Wound, Ostomy, and Continence Nurses Society™ (WOCN®)

Peristomal Skin Assessment Guide for Clinicians

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Funded through an educational grant from 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 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. Evolving terminology also uses the term irritant contact dermatitis (ICD) related to fecal or urinary stoma or fistula. 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 original 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 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 up to 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 (intact or ruptured)
  • 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

Start Over

Analyze results

Healthy Peristomal Skin

Healthy Peristomal Skin Healthy Peristomal Skin

Patient Education

Review Management of Pouching System Regimen

Introduce Peristomal Skin Assessment Guide for Consumers for periodic independent review of peristomal skin health.

Start Over

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 nurse/NSWOC

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

Start Over

Analyze results

Peristomal Moisture Associated Skin Damage (PMASD - Maceration)

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

When effluent undermines the skin barrier, it is trapped against the skin in the immediate peristomal skin resulting in skin damage.

Results analysis

Color of skin damage, White/Gray, confirms a clinical diagnosis based on visual assessment.

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 convex pouching system and/or an ostomy belt 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

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

Introduce Peristomal Skin Assessment Guide for Consumers for periodic independent review of peristomal skin health.

Change pouching system on schedule and whenever there is peristomal itching and/or burning OR skin barrier leaks or loosens. Do not reinforce with tape.

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

Ensure secure seal prior to water activities.

Consider options for drying pouch system after exposure to external source of moisture (e.g., swimming, bathing).

In urinary stomas, consider acidification of urine with cranberry tablets or vitamin C supplements. Additional water intake unless contraindicated may also be considered. Also ensure patient uses night drainage bag placed at the foot of the bed.

Refer to WOC nurse

  • If no improvement after 7-14 days of management
  • If probable contributing factors unclear or not identified

Start Over

Analyze results

Peristomal Moisture Associated Skin Damage (PMASD – Irritant Dermatitis)

Peristomal Moisture Associated Skin Damage (PMASD –Irritant Dermatitis) Peristomal Moisture Associated Skin Damage (PMASD –Irritant Dermatitis) Peristomal Moisture Associated Skin Damage (PMASD –Irritant Dermatitis) 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 and consistency of output
  • Consider use of a barrier ring
  • Consider use of convex pouching system and/or an ostomy belt 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

Thin 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.

Not to be confused with allergic contact dermatitis. If concern (or suspicion) for allergy as cause, consider changing brand of product and/or referral to dermatology.

Patient Education

  • Introduce Peristomal Skin Assessment Guide for Consumers for periodic independent review of peristomal skin health.
  • 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 or urine, increase frequency of pouching system changes.
  • Treatment of open areas with skin barrier powder. Apply alcohol-free liquid skin barrier if used.

Refer to WOC nurse

  • If no improvement after 7-14 days of management
  • If probable contributing factors unclear or not identified

Start Over

Analyze results

Peristomal Moisture Associated Skin Damage (PMASD - Fungal)

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

Results analysis

Solid rash with distinct satellite lesions confirms a clinical diagnosis based on visual assessment.

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.

Antifungal powder: Select an azole, such as miconazole, or polyenes such as nystatin.

Discontinue topical management when problem resolves/skin recovers. If no improvement, consider systemic antifungal therapy to augment topical therapy.

Patient Education

  • Introduce Peristomal Skin Assessment Guide for Consumers for periodic independent review of peristomal skin health.
  • Dry pouching system well after bathing, swimming, or contact with water or steam
  • Proper technique for using antifungal powder, and how to monitor skin appearance and when to discontinue use

When to refer to WOC nurse, primary care provider (PCP) or dermatology provider

  • If no improvement after 7-14 days of management
  • If probable contributing factors unclear or not identified

Start Over

Analyze results

Peristomal Medical Adhesive Related Skin Injury (PMARSI – Adhesion)

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

Manage Probable Contributing Factors: PMARSI 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
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

Refer to WOC nurse

  • If no improvement after 7-14 days of management
  • If probable contributing factors unclear or not identified

Start Over

Analyze results

Peristomal Medical Adhesive Related Skin Injury (PMARSI – Folliculitis)

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

Results analysis

Red papules or pustules at hair follicles confirms a clinical diagnosis based on visual assessment.

Manage Probable Contributing Factors: Damage to Hair Follicles

Probable cause

  • Multidirectional shaving
  • Pulling of hair with pouch removal
  • Proper pouch removal technique:
    • Loosen edges of adhesive product
    • With fingers of opposite hand push skin down away from adhesive
    • Gently remove adhesive product in the direction of hair growth keeping it close to the skin surface
    • When product is removed, slide fingers of opposite hand if necessary to support newly exposed skin
  • Consider use of adhesive remover to prevent skin damage
    • If skin loss is present consider additional topical treatment options
  • Topical Treatment:

Patient Education

  • Removal of pouching system:
    • Remove by pushing down on skin and pulling gently to remove the pouching system
  • Hair removal:
    • Remove hair by clipping with scissors or shaving with a single-use disposable razor away from the stoma and in the direction of hair growth when possible. Avoid use of depilatories or dry shaving. The person with an ostomy may consider permanent hair removal techniques.
  • Use of adhesive remover. If used, teach to rinse and dry skin gently
  • Skin cleansing: Routinely cleanse the peristomal skin with a plain soft material such as paper towel, washcloth, or nonsterile gauze, and clean water.
    • Consider temporary use of mild antibacterial soap with thorough rinsing until inflammation resolves

Refer to WOC nurse

  • If no improvement after 7-14 days of management
  • If probable contributing factors unclear or not identified

Start Over

Analyze results

Referral

Referral Referral Referral Referral

Results analysis

Findings of deeper full thickness skin loss with or without purulent drainage suggest skin damage may be related to systemic problem.

Referral

  • Report assessment findings to physician or advance practice nurse.
  • Initiate referral to a WOC 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 better seal.
  • Consider use of convex pouching system and/or an ostomy belt 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 shallow open areas with skin barrier powder. Dust powder on area of skin loss and brush away excess.
  • Apply pouching system.

If crater or full thickness skin loss:

  • Rinse open area with saline or tap water.
  • Fill area with skin barrier powder or absorbent wound dressing.
  • Consider use of a thin cover dressing over powder or absorbent dressing.
  • Apply pouching system over thin cover dressing ensuring skin barrier opening is sized to fit closely around stoma base.

If pain reported:

  • Address pain management; individualize to patient need

Patient Education

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Definitions

blister1

Blister
Elevation of epidermis that contains clear fluid.

convexity

Convexity
Outward curving of the skin barrier toward the abdomen to promote a seal between the skin and pouching system. Essential characteristics of convexity are depth, compressibility, flexibility, tension location and slope.

skin_loss1

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

flush stoma1

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

stoma2
flush healthy_skin1

Healthy Peristomal Skin
Abdominal skin surrounding the stoma beneath the adhesive portion of the ostomy pouching system (barrier and tape). Peristomal skin should have the same appearance as skin on the rest of the abdomen.

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
pmarsi
purulent

Purulent
Consisting of, containing, or discharging pus.

purulent
pustule

Pustule
An elevation of the skin that contains pus.

retracted-stoma

Retracted Stoma
A stoma that is located below peristomal skin. Also known as recessed stoma.

retracted-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:
An unpleasant feeling of the skin that provokes the urge to scratch.

patchy

Patchy
Scattered distribution of skin damage.

papule

Papule
A solid, elevated lesion with no visible fluid.

Peristomal Skin Folds/Creases

Peristomal Skin Folds/Creases
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): 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
Effective pouch seal is a skin barrier opening sized to fit closely around stoma base, prevent undermining or leakage, and ensure a predictable wear time.

Powder Application

Skin Barrier Powder Application
A. Sprinkle powder on to skin

Powder Application

B. and dust off excess.

skin loss

Skin Loss from undermining or leakage of pouching system
Loss of epidermal layer of skin: may be uniform or patchy; edges may be well defined or irregular; When effluent undermines the skin barrier, it is trapped against the skin in the immediate peristomal skin resulting in skin damage. When leakage occurs, effluent extends beyond the border of the skin barrier.

Skin Overgrowth

Skin Overgrowth
Thickening and/or elevation of epidermal/dermal layers due to chronic irritation.

Skin Overgrowth
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Peristomal Skin Care Products

  Coloplast Convatec Dansac Hollister Marlen Nu-Hope Safe n Simple
Liquid skin barrier  (wipes or spray); skin protectant  X X X X     X
Adhesive remover (wipes or spray) X X X X     X
Stoma powder; ostomy powder; skin barrier powder X X X X   X X
Skin barrier ring X X X X X X X
Stoma paste; skin barrier paste (tube or strips) X X X X   X X
Skin barrier sheet X X     X X X
Ostomy Belt X X X X X X  
Stoma Measuring Guide X X   X      
Flat skin barrier pouch systems X X X X X X  
Convex skin barrier pouch systems X X X X X X  

 

Disclaimers:
Product names are examples only and are not inclusive or intended as an endorsement.
It is important to follow the manufacturer’s directions regarding the use and application technique for specific products in order to achieve the desired results.
The WOCN Society does not endorse any specific brands or products.

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Patient Education

Manage current pouching system regime.

  • Characteristics of normal peristomal skin
  • Findings that would suggest evaluation by WOC nurse/NSWOC 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