How do I treat irritation or infection of the periumbilical skin?

Treatment of Periumbilical (Peristomal) Skin Irritation or Infection

For irritation around gastrostomy tubes, apply zinc oxide-based skin protectants to protect the skin from gastric contents, use foam dressings instead of gauze to lift drainage away from the skin, and treat any fungal infections with topical antifungal agents. 1

Initial Assessment and Identification of Cause

The first step is determining whether you're dealing with simple irritation from leakage or an actual infection:

• Leakage-related irritation presents with skin maceration, erythema, and breakdown from exposure to gastric contents 1
• Infection shows signs of purulent drainage, increased warmth, spreading erythema, and systemic symptoms like fever 1
• Fungal infection often accompanies leakage and presents with satellite lesions or characteristic appearance 1

Management of Non-Infected Irritated Skin

Primary Skin Protection Strategy

Apply zinc oxide-based barrier creams, pastes, or films directly to the affected peristomal skin to create a protective layer against gastric contents 1. This is the cornerstone recommendation from ESPEN guidelines with 93% consensus 1.

Dressing Selection

• Use foam dressings rather than gauze - foam lifts drainage away from the skin surface, while gauze traps moisture and worsens maceration 1
• Change dressings using aseptic technique if erosions are extensive 1
• Apply stoma adhesive powder or additional zinc oxide if initial measures are insufficient 1

Address the Source of Leakage

The irritation won't resolve unless you stop the leakage:

• Verify proper tension between internal and external bolsters - there should be approximately 1 cm of play between the skin and external bolster 1
• Check that the tube is not over-tightened, which increases infection risk and leakage 1
• Ensure the tube is properly secured to prevent excessive movement 1
• Consider proton pump inhibitors to decrease gastric acid secretion and minimize leakage 1

Management of Infected Peristomal Skin

Bacterial Infection

For early, mild peristomal infection without systemic signs, use oral broad-spectrum antibiotics for 5-7 days 1. The most common organisms are Gram-positive bacteria, particularly Staphylococcus and Streptococcus 1, 2.

• If systemic signs are present (fever, elevated white blood cell count), use intravenous broad-spectrum antibiotics with local wound care 1
• Take bacterial swabs before starting antibiotics to guide therapy 1
• Patients with diabetes, obesity, poor nutritional status, or immunosuppression are at higher risk for infection and may need more aggressive treatment 1

Fungal Infection

Apply topical antifungal agents when fungal infection is suspected or confirmed, particularly when associated with leakage 1. Local fungal infections commonly accompany peristomal leakage 1.

Daily Skin Care Protocol

• Cleanse the affected area at least once daily with an antimicrobial cleanser 1
• Gently cleanse without causing trauma to fragile skin 1
• Keep the area as dry as possible between cleanings 1
• Avoid greasy creams that may facilitate folliculitis 1

Management of Granulation Tissue

If excessive granulation tissue develops (appears as vascular, easily bleeding tissue):

• Apply topical corticosteroid cream or ointment for 7-10 days combined with foam dressing for compression 1
• Alternative: cauterization with silver nitrate applied directly to the overgranulation tissue 1
• Ensure the tube is properly secured to reduce friction and movement 1

When Conservative Measures Fail

If skin breakdown persists despite appropriate treatment:

• Consider temporary tube removal for 24-48 hours to allow tract closure, then replace with better-fitting tube 1
• In refractory cases, place a new gastrostomy at a different site 1
• Consult wound and ostomy nurses - they are invaluable resources for managing complex peristomal skin problems 1

Critical Pitfalls to Avoid

• Never use topical steroids without dermatology supervision for routine irritation - they can cause perioral dermatitis and skin atrophy if used inappropriately 1
• Don't replace with a larger-diameter tube - this usually worsens leakage by enlarging the tract 1
• Don't ignore signs of infection - sepsis is a major cause of mortality in patients with gastrostomy tubes 1
• Avoid excessive tightening of the external bolster - this increases infection risk and causes pressure necrosis 1