What is the best course of treatment for a patient with a protruding stoma and worsening skin breakdown around the stoma?

Management of Protruding Stoma with Worsening Peristomal Skin Breakdown

The patient with a protruding stoma that was manually reduced and worsening skin breakdown requires immediate consultation with a wound ostomy and continence (WOC) nurse specialist or enterostomal therapist for proper assessment and treatment. 1

Assessment of the Stoma and Skin Condition

Stoma Assessment

• Evaluate for signs of stomal prolapse (elongation of intestinal portion of stoma)
• Check for:
  • Pain, obstipation, or purple/black discoloration (indicating ischemia requiring emergency surgery)
  • Proper positioning of the stoma after reduction
  • Adequate tension between internal and external bolsters 1

Skin Assessment

• Identify the cause of skin breakdown:
  • Leakage around appliance (most common cause)
  • Allergic reaction to appliance (presents as itching and redness in shape of product)
  • Fungal infection (itchy maculopapular rash with satellite borders)
  • Folliculitis
  • Pyoderma gangrenosum (painful ulcers with purple halo, especially in IBD patients) 1

Treatment Algorithm

1. Immediate Interventions

• Ensure proper tension between internal and external bolsters - should be very low traction without excessive tension 1
• Correct any side torsion of the tube that may be causing stoma tract enlargement 1
• Apply zinc oxide-based skin protectants to protect the surrounding skin from leakage 1

2. Appliance Management

• Reassess current pouching system for proper fit
• Consider:
  • Foam dressings rather than gauze (lifts drainage away from skin)
  • Barrier films, pastes, or creams containing zinc oxide
  • Powder absorbing agents for excessive moisture 1
• If fungal infection is suspected, apply antifungal powder to the skin and seal with skin sealant 1

3. Specialized Interventions

• For persistent leakage:
  • Stabilize the tube using a clamping device
  • Consider switching to a low-profile device 1
  • Evaluate for proper balloon size and tube length if using a button gastrostomy 1
• For granulation tissue (common complication):
  • Clean the area daily with antimicrobial cleanser
  • Apply topical antimicrobial agent under fixation device
  • Consider foam or silver dressing over affected area 1

4. Follow-up Care

• Clean stoma site twice weekly with soap and water of drinking quality 1
• Gently and thoroughly dry the area after cleaning 1
• If no improvement after 2 weeks of treatment, patient should be evaluated by a surgeon or enterostomal therapist 1

Prevention of Future Complications

• Minimize traction on the stoma site with appropriate fixation or securement 1
• Ensure proper fit of pouching system to prevent leakage
• Regular assessment of the stoma and surrounding skin
• Patient education on proper stoma care and early recognition of complications 1

Caution

• If the stoma appears ischemic (purple/black discoloration) with pain and obstipation, this is a surgical emergency requiring immediate intervention 1
• Pushing a prolapsed stoma back should only be done gently with the patient in a relaxed position 1
• If manual reduction is difficult, a cup of sugar applied directly to the stoma for 20 minutes may help with reduction 1