Wound, Ostomy and Continence Nurses Society™

Peristomal Skin Assessment Guide

Developed in partnership with Hollister Incorporated

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Peristomal Skin Complications:
Assessment and Management

Peristomal skin damage is never normal. Peristomal skin complications are broadly defined as an alteration to the skin around the stoma. These complications can cause problems with barrier adhesion and patient comfort. Determining the etiology of the complication helps to address the problem, and plan the care. As signs and symptoms vary, proper identification can present challenges to the clinician and patient.

This Peristomal Skin Assessment Guide has been developed to help standardize assessments, identify probable reasons for the complication, and provide simple options for management.

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How to Use This Guide

This Peristomal Skin Assessment Guide is intended for use with adult patients. It is intended to indicate the source of some common complications, next steps and when to refer to a WOC/ET nurse for additional support.

This guide is not meant to replace expert clinical assessment and intervention.

For your assessment:

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About

Peristomal skin complications can occur from a wide variety of sources. Understanding the source can help target appropriate management strategies. Two of the most common sources are Peristomal Moisture Associated Skin Damage (PMASD) and Peristomal Medical Adhesive Related Skin Injury (PMARSI).

PMASD is defined as inflammation to the peristomal skin as a result of exposure to a moisture source such as urine or stool. Clinical experience also suggests that exposure to external moisture sources such as swimming, and the use of hot tubs, may also influence the presence of PMASD. This guide will help identify various PMASD sources including: irritant dermatitis, maceration, and fungal rash.

PMARSI is defined as erythema or other abnormal skin manifestations such as blisters, erosions or tears that persist for 30 minutes or more after removal of the adhesive. This guide will help identify various PMARSI sources including: folliculitis, and skin stripping (trauma).

Thank you to the dedicated developers of the Peristomal Skin Assessment Guide:

Mikel Gray, PhD, FNP, PNP, CUNP, CCCN, FAANP, FAAN
Professor and Nurse Practitioner, Department of Urology,
University of Virginia, Charlottesville, Virginia

Janice C. Colwell, MS, RN, CWOCN, FAAN
Advanced Practice Nurse – Ostomy Care Services
University of Chicago, Chicago, Illinois

Dorothy Doughty, MN, RN, CWOCN, FNP, FAAN
Emory University Hospital, Atlanta, Georgia

Margaret Goldberg, MSN, RN, CWOCN
Clinical Nurse Specialist/WOC Nurse,
Delray Medical Center, Delray Beach, Florida

Jo Hoeflok, RN (EC), BSN, MA(LS), CETN(C), CGN(C)
Nurse Practitioner for Gastroenterology & General Surgery
St. Michael’s Hospital, Toronto, Ontario, Canada

Andrea Manson, RN, BSN, ET
Ostomy Care & Supply Centre,
New Westminster, British Columbia, Canada

Laurie McNichol, MSN, RN, CNS, GNP, CWOCN, CWON-AP, FAAN
Clinical Nurse Specialist/WOC Nurse,
Cone Health, Wesley Long Hospital, Greensboro, North Carolina

Samara Rao, BScN, RN, CETN(C)
Alberta Health Services Royal,
Alexandra Hospital, Edmonton Alberta, Canada

Joy Boarini, BSN, MSN, WOC Nurse
Hollister Incorporated, Libertyville, IL USA

Diane Owen, BSN, MBA
Hollister Incorporated, Libertyville, IL USA

Ginger D. Salvadalena, PhD, RN, CWOCN
Hollister Incorporated, Libertyville, IL USA

Karen Spencer, BN, ET
Hollister Incorporated, Libertyville, IL USA

The WOCN Society does not endorse any specific brands or products.

How to Use This Guide

This Peristomal Skin Assessment Guide is intended for use with adult patients. It is intended to indicate the source of some common complications, next steps and when to refer to a WOC/ET nurse for additional support.

This guide is not meant to replace expert clinical assessment and intervention.

For your assessment:

  • Remove the patient’s pouching system.
  • Assess the patient in both the sitting and lying positions.
  • Answer four assessment questions and review results.
  • Choose the most appropriate answer that corresponds with your assessment.
  • Document assessment and results per facility protocol.
Start

Assess your patient

What is the location/distribution of the skin damage?

  • Free of any damage, no rash
  • Immediately bordering the stoma
  • Not bordering the stoma
  • Solid rash with distinct satellite lesions
  • Papules or pustules at hair follicles
  • Patchy, scattered distribution

Assess your patient

What color is the skin damage?

  • No persistent redness; variation in pigmentation may occur
  • Red
  • White/gray
  • Red AND White/Gray

Assess your patient

What characteristics do you observe?

  • Skin intact: not moist; no blisters; no overgrowth
  • Areas of skin loss (open and moist)
  • Crater; deep tissue loss
  • Skin overgrowth
  • Maceration, waterlogged
  • Blisters
  • Purulent drainage
  • Areas of skin loss AND skin overgrowth

Assess your patient

What information does the patient report?

  • No pain, no persistent itching or burning, able to maintain pouch seal
  • Persistent itching/burning
  • Persistent pain in the area of involvement
  • Unable to maintain pouch seal for 24 hours
  • Sensitivity to touch or pressure

Analyze results

Normal Peristomal Skin

Normal Peristomal Skin Normal Peristomal Skin

Patient Education

Review Management of Pouching System Regimen

  • Review characteristics of normal peristomal skin
  • Identify peristomal skin changes that would suggest evaluation by WOC/ET nurse or physician
  • Ensure the skin barrier is sized to fit closely around stoma base
  • Change barrier if experiencing burning, itching, and leakage
  • Change pouching system at intervals that provide predictable and reliable wear time and help maintain healthy skin
  • Cleanse peristomal skin with warm tap water
  • Remove hair around stoma if indicated
  • Gently remove pouching system:
    • Loosen edges of adhesive product
    • With fingers of opposite hand, push skin down and away from adhesive
    • Gently remove adhesive product back over itself in the direction of hair growth, keeping it close to the skin surface
    • As product is removed, continue moving fingers of opposite hand as necessary to support newly exposed skin

Analyze results

Peristomal Moisture Associated Skin Damage (PMASD)

Peristomal Moisture Associated Skin Damage (PMASD) Peristomal Moisture Associated Skin Damage (PMASD) Peristomal Moisture Associated Skin Damage (PMASD)

Manage Probable Contributing Factors: Evaluate and Revise Pouching System

Skin Barrier/Pouch Change
Instruct to change skin barrier promptly when:

  • There is itching and/or burning
  • Skin barrier leaks or loosens

Barrier Contour
Consider use of an ostomy belt or convex skin barrier/pouch for:

  • Retracted Stoma
  • Flush Stoma
  • Peristomal skin folds

or

Consider flexible, flat one-piece skin barrier/pouch for:

  • Stoma in deep fold/crease

Skin Barrier Opening
Ensure skin barrier opening is sized to fit closely around stoma base

Wear Time
Consider if pouching system actual wear time is longer than recommended

Topical Treatment

Choose best option based on availability.
Skin Barrier Powder +/- Skin Sealant
Dust powder on area of skin loss or excessive moisture. Brush away excess.
Seal powder with “no sting” skin sealant or water if desired.

Hydrocolloid Sheet for Areas of Skin Loss
Size the sheet to fit around the stoma and use it as a base under pouching system.

Discontinue topical management when problem resolves/skin recovers.

Patient Education

  • Cause of peristomal skin condition, and reason for topical management
  • Evaluate skin at each pouch change and when to seek additional assistance
  • Possible lifestyle modifications: Avoid long term exposure to external moisture sources (swimming, hot tubs, steam); implement measures to reduce peristomal perspiration; or change pouch more frequently

Refer to WOC/ET Nurse

  • If no improvement after 7 days of management
  • Probable contributing factors unclear or not identified

Analyze results

Peristomal Moisture Associated Skin Damage (PMASD -Maceration)

Peristomal Moisture Associated Skin Damage (PMASD -Maceration) Peristomal Moisture Associated Skin Damage (PMASD -Maceration)

Manage Probable Contributing Factors: Overhydration of Barrier and Skin

Assure Appropriate Frequency of Pouching System Change
Remove pouching system and assess adhesive side of skin barrier for degree of softening and whitening (overhydration). If there is significant overhydration of the barrier, change pouching system more frequently.

Assess Fit of Barrier/Pouching System
Ensure skin barrier opening is sized to fit closely around stoma base

Assess stomal height, location of stomal opening (os), and peristomal skin surface (folds, creases, and valleys).

  • Consider use of an ostomy belt and/or convex pouching system for patient with retracted stoma, flush stoma, or peristomal skin folds.
  • or

  • Consider flexible, flat one-piece pouching system for patient with stoma in deep fold/crease.

Topical Treatment

Skin Barrier Powder +/- Alcohol-free Liquid Skin Barrier Treatment of overhydrated areas: Dust with Skin Barrier Powder; brush off excess. Optional: Apply alcohol-free liquid skin barrier over powder to form protective film.

Discontinue topical management when problem resolves/skin recovers.

Patient Education

Change pouching system on schedule and whenever there is peristomal itching and/or burning OR skin barrier leaks or loosens.

Assess adhesive side of barrier and skin at each pouch change. If the barrier or skin appears overhydrated, increase frequency of pouch changes.

Refer to WOC/ET Nurse

  • If no improvement after 7 days of management
  • Probable contributing factors unclear or not identified

Analyze results

Peristomal Moisture Associated Skin Damage (PMASD –Irritant Dermatitis)

Manage Probable Contributing Factors: Poor Fit of Pouching System

Assess Fit of Pouching System:

Ensure skin barrier opening is sized to fit closely around stoma base

  • Assess stomal height, location of stomal opening (os), peristomal skin surface (folds, creases, and valleys), and volume of output
  • Consider use of a barrier ring for patients with high-volume output
  • Consider use of an ostomy belt and/or convex pouching system for patient with retracted stoma, flush stoma, or peristomal skin folds
  • or

  • Consider flexible, flat one-piece pouching system for patient with stoma in deep fold/crease

Assure Appropriate Frequency of Pouching System Change

  • Change barrier if experiencing burning, itching or leakage
  • Change pouching system at intervals that provide predictable and reliable wear time and help maintain healthy skin
  • Remove pouching system and assess adhesive side of skin barrier for evidence of undermining/leakage of stool. If there is evidence of undermining/leakage, increase frequency of pouching system changes.

Topical Treatment

Skin Barrier Powder +/- Alcohol-free Liquid Skin Barrier
Treatment of open areas: Dust with Skin Barrier Powder; brush off excess. Optional: Apply alcohol-free liquid skin barrier over powder to form protective film.

And/Or

Hydrocolloid Sheet for Areas of Skin Loss
Size the sheet to fit around the stoma and use it as a base under pouching system.

Discontinue topical management when problem resolves/skin recovers.

Patient Education

  • Change pouching system on schedule and whenever there is itching and/or burning OR skin barrier leaks or loosens.
  • Assess adhesive side of barrier and skin at each pouch change. If there is evidence of undermining of stool, increase frequency of pouching system changes.
  • Treatment of open areas with skin barrier powder. Apply alcohol-free liquid skin barrier if included in plan of care.

Refer to WOC/ET Nurse

  • If no improvement after 7 days of management
  • Probable contributing factors unclear or not identified

Analyze results

Peristomal Moisture Associated Skin Damage (PMASD -Fungal)

Peristomal Moisture Associated Skin Damage (PMASD -Fungal) Peristomal Moisture Associated Skin Damage (PMASD -Fungal)

Manage Probable Contributing Factors: Excessive Skin Moisture and Overgrowth of Fungal Organisms

Assure Appropriate Frequency of Pouching System Change
Remove pouching system and assess adhesive side of skin barrier for degree of softening and whitening (overhydration). If there is significant overhydration of the barrier, change pouching system more frequently.

Skin Barrier Opening
Ensure skin barrier opening is sized to fit closely around stoma base.

Topical Treatment

Antifungal Powder +/- Alcohol-free Liquid Skin Barrier Dust powder on affected area. Brush away excess. Seal powder with alcohol-free liquid skin barrier if desired.

Discontinue topical management when problem resolves/skin recovers.

Patient Education

  • Dry pouching system well after bathing, swimming, or contact with water or steam
  • Proper technique for using antifungal powder, and how to monitor and when to discontinue use

Refer to WOC/ET Nurse

  • If no improvement after 7 days of management
  • Probable contributing factors unclear or not identified

Analyze results

Peristomal Medical Adhesive Related Skin Injury (PMARSI – Adhesion)

Peristomal Medical Adhesive Related Skin Injury (PMARSI) Peristomal Medical Adhesive Related Skin Injury (PMARSI)

Manage Probable Contributing Factors: Adhesive Skin Injury

Adhesive Removal

  • Adhesive removal technique
  • Options for removal of residual adhesive: Do not remove excessive adhesive (pouch over and remove with next system removal) OR use a commercial medical adhesive remover.
  • Do not use tackifiers (products that increase adhesion) or tincture of benzoin.

Topical Treatment

Adhesive Remover or Releaser
Consider use to minimize damage to skin.

Treatment of open areas:
Dust with skin barrier powder; brush off excess. Optional: Apply alcohol-free liquid skin barrier over powder to form protective film.

If skin injury is limited to area of tape border, consider trimming tape border, using barrier-only system, or adding hydrocolloid dressing under tape border.

Patient Education

  • Gentle removal of pouch by pushing down on skin and pulling gently on the pouching system.
  • Use of adhesive remover/releaser. If adhesive remover is used, wash and dry skin.
  • Treatment of open areas with skin barrier bowder Apply alcohol-free liquid skin barrier if included in plan of care.

Refer to WOC/ET Nurse

  • If no improvement after 7 days of management
  • Probable contributing factors unclear or not identified

Analyze results

Peristomal Medical Adhesive Related Skin Injury (PMARSI – Folliculitis)

Peristomal Medical Adhesive Related Skin Injury (PMARSI) Peristomal Medical Adhesive Related Skin Injury (PMARSI)

Manage Probable Contributing Factors: Damage to Hair Follicles

Adhesive Removal technique

  • Loosen edges of adhesive product
  • With fingers of opposite hand, push skin down and away from adhesive
  • Gently remove adhesive product back over itself in the direction of hair growth, keeping it close to the skin surface
  • As product is removed, continue moving fingers of opposite hand as necessary to support newly exposed skin

Hair Removal
Frequency and technique: Clipping or use of electric razor recommended; frequency dependent on rate of hair growth.

Topical Treatment

Adhesive Remover or Releaser
Consider use to prevent skin damage. If patchy skin loss is present, consider additional topical treatment options.

Skin Cleansing
Recommend use of mild antibacterial soap with thorough rinsing until inflammation resolves.

Treatment of open areas (if any)
Dust with Skin Barrier Powder; brush off excess.

Patient Education

  • Removal of pouching system:
    • Gently remove pouch by pushing down on skin and pulling gently on the pouching system.
  • Use of adhesive remover/releaser. If adhesive remover is used, wash and dry skin.
    • Skin cleansing: Recommend use of mild antibacterial soap with thorough rinsing until inflammation resolves.
    • If indicated, treat open areas by dusting with skin barrier powder and brushing off excess..
    • Frequency and technique for hair removal: Clipping or use of electric razor recommended; frequency dependent on rate of hair growth.

Refer to WOC/ET Nurse

  • If no improvement after 7 days of management
  • Probable contributing factors unclear or not identified

Analyze results

Referral

Referral

  • Report assessment findings to physician or advance practice nurse.
  • Initiate referral to a WOC/ET Nurse.

Interim Interventions

If unable to maintain pouch seal for 24 hours:
Assess Fit of Pouching System:

  • Ensure skin barrier opening is sized to fit closely around stoma base.
  • Assess stomal height, location of stomal opening (os), peristomal skin surface (folds, creases, and valleys), and volume of output.
  • Consider use of a barrier ring for patients with high-volume output.
  • Consider use of an ostomy belt and/or convex pouching system for patient with retracted stoma, flush stoma, or peristomal skin folds.
  • OR

  • Consider flexible, flat one-piece pouching system for patient with stoma in deep fold/crease.
  • Change pouch when leaking, and do not reinforce with additional tape.

If purulent drainage:

  • Assess for other signs of infection and report.
  • Rinse open area with saline or tap water.
  • Fill any open areas with skin barrier powder. Dust powder on area of skin loss and brush away excess.
  • Apply pouching system.

If ulcer or full thickness skin loss:

  • Rinse open area with saline or tap water.
  • Fill area with skin barrier powder or absorbent wound dressing.
  • Cover powder or dressing with a hydrocolloid sheet.
  • Apply pouching system over hydrocolloid sheet.

If pain reported:

  • Address pain management; individualized to patient need

Patient Education

  • Importance of follow-up care with specialist
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Definitions

blister

Blister
Elevation of epidermis that contains clear fluid.

convexity

Convexity
Outward curving of the skin barrier toward the abdomen to promote a good seal between the skin and pouching system where flat barriers would not be successful.

crater

Full thickness skin loss
Loss of epidermis and dermis; wound extends into fat.

flush stoma

Flush Stoma
A stoma that is level with the peristomal skin.

Pigmentation: Normal

Pigmentation: Normal
Normal coloration of the skin.

pmarsi

Peristomal Medical Adhesive Related Skin Injury (PMARSI) – Folliculitis
Inflammation of hair follicles.

pmarsi
pmarsi

Peristomal Medical Adhesive Related Skin Injury (PMARSI) – Adhesive Injury
Skin injury related to use and/or removal of adhesives.

pmarsi
purulent

Purulent
Consisting of, containing, or discharging pus.

pustule

Pustule
An elevation of the skin that contains pus.

retracted-stoma

Retracted Stoma
The disappearance of normal stomal protrusion below skin level. Also known as recessed stoma.

Sensations
Burning:
Persistent pain,tingling, prickling sensation of the skin in the area of involvement; may be constant or may occur when stoma functions.

Itching:
Intense, distracting, or irritating sensation at the area of peristomal skin.

patchy

Patchy
Scattered distribution of skin damage.

papule

Papule
A solid, elevated lesion with no visible fluid.

peristomal

Peristomal Skin
The area around the stoma starting at the skin/stoma junction and extending outward to the area covered by the pouching system.

Peristomal Skin Folds/Creases

Peristomal Skin Folds/Creases
Alteration in the abdominal contours resulting in a linear defect.

PMASD: Fungal Rash

Peristomal Moisture Associated Skin Damage (PMASD): Fungal Rash
Characterized by a confluent center and distinct satellite lesions.

PMASD: Fungal Rash
(PMASD -Maceration)

Peristomal Moisture Associated Skin Damage (PMASD): Maceration
The softening and breaking down of skin resulting from prolonged exposure to moisture.

(PMASD -Maceration)
(PMASD): Irritant Dermatitis (Acute)

Peristomal Moisture Associated Skin Damage (PMASD): Irritant Dermatitis (Acute)
Areas of skin loss and inflammation due to exposure to stool and/or urine.

(PMASD): Irritant Dermatitis (Chronic)

Peristomal Moisture Associated Skin Damage (PMASD): Irritant Dermatitis (Chronic)
Areas of skin overgrowth and areas of skin loss/inflammation due to repeated exposure to stool and/or urine.

Pouch Seal

Pouch Seal
The internal opening must be the correct size to accommodate the individual’s stoma while protecting the skin from contact with waste.

Powder Application

Skin Barrier Powder Application
A. Sprinkle powder on to skin

Powder Application

B. and dust off excess.

Proper Fit of Skin Barrier

Proper Fit of Skin Barrier
The barrier fits closely around the base of the stoma with minimal or no skin exposed.

skin loss

Skin Loss
Loss of epidermal layer of skin: may be uniform or patchy; edges may be well defined or irregular.

Skin Overgrowth

Skin Overgrowth
Thickening and/or elevation of epidermal/dermal layers.

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Peristomal Skin Care Products

Ostomy Accessories


Skin Barriers and Skin Barrier Accessories

Flat Barrier

Flat Barrier

Hydrocolloid Sheet

Hydrocolloid Sheet

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Patient Education

Manage current pouching system regime.

  • Characteristics of normal peristomal skin
  • Findings that would suggest evaluation by WOC/ET nurse or physician
  • How to ensure the skin barrier is sized to fit closely around stoma base
  • Change pouch for burning, itching, and leakage
  • Change pouching system at intervals that provide predictable and reliable wear time and help maintain healthy skin
  • Cleanse with warm tap water
  • Routine hair removal if indicated
  • How to gently remove pouching system:
    • Loosen edges of adhesive product
    • With fingers of opposite hand, push skin down and away from adhesive
    • Gently remove adhesive product back over itself in the direction of hair growth, keeping it close to the skin surface
    • As product is removed, continue moving fingers of opposite hand as necessary to support newly exposed skin