounding stoma in patients utilizing skin barriers and adhesive apparatus. J Jpn Soc Coloproctol 1997; 50:423–28.
2. Salvadalena G & Menier M. How common is peristomal itching in the absence of visible skin problems? Poster presentation WOCN/CAET Joint Conference 2016, Montreal, Quebec.
3. Meisner S, Lehur PA, Moran B et al. Peristomal skin complications are common, expensive, and difficult to manage: a population cost-modelling study. PLoS One 2012; 7:e37813.
4. Nichols T & Riemer M. Body image perception, the stoma, and peristomal skin condition. Journal of Gastrointestinal Nursing 2011; 9(1):22–27.
5. Nichols T & Inglese G. The burden of peristomal skin complications on an ostomy population as assessed by health utility and the physical component summary of the SF-36v2. http://dx.doi.org/10.1016/j.jval.2017.07.004
6. Taneja C, Netsch D, Rolstad BS, Inglese G, Lamerato L & Oster G. J Wound Ostomy Continence Nurs 2017; 44(4):350–357.
Paris Purnell RN, STN
Senior Manager, Clinical Education Hollister Incorporated
Andrea Farrugia RN, STN
Ostomy Association of Melbourne
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WCET Journal Supplement, 38(1)
Peristomal moisture-associated skin damage and the significant role of pH
Stoma care nursing is a dynamic, challenging and multiskilled role. A fundamental responsibility of this role is educating and supporting the person with an ostomy to achieve an optimum seal around their stoma while maintaining healthy peristomal skin.
Peristomal moisture-associated skin damage (PMASD)1, also referred to as irritant contact dermatitis, is explained by Lyons and Smith2 as the “most common single cause of peristomal skin problems, occurring where skin is repeatedly bathed in leaking stoma effluent”. Throughout 2015, Hollister Incorporated ran a global education program “Ostomy Care Confidential” in the United States, United Kingdom and Australia/New Zealand in which 919 nurses participated. During these events nurses were asked to vote on various stoma care-related subject areas. When asked, “What is the most common peristomal skin problem in your practice?", 91% of nurses agreed that irritant contact dermatitis is their greatest challenge to peristomal skin health (Figure 1). Stoma care nurses are acutely aware of the dangers of stoma output on skin; however, there appears to be a need for deeper understanding of the biochemical processes resulting in irritant contact dermatitis.
Wendy Rae RGN, SCN
Senior Manager, Clinical Education Hollister Incorporated
Sue Pridham DipN, BA Hons, SCN
Manchester Royal Infirmary, UK
This paper will focus on the interaction between stomal effluent and peristomal skin, which often leads to PMASD and devastating effects on the person living with an ostomy.
Understanding the function of the integumentary system and the gastrointestinal tract (GI) should be an integral component within stoma care nurse education. The process of chemical digestion and pH influence in the GI tract is key to understanding the correlation between stoma effluent and certain peristomal skin complications.
GI TRACT
There are six major functions of the GI tract including: ingestion, secretion, mixing and moving, digestion, absorption and, finally, excretion. Each function plays a crucial role in the digestive process to break down food, promote absorption of nutrients and remove residual waste.
The mouth, stomach and small intestine are three primary areas of digestion and absorption. From initial ingestion, food starts the process by being broken down into smaller particles in the mouth and chemical digestion commences with the introduction of saliva. The stomach continues the demolition job started in the mouth, serving as a holding area for ingested food, and degrading content, both physically and chemically. Primary protein digestion through secretion of hydrochloric acid and enzyme pepsin occurs in the stomach.
Peristomal Moisture Associated Skin Damage and the Significant Role of pH
Authors: Wendy Rae RGN SCN Senior Manager Clinical Education Hollister Incorporated Sue Pridham Dip.N., BA Hons., SCN Manchester Royal Infirmary, UK Stoma care nursing is a dynamic, challenging and multi-skilled role. A fundamental responsibility of this role is educating and supporting the person with an ostomy to achieve an optimum seal around their stoma whilst maintaining healthy peristomal skin.
Peristomal moisture associated skin damage (PMASD)1 also referred to as irritant contact dermatitis is explained by Lyons & Smith, 20102 as the “most common single cause of peristomal skin problems, occurring where skin is repeatedly bathed in leaking stoma effluent”. Throughout 2015 Hollister Incorporated ran a global education program “Ostomy Care Confidential” in the United States, United Kingdom and Australia/New Zealand in which 919 nurses participated. During these events nurses were asked to vote on various stoma care related subject areas. When asked, “What is the most common peristomal skin problem in your practice? 91% of nurses agreed that irritant contact dermatitis is their greatest challenge to peristomal skin health (table 1). Stoma care nurses are acutely aware of the dangers of stoma output on skin however, there appears to be a need for deeper understanding of the biochemical processes resulting in irritant contact dermatitis.
Table 1
Prevalence of Peristomal Skin Complications by Diagnosis
Ostomy Care Confidential Program Results 2015
This paper will focus on the interaction between stomal effluent and peristomal skin which often leads to Peristomal Moisture Associated Skin Damage and devastating effects on the person living with an ostomy.
Figure 1: Prevalence of peristomal skin complications by diagnosis Ostomy Care Confidential program results, 2015
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This highly acidic environment can fluctuate between pH 1.0 and 2.0 during a meal, rising to pH 4.0–5.0 when at rest.
Once stomach digestion is complete, parasympathetic pancreatic stimulation occurs3. The pancreas will secrete digestive enzymes into the duodenum via the pancreatic duct. Enzymes break down larger food nutrients into smaller molecules ready for absorption through the epithelial villi and transported to blood. These enzymes are released in an inactive form and only become active in the duodenum in the presence of enterokinase produced by the small intestine4. This prevents auto-digestion of the pancreas. As well as secreting enzymes, the pancreas critically discharges sodium bicarbonate as part of its exocrine function. The pancreas will secrete between 1 and 1.5 litres of sodium bicarbonate over the course of the day. This essential function neutralises the highly acidic stomach content as it enters the duodenum, creating a natural pH-buffered environment for optimal enzymatic digestion. Enzymes are affected by even minor fluctuations in pH value. At pH optima enzymes will be highly active; if this environment changes they rapidly denature and activity levels decrease or stop (Figure 2).
The preferred pH environment for many digestive enzymes
can be described as near neutral. The loss of small bowel
through surgery will not in itself change pH of the intestinal
tract. It will, however, make the transit time shorter to the
stoma, resulting in continuing high levels of enzyme activity
at point of excretion.
Table 1: Results and statistics of pH measurements in normal subjects5
Site Mean pH
Ileum 7.49
Left colon 7.04
INTEGUMENTARY SYSTEM
Human skin is a highly complex organ with multiple
functions critical to the maintenance of life. Protection,
excretion, regulation, sensation, synthesis and blood reservoir
all have roles to play6. Although each of these could be
considered protective to life, the physical and chemical
barriers are perhaps the most significant of these when
concerned with positive outcomes and quality of life of the
person with a stoma.
The skin’s physical or mechanical barriers are provided by
the continuity of skin and the hardness of its keratinised
cells. The chemical barriers are provided by skin secretions
and melanin. The skin's ability to maintain an acidic pH
is vital to the body's defence of almost constant bacterial
attack. Potentiometric measurements revealed skin pH values
between 4.2 and 5.6 give the outermost layer of the skin an
“acid mantle”7. The "acid-mantle" of the stratum corneum
is important for both permeability barrier formation and
cutaneous antimicrobial defence8. The influence pH changes
have upon maintaining healthy peristomal skin requires
careful consideration when taking into account that a great
number of people with an ostomy experience PMASD caused
by stomal output coming into contact with the peristomal
skin. How does stomal effluent impact the pH of the skin and
break down its natural defence mechanism?
Problems quickly begin when stoma effluent containing
active digestive enzymes makes contact with peristomal skin.
Although fluid in the stomach is acidified, intestinal stoma
output has been buffered to a near-neutral pH value by the
action of the pancreas. The near-neutral pH of ileostomy
and colostomy output is problematic due to the influence it
has upon GI enzymatic activity. A clear comparison can be
made when dealing with a colostomy. It is less common to see
peristomal skin complications around a colostomy. A more
viscous consistency of output has a disabling effect on the
enzymes9.Figure 2
Dedicated to Stoma Care
Acidic stomach environment pH 3.5-1.0
Oesophageal pH 6.0-7.0
Skin pH 4.0-6.0
Pancreas neutralizes intestinal juice to pH 7.8-8.3
ColostomyOutput neutral pH 7.0
Digestive enzymes at work, active in neutral to mild alkaline environment
IleostomyOutput neutral to
alkaline pH 7.0-8.0
JejunostomyOutput neutral to
alkaline pH 7.0-8.0
pH Levels in the GI Tract
The Dansac logo is trademark of Dansac A/S ©2018 Dansac A/S
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WCET Journal Supplement, 38(1)
Generally when stoma output comes into contact with skin, the naturally acidic pH is unable to handle this buffered solution, causing it to rise, enabling enzymes to remain active in their preferred pH environment and continue their role of digestion. This time, however, the digestion will occur on the proteins and lipids contained within the skin's structure. Skin basically makes a “good meal” for the digestive enzymes. If allowed, digestive enzymes are highly damaging to peristomal skin. Studies have shown skin irritation potential of faecal material at various pH values; however, they showed more severe skin reactions at a higher pH (alkaline). Such increase in skin response presumably results from raised enzyme activities in an alkaline environment10.
It is also known that the stratum corneum plays an important role in the skin’s function as a barrier to water loss. When the outermost layer of the skin is impacted by stomal effluent there is an increase in the transepidermal water loss of the skin barrier. Excessive water loss and subsequent increased penetration of irritants and allergens, alteration in the epidermal calcium gradient, slow/deficient lipid product, and an increase in pH of the skin can all predispose one to developing irritant contact dermatitis11.
This enzymatic damage of stomal output on peristomal skin can occur quickly and with devastating impact to the patient, resulting in pain, difficulty in achieving adequate pouch seal and considerable embarrassment and distress from pouch failure or leakage. The impacts are multifaceted, affecting clinical, quality of life, and economic outcomes.
The ostomy industry has long since been aware of this physiological and biochemical effect on skin. Product manufacturers strive to meet the needs of both clinician and ostomate in the development of advanced skin barrier technologies. Ideally, ostomy skin barriers should be designed to buffer stomal output while maintaining the naturally acidic pH of skin and not that favoured by enzymes. For the person with an ostomy, this could ensure peristomal skin maintains a healthy acidic pH when exposed to near-neutral stomal output loaded with active digestive enzymes. This would be good for skin and bad for digestive enzymes.
Decreased pH in the faecal environment may, therefore, decrease skin irritation potential of digestive enzymes12. A diaper study by Buckingham and Berg13 demonstrated that enzyme activity characteristically responds to changes in pH. It follows that changes in the pH of the diapered environment may affect the activity and, therefore, the irritancy of faecal enzymes. Despite this, many studies continue to report high numbers of patients experiencing irritant contact dermatitis. William et al.14 reported 77% of all participants
Skin anatomy:• Skin is acidic• Acid mantle pH 4.0–6.0• Keeps in lipids and moisture• Blocks toxins and bacteria• Maintains peristomal skin health
experienced sore skin at some point since their stoma was created; with 23% saying they had sore skin on a regular basis. Seventeen per cent of participants reported regular daytime leakage and 15% during the night, irrespective of stoma type and appliance.
Understanding skin and enzymatic damage, and having product options that could further denature the enzyme environment by providing a higher degree of buffering capability in the preferred range of healthy peristomal skin, may decrease the number of people suffering from a peristomal skin complication.
Peristomal skin health is fundamental to successful clinical outcomes and improved quality of life for the person living life with a stoma. There is an extensive range of ostomy products available helping both nurse and ostomate to make the best product selection to meet unique and individual needs. New innovation and product technologies should be considered during the decision-making process as this may support proactive practice.
CASE STUDIES
The following case studies describe improved or resolved peristomal skin complications during use of a product specifically designed to buffer stomal output as part of the ostomy care plan recommended by the stoma care nurse.
Physiology:• Digestive enzymes in stoma output
highly corrosive to skin• Enzymes in near neutral
environment break down protein-rich skin cells
• The result = irritant contact dermatitis
Goals:• Prevent stoma output from
contacting skin• Ensure good skin barrier seal around
the stoma• Select ostomy barrier designed to
buffer stoma output pH, denature enzyme activity and maintain skin in a natural healthy environment
Figure 3
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DISCLAIMER
These case studies represent individual nurse/patient experiences and are not meant to suggest all patients will share the same experience.
CONCLUSION
Gray et al.1 conclude that PMASD is a prevalent and clinically relevant complication of faecal ostomies. Nevertheless, evidence concerning its aetiology, epidemiology and pathophysiology is particularly sparse.
This article set out to explore current clinical opinion and prevalence toward PMASD, finding that this in conjunction with leakage remains the greatest concern for stoma care nurses and ostomates alike.
Having looked in detail at the pathophysiological processes of enzymatic digestion and the devastating impact this can have on peristomal skin, it is clearly evident that nurse specialists need to be proactive in prevention management, leading to better clinical outcomes.
Two case studies describe positive results when using a product specifically designed to buffer the preferred near-neutral pH environment of digestive enzymes to that of skin. Science has shown us that this may denature enzymatic activity, protecting skin from attack whilst maintaining the skin's natural healthy acidic pH condition.
Further studies into the potential clinical benefits of buffering technology are needed; however, could we be entering a new dawn in stoma care management where science meets physiology for improved patient outcomes?
REFERENCES
1. Gray M, Colwel J, Doughty D et al. Peristomal moisture-associated skin damage in adults with fecal ostomies: A comprehensive review and consensus. JWOCN Sept–Oct 2013; 38(5):541–53.
2. Lyon CC & Smith AJ. Abdominal Stomas and their Skin Disorders, 2nd Edn. Informa Healthcare, 2001. ISBN-13: 978 0 415 55348 3.
3. Montague SE, Watson R & Herbert RA. Physiology for nursing practice, 3rd Edn. Elsevier, 2005.
4. Wilmaier EP, Raff H & Stron KT. Human physiology. The mechanisms of body function, 11th Edn. McGraw-Hill International Edn, 2008.
5. Evans DF, Pye G, Bramley R, Clark AG, Dyson TJ & Hardcastle JD. Measurement of gastrointestinal pH profiles in normal ambulant human subjects. Gut 1988; 29:1035–1041.
6. Marieb E. Covering, Support, and Movement of the Body in Unit 2: The Integumentary System. Human Anatomy and Physiology, 2nd Edn. 1992. ISBN 0-8053-4120-X.
7. Blank HI. Measurement of pH of the skin surface. J invest Dermatol 1939; 2:67–79.
8. Schmid-Wendtner M-H & Korting HC. The pH of the skin surface and its impact on the barrier function. Skin Pharmacol Physiol 2006; 19(6):296–302.
9. Rutishauser S. Physiology and Anatomy, a basis for nursing and health care. Churchill Livingstone, 1994.
10. Andersen PH, Bucher AP, Lee PC, Davis JA & Maibach HI. Faecal enzymes: in vivo skin irritation. Contact Dermatitis 1993; 30:152–158.
11. Eberting CL, Blickenstaff N & Goldenberg A. Pathophysiologic treatment approach to irritant contact dermatitis. Curr Treat Options Allergy 2014; 1:317–328.
12. Andersen PH, Bucher AP, Saeed I, Lee PC, Davis JA & Maibach HI. Faecal enzymes: in vivo human skin irritation. Contact Dermatitis 1994; 30(3):152–158.
13. Buckingham KW & Berg RW. Etiologic factors in diaper dermatitis: the role of feces. Pediatr Dermatol 1986; 3(2):107–112. ISSN: 0736-8046.
14. Williams J, Gwilliam B, Sutherland N et al. Evaluating skin care problems in people with stomas. Br J Nurs 2010; 19(17):S6–S15.
End ileostomy
• PMASD secondary to leakage (Figure 6)
• Barrier seal with pH buffering as part of the overall care plan
• Improvement in five days (Figure 7)
• 24-hour wear time
6 7
Loop ileostomy
• PMASD secondary to leakage (Figure 4)
• Barrier seal with pH buffering as part of the overall care plan
• Improvement in five days (Figure 5)
• 24-hour wear time
4 5
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WCET Journal Supplement, 38(1)
Maintaining peristomal skin integrity is a concern for the tens of thousands of people that undergo ostomy surgery annually. The evidence suggests that as many as two-thirds of all people with an ostomy may develop a serious peristomal skin complication1. It is well documented that a peristomal skin complication can impact health-related quality of life, health economics, with increased use and cost of supplies, and clinical outcomes, as the skin condition may progress into a more severe condition, causing discomfort and pain, and impacting barrier wear time2.
The skin serves as a protective barrier, both internally and externally, by preventing the loss of essential body fluids, the penetration of toxic substances and minimising any additional external assaults3. The peristomal skin is unique in that it is impacted by having an ostomy that secretes excretory irritants that may come in contact with the skin and because it is in continuous contact with an ostomy skin barrier. Some of the obstacles and risks that a person with an ostomy will face will be explored in this paper.
PERISTOMAL MOISTURE-ASSOCIATED SKIN DAMAGE (PMASD)
PMASD is one of the most common causes of peristomal skin complications4. It is defined as inflammation and erosion of the skin adjacent to the stoma, associated with exposure to effluent such as urine or stool5. A person with a stoma is at risk when effluent comes in contact with the peristomal skin with any leakage under the skin barrier. This leakage can initiate a cascade of events that results in weeping, unhealthy
Elizabeth Taggart BSN, RN, CWOCN
Ostomy Wound Services Memorial Medical Center, Springfield, IL
Karen Spencer BN, ET
Director, Clinical Education, Hollister Incorporated
Maintaining peristomal skin health with ceramide-infused hydrocolloid skin barrier
peristomal skin, pain, discomfort, and non-adherence of the next ostomy skin barrier, causing further leakage.
MEDICAL ADHESIVE-RELATED SKIN INJURY (MARSI)
MARSI is a skin injury related to the improper technique with application and/or removal of adhesive products which may cause skin trauma6. An ostomy skin barrier can be removed daily to weekly depending on the desired wear time. This repeated barrier removal may result in a MARSI and is associated with an elevated trans-epidermal water loss (TEWL) due to the surface stripping of the outer layer of the skin3. Although there may be no visible damage with ostomy barrier removal, there is constant exfoliation of the outer skin layer with removal of any adhesive product.
PMASD
MARSI
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BARRIER OCCLUSION
A person with an ostomy continuously wears an ostomy skin barrier that occludes the peristomal skin for extended periods of time. This ongoing use of an occlusive skin barrier may cause certain histological changes3 and may place the peristomal skin at risk for breakdown. The changes to the peristomal skin may include:
• Thickening of the skin (friction and other injury causing reactive cellular proliferation).
• Inflammatory cell infiltration (reactive to cutaneous barrier compromise).
• Epidermolysis: Where the epidermis detaches from the dermis and forms blisters with fluid between the two layers.
that are infused with zinc, aloe, medicinal honey, vitamins or ceramides to maintain intact healthy skin.
CERAMIDE-INFUSED HYDROCOLLOID SKIN BARRIERS
The support for ceramide-infused hydrocolloid skin barriers has grown since first acknowledged in Japan as potentially having peristomal skin health benefits8. Ceramides are lipid-based molecules that are a natural component of human skin, especially in the stratum corneum. Ceramide links the cells of the epidermis together to form a waterproof, protective barrier. The skin cells are considered like bricks and ceramide as the mortar. A strong brick wall helps minimise the impact the external environment has on the skin. This is particularly so with peristomal skin that is at risk due to occlusion, exposure to leakage and mechanical trauma. Stratum corneum-associated ceramide in the skin also helps prevent TEWL, and as a structural moisturiser, it keeps the skin hydrated. It is important to keep skin hydrated because it is less likely to trigger the inflammatory response common with dry and disrupted skin that is associated with itching.
PERISTOMAL ITCHING
Peristomal itching as a response from histamine and other inflammatory markers under the ostomy skin barrier may create physical discomfort to the patient. In a study of 164 individuals, peristomal itching was reported by 87% of individuals with a stoma; 36% of the time the skin was self-reported as appearing healthy. Seventy-one per cent (71%) of nurses in the study recalled a time when patients reported peristomal itching when the skin was free of peristomal skin complications7.
The peristomal skin is an environment in which skin conditions are very likely to occur due to a variety of factors described. An overarching goal of good ostomy management is to limit the occurrence and severity of peristomal skin complications by creating an optimal environment at the interface between the peristomal skin and ostomy skin barrier. To mitigate the potential for serious peristomal skin complications, ostomy product manufacturers have recently begun to introduce products with new barrier formulations
A case series documented the use of an ostomy skin barrier infused with ceramide (CeraPlus skin barrier with Remois technology, Hollister Incorporated). Each of the patients in this case series presented with a peristomal skin complication and was evaluated using the DET scale9. The Ostomy Skin Tool is a standardised measuring instrument for assessing the extent and severity of peristomal skin change in terms of discoloration (D), erosion (E), and tissue overgrowth (T) (DET). The DET scale has a range of 0 to 15, with 0 indicating healthy normal peristomal skin and a score of 15 indicating severe skin trauma; more than 50% of skin area discoloured, eroded or ulcerated with tissue overgrowth. Consent of patients authorising anonymous use of data was obtained.
CASE STUDIES
Case 1
An adult patient with an end ileostomy. The patient presented with acute dermatitis and a probable secondary yeast component under the peristomal skin barrier; 50% of
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WCET Journal Supplement, 38(1)
the area was discoloured with pain, itching and burning. The
skin appeared shiny and 50% of the peristomal skin suffered
from erosion and ulceration with damage to the upper level
of the skin. Prior to using the ceramide-infused barrier, the
patient’s DET score was assessed as 9 out of a possible 15.
The patient was directed to use a ceramide-infused ostomy
skin barrier as part of the overall plan of care. There was no
change in resource utilisation and the patient remained with a
three-day wear time. After using the ceramide-infused barrier
over a period of 21 days, the patient’s DET score was rated as
0, as the skin condition returned to a normal appearance with
no discoloration and no skin erosion or ulceration.
Case 2
An adult patient with a colostomy. The patient presented
with peristomal skin complications; the area beneath the
hydrocolloid adhesive skin barrier clinically demonstrated
50% discoloration with associated pain, itching and burning.
More than 50% of the peristomal skin suffered from erosion
(loss of surface epidermis with an epidermal base) and
ulceration (loss of epidermis with a dermal or deeper base).
The lower layers of the skin were damaged with associated
excess moisture and bleeding. In addition, the patient had a
resource utilisation of one pouching system change every two
days. Prior to using the ceramide-infused barrier, the patient’s
DET score was 10 out of a possible 15.
Before using ceramide-infused hydrocolloid skin barrier DET score 9
After using ceramide-infused hydrocolloid skin barrie over a period of 21 days DET score 0
Before using ceramide-infused hydrocolloid skin barrier DET score 10
After using ceramide-infused hydrocolloid skin barrier over a period of 14 days DET score 0
The patient was directed to use a ceramide-infused hydrocolloid skin barrier. Resource utilisation was reduced to one pouching system change every four days. After using
the ceramide-infused barrier over a period or 14 days, the
patient’s DET score was 0, with a return to normal appearing
peristomal skin with no skin breakdown and no erosion or
ulceration
DISCLAIMER
These studies represent individual nurse/patient experiences
and are not meant to suggest all patients will share the same
experience.
CONCLUSIONS
The studies in which patients who experienced non-intact
peristomal skin including discoloration, irritation, and
erosion, benefited from the use of a ceramide-infused skin
barrier. Peristomal skin complications can be a persistent
problem for those that have undergone ostomy surgery. The
authors conclude that the use of a ceramide-infused skin
barrier may help reduce the potential for such problems.
REFERENCES
1. Lyon C & Smith A. Abdominal Stomas and Their Skin Disorders. London: Martin Dunitz Ltd, 2001, p. IX.
2. Neil N, Inglese G, Manson A & Townshend A. A cost-utility model of care for peristomal skin complications. JWOCN 2015; 00(00):1–7.
3. Rolstad B, Ermer-Seltun J & Bryant R. Relating knowledge of anatomy and physiology of the skin to peristomal skin care. Journal of Gastrointestinal Nursing 2011; 9(9).
4. Gray M, Colwell J, Doughty D et al. Peristomal moisture-associated skin damage in adults with fecal ostomies. JWOCN July/August 2013.
5. Wound, Ostomy and Continence Nurses Society Core Curriculum: Ostomy Management. Philadelphia: Wolters Kluwer, 2016, p. 178.
6. McNichol L, Lund C, Rosen T & Gray M. Medical adhesives and patient safety: State of the Science. JWOCN July/August 2013.
7. Salvadalena G & Menier M. How common is peristomal itching in the absence of visible skin problems? Poster presentation, WOCN/CAET Joint Conference, Montreal, Quebec, 2016.
8. Ishii H, Komiyama K, Mizokami C, Sinden M & Mizokami Y. Prospective evaluation of skin barriers containing ceramide for stoma patients. WCET Journal 2016; 36(2):8–12.
9. Jemec GB et al. Assessing peristomal skin changes in ostomy patients: validation of the Ostomy Skin Tool. Br J Dermatol 2011; 164(2):330–335.
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Thom NicholsBiostatistician: Research Fellow Statistics and Health Economics Hollister Incorporated
Gary IngleseSenior Director, Global Market Access Hollister Incorporated
The burden of peristomal skin complications on health utility and quality of life
It is well documented in the published literature that peristomal skin complications (PSCs) are a common and recurrent problem for those that have undergone ostomy surgery1. While PSCs arise from many causes, and can be both acute and chronic in nature, it is commonly the depletion of the stratum corneum, through the repeated application and removal of ostomy appliances that provides ideal conditions for irritant reactions. Enzyme-rich stomal effluent coming into contact with compromised peristomal skin can result in acute or chronic irritant contact dermatitis2. This can become an intermittent yet lifelong problem for ostomates. It is estimated that PSCs affect upwards of two-thirds of ostomates at some point in time3, and are estimated to account for up to 40% of all ostomy-related visits to a stoma specialist nurse4,5.
In recent years, studies of PSCs have revealed that the burden of this problem is more than a dermatologic issue. The burden of PSCs is demonstrated to not only affect the physical wellbeing of the ostomate, but also have socio-economic impact. Recent published studies have shown that peristomal skin problems are an economic issue, a quality of life (QoL) issue, a health utility issue, and a societal issue5-8. What is apparent from this is that PSCs are health stressors influencing the burden of health, societal interactivity, and economic status of the ostomate, thus maintaining the integrity of a patient’s peristomal skin is a primary health care objective. Nichols and Inglese, writing in Value in Health7 concluded that as peristomal skin integrity improves, health utility, quality-adjusted lifetimes, and associated QoL improves. But, what is meant by this?
To fully understand this, one must first have a fundamental understanding of health utility. Simply put, health utility is a single value, between 0 and 1, that reflects the health-related quality of life (HRQoL) of an individual at a particular point in time7. Perfect health has a utility value of 1. Death has a utility value of 0. The utility approach to assessing health can
be used to measure the impact that a condition, or disease state, has on the HRQoL of the individual.
Health utility may be best described in Figure 1 where increasing utility values represent decreases in the impact that a condition or disease state has on the individual9. Maruish10 reports the average health utility for adults in the US as 0.74. A recent study by Hollister Incorporated of 2,329 US ostomates reports the health utility of ostomates with intact, non-compromised, peristomal skin similar to this; at 0.75 (Hollister Pouching System Impact Assessment — data on file). However, this study also found that at various levels of compromised peristomal skin health utility values decreased:
Healthy skin = 0.75; Mild PSC = 0.69; Moderate PSC = 0.64; Severe PSC = 0.59. Thus, as a PSC worsens, health utility decreases. The question then becomes what is the impact on HRQoL?
Figure 1
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PERISTOMAL SKIN COMPLICATIONS NEGATIVELY IMPACT HRQoL
The International Society for Quality of Life Research defines HRQoL as the functional effect of a medical condition upon a patient11. It is subjective and multidimensional in that it must consider varying domains of life such as physical and emotional domains, social interaction, vitality, pain and so on. In an ostomy population the functional effect of peristomal skin conditions upon the ostomate is shown to vary according to the severity of the peristomal skin condition7. Utilising the SF-36v2, a generic health survey instrument, as part of the Hollister Pouching System Impact Assessment, the data found statistically significant decreases in health utility between peristomal skin severity levels for the domains of Physical Functioning, Role-Physical, Bodily Pain, and General Health. Briefly, as peristomal skin health worsened, the health utility values of these domains decreased. Utilising the overall summary component of these domains, the Physical Component Summary, it was shown that as physical limitations in the ostomy sample increased, increases in the severity of peristomal skin impacted the associated health utility. Translating the health utility data to a quality time reference such as quality-adjusted life days indicated that as physical limitations in the ostomy sample increased, increases in the severity of peristomal skin impacted the quality time of the ostomate.
Quality time is often referred to as quality-adjusted life years (QALYs). Simply put, it is the health utility-adjusted quality time that a person would have in a given period of
time. As an example, if someone has a health utility value of 1 (best attainable health), and they live for 10 years they are said to have 10 quality years. However, if the person has a health utility value of 0.75 they are said to have 7.5 quality-adjusted life years out of 10 possible. But, peristomal skin irritation is an intermittent condition and speaking of quality years may not represent the most interpretable time duration. Speaking in terms of a month, or 30 days, may be more appropriate. For a person with a health utility value of 1 we would say they have 30 quality days out of a possible 30. For a person with a health utility value of 0.75 they would have 22.5 quality-adjusted life days out of 30 possible (0.75 x 30 days). The Hollister Pouching System Impact Assessment found that, on average, the difference between intact non-compromised peristomal skin and severely irritated peristomal skin costs the ostomate approximately 3.7 quality days per month7. This is shown to be statistically significant (p<0.001). Thus, moving an ostomate with severely irritated peristomal skin to a condition of intact, non-compromised skin may have the potential to provide, on average, an additional 3.7 quality days per month7. Similar results were found for QoL. The ostomates were asked to rate their overall QoL (visual analog scale 0 to 100). It was shown that as QoL decreased there were associated increases in the severity of peristomal skin condition. The data indicated that on average, the difference between QoL with intact non-compromised peristomal skin, and severely irritated peristomal skin was 15.8 units of a 0 to 100 unit scale (81.4 – 65.6=15.8). This is shown to be statistically significant (p<0.001).
Figure 2
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SUMMARY
Non-intact peristomal skin is considered a health stressor common to the ostomy population, and the effects of PSCs are numerous, debilitating and costly. However, as peristomal skin condition improves increases in health utility, quality-adjusted lifetimes, and associated QoL also improve. Thus, the successful treatment of a peristomal skin complication has a much broader definition than that of a clinical outcome. It is also the giving back to the individual quality time in their life and this is seen, in the collective, as an overall socio-economic benefit to society.
REFERENCES
1. Salvadalena G. Incidence of complications of the stoma and peristomal skin among individuals with colostomy, ileostomy, and urostomy: a systematic review. JWOCN 2008; 35(6):596–607.
2. Lyon C & Smith A, editors. Abdominal Stomas and Their Skin Disorders, 2nd Edn. CRC Press, 2009, Chapter 3, p. 52.
3. Lyon C & Smith A, editors. Abdominal Stomas and Their Skin Disorders. London: Martin Dunitz, 2001. p. ix.
4. Erwin-Toth P, Stricker LJ & van Rijswijk L. Wound wise: peristomal skin complications. Am J Nurs 2010; 110:43–8.
5. Meisner S, Lehur PA, Moran B et al. Peristomal skin complications are common, expensive, and difficult to manage: a population based cost modeling study. PLoS One 2012; 7:e37813.
6. Nichols T & Riemer M. Body image perception, the stoma, and peristomal skin condition. Journal of Gastrointestinal Nursing 2011; 9(1):22–27.
7. Nichols T & Inglese G. The Burden of Peristomal Skin Complications on an Ostomy Population as Assessed by Health Utility and the Physical Component Summary of the SF-36v2. http://dx.doi.org/10.1016/j.jval.2017.07.004
8. Taneja C, Netsch D, Rolstad BS, Inglese G, Lamerato L & Oster G. Clinical and economic burden of peristomal skin complications in patients with recent ostomies. J Wound, Ostomy Continence Nurs July/August 2017; 44(4):350–357.
9. Bell CM, Chapman RH, Stone PW, Sandberg EA & Neumann PJ. A comprehensive catalog of preference scores from published cost-utility analysis. Medical Decision Making 2001; 21:288.
10. Maruish ME, editor. 2009 Normative Data, in User’s Manual for the SF-36v2 Health Survey, 3rd Ed, Lincoln RI., QualityMetric Incorporated, Chapter 14, 2011, p. 240.
11. http://www.isoqol.org/about-isoqol/what-is-health-related-quality-of-life-research
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WCET Journal Supplement, 38(1)
All stoma care nurses (SCNs) strive to maintain healthy
peristomal skin for people living with an ostomy. All
SCNs will also experience, at some point, the challenges
of managing peristomal skin complications (PSCs) and the
inherent difficulties of achieving resolution. When combined
with the reported rates of PSCs that can range from 61%
to 77%1-3, the need to reflect on its origins and on possible
solutions is emphasised. The current authors have initiated
that exploration, providing insights to peristomal skin health
and the potential role of new barrier technologies in ostomy
care.
The negative impact of PSCs on a person’s life is broad
and significant. Thom Nichols and Gary Inglese reviewed
various metrics that revealed the burden of PSCs. They
were able to clearly identify that PSCs envelop more than
damaged skin. Their review highlighted results that included
reduced health utility scores and a poorer overall quality of
life for those living with PSCs. Spencer and Taggart detailed
the range of PSCs that can occur, and shared their positive
experiences of utilising a ceramide-infused hydrocolloid
skin barrier on skin conditions and their recovery. Rae and
Pridham further examined the origins of peristomal skin
breakdown by reviewing the importance of stomal effluent
and its enzymatic activity on peristomal skin condition.
They also shared their positive results of using a new barrier
technology designed to buffer faecal enzymes and to reduce
their impact on skin integrity.
These reviews have illuminated some of the origins of
PSCs and the possible impact of new barrier formulations
for maintenance of peristomal skin health. These
experiences, however, suggest that a different approach
Jo Hoeflok RN, BSN, MA, CETN(C), CGN(C)
Conclusion
Time to consider prevention in ostomy care
to the management of peristomal skin is required. The
profound impact on individuals living with PSCs warrants
re-examination of the usual responses to care. Continuing
to rely on traditional methods such as waiting for patient
self-identification of PSCs is insufficient. The literature
suggests that persons with an ostomy may not correctly
identify skin-related issues and may view damaged skin as
normal4, ultimately perpetuating the problem and its impact.
In 2011, Purnell stated that ostomy care and the response to
peristomal skin problems was a reactive process5. He further
commented that a more proactive approach to care may
positively influence peristomal skin health, proposing that
“the selection of an appropriate ostomy skin barrier prior to
its application” should be a part of the process5.
That need to focus on a preventive-based mode of care was
further emphasised by the World Council of Enterostomal
Therapists in 2014 when they published their International
Ostomy Guideline Recommendations6. Those guidelines
included the following:
3.2.4 Patients, families and ostomy nurses/clinicians need
to implement prevention and management plans of care to
address potential or actual peristomal and stomal complications.
SOE=B6
By highlighting the need to be proactive, the World
Council of Enterostomal Therapists recognised that it was
insufficient to simply treat PSCs, and that ostomy care begins
with prevention. The case studies outlined by the authors
demonstrate that new barrier formulations can help prevent
peristomal skin breakdown. While some patients may also
need treatment aimed primarily at the cause of the skin
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abnormality, a preventative approach would suggest that these barriers would be first-line choices, supporting the SCN goal of maintaining intact peristomal skin.
The origins of PSCs are complex and multifactorial. Not one single approach will be sufficient to eradicate skin complications from the experiences of people living with an ostomy. However, the authors of this supplement have provided insights to some of its origins and to possible solutions. Understanding the foundations of healthy skin and the proactive selection of ostomy skin barriers and their utilisation may be some of the first steps towards a prevention-based approach to ostomy care, and towards the amelioration of PSCs.
A Closer Look at
the Science of Skin Health
Ostomy Care Healthy skin. Positive outcomes.
The importance of peristomal skin health in ostomy care cannot be overstated.
The condition of the skin greatly affects how well products can adhere, as well as the comfort
and well-being of patients living with a stoma.
Ceramides play a key role in skin health. They:
• Are a natural component of human skin and are abundant in healthy skin
• Help protect the skin’s natural moisture barrier
• Help decrease transepidermal water loss (TEWL) from damaged or eroded skin
Contact your Hollister Ostomy Care representative to learn more about how our products
infused with ceramide help support healthy peristomal skin from the start.
Hollister.com
This supplement has been supported by
March 2018
http://www.hollister.com.au/
REFERENCES
1. Ratliff C. Factors related to ostomy leakage in the community setting. J Wound Ostomy Continence Nurs 2014; 41(3):249–253.
2. Redmond C, Cowin C & Parker T. The experience of faecal leakage among ileostomists. Br J Nurs 2009; 18(17):S14–S17.
3. Richbourg L, Thorpe J & Rapp C. Difficulties experiences by the estimate after hospital discharge. J Wound Ostomy Continence Nurs 2007; 34(1):70–79.
4. Williams J, Gwillam B, Sutherland N et al. Evaluating skin care problems in people with stomas. Br J Nurs 2010; 19(17):S6–15.
5. Purnell P. Proactive decisions vs reactive responses. World Council of Enterostomal Therapists Journal 2011; 32(1):17–18.
6. Stelton S, Zulkowski K & Ayello E. Practice implications for peristomal skin assessment and care from the 2014 World Council of Enterostomal Therapists International Ostomy Guideline. Adv Skin Wound Care 2015; 28(6):275–284.
A Closer Look at
the Science of Skin Health
Ostomy Care Healthy skin. Positive outcomes.
The importance of peristomal skin health in ostomy care cannot be overstated.
The condition of the skin greatly affects how well products can adhere, as well as the comfort
and well-being of patients living with a stoma.
Ceramides play a key role in skin health. They:
• Are a natural component of human skin and are abundant in healthy skin
• Help protect the skin’s natural moisture barrier
• Help decrease transepidermal water loss (TEWL) from damaged or eroded skin
Contact your Hollister Ostomy Care representative to learn more about how our products
infused with ceramide help support healthy peristomal skin from the start.
Hollister.com