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388 Mahmoud and Bradley
Figure 5 Flush urostomy surrounded by epithelial hyperplasia.
Treatment of LBP is facilitated by prompt histological diagnosis. Top-
ical steroids (clobetasol propionate) and oral tetracycline (1–2 g/day) for 2
months results in resolution of the bullae [20].
Pseudoverrucous Lesions (Epidermal Hyperplasia)
This condition involves overgrowth of peristomal epithelial tissue chroni-
cally exposed to moisture. The area appears moist and red with heaped up
edges. The term pseudoverrucous refers to the fact that the excrescences
look like HPV-induced condylomate (Figs. 5 and 6). The lesions are typi-
cally painful and are caused by ill-fitting ostomy appliances with oversized
wafer openings, resulting in exposure of large areas of skin. Urostomies
and high-output stomas are most commonly affected [13]. The thickened,
wart-like skin may require surgical removal or treatment with silver nitrate
in the office [8,21]. Preventive maintenance is the best approach to this
problem. Properly fitted stoma face-plate apertures that hug the muco-
epithelial junction provide a permanent solution.
Psoriasis
Individuals vulnerable to psoriasis and eczema in other areas of the body
may develop peristomal manifestations of the disease. Trauma to the peris-
tomal skin caused by repeated appliance manipulation may be the insti-
gating element responsible for the development of psoriasis. Manifestations
of such a traumatic etiology constitute the Ko
¨
bner reaction and are de-
Peristomal Skin Conditions 389
Figure 6 Peristomal epithelial hyperplasia adjacent to an ileostomy placed in a
skin crease. The seal between the skin and the appliance cannot be maintained.
scribed in a number of other dermatoses as well, including lichen sclerosis
[22]. Clinically, peristomal psoriasis is characterized by flaking, scaling,
white or red lesions in patients with a history of psoriasis in other, more
typical areas such as the elbows, intragluteal clefts, mammary folds, and
pretibial areas (Fig. 7). Treatment options include topical corticosteroids,
methotrexate, topical retinoids, and ultraviolet light exposure [23]. Special
attention to atraumatic pouching options such as the nonadhesive karaya
ring pouch with belts may be necessary to avoid initiation of the lesions.
Uncommon Peristomal Dermatoses—Hidradenitis
Suppurativa and Lichen Sclerosis
A review of the recent literature reveals rare reports of peristomal manifes-
tations of relatively common dermatoses. A complete differential diagnosis
of peristomal complaints should include these problems and, although rare,
they should be considered because they are easily diagnosed and treated.
Hidradenitis suppurativa is a very common, chronic, suppurative, cic-
atricial cutaneous disease exhibiting cystic, inflamed, and infected lesions
arising in keratin-blocked hair follicles of the axilla groin, and perianal
area. The lesions emit a foul, purulent material when incised and heal by
granulation. Typically, however, they recur with a course marked by cycles
of recurrence, eruption, and scarring. Subcutaneous tunneling is the hall-
mark of hidradeni tis suppurativa and surgical unroofing of the tracks aids
390 Mahmoud and Bradley
Figure 7 Peristomal psoriasis.
healing and reduces recurrence . Ca se repo rts of peris tom al h idr ade nit is
suppurativa include descriptions, obtained by Ga str ogr afin study or o n
visual inspection with a fib ero pti c scope, of typical lesions connected by
subcutaneous tun nel s that fail to conn ect with the lumen of the bowel
[24]. Although Church’s group has reported the presence of an associa-
tion between perianal Cr ohn’s d ise ase and hidradenitis suppurativa,
Crohn’s disease with perist oma l fistulizatio n must be ru led out [25]. The
possible coexistence of these conditions, however, should be consider ed.
The etiology of the problem is unclear. Genetically predi spo sed individu-
als ha ve a defective kera tin maturing process that results in follicular
blockage and bacterial o ver gro wth. Ot her s have reported the proble m fo l-
lowing occlusion of axillary skin with tape [26]. T he presence of the
disease i n the peristomal ar ea may result f rom occlusion of follicles with
appliance adhesives. Treatmen t invol ves inci sion an d drain age of infe cted
unruptured cysts, unroofin g of sub cut aneous tracks, good wound care,
systemic antibiotic s when indicated, and avoidance of face plat es secured
by tape.
Lichen sclerosis most commonly occurs (85%) on the genital area of
elderly patients and is characterized histologically by atrophic epidermis,
hyaline changes in the dermis, and a dense, band-like infiltrate of lympho-
cytes [27]. Extragenital lichen sclerosis has been described on skin underly-
ing tight clothing, on injection sites, and in areas affected by sunburn [28].
In case reports of peristomal lichen sclerosis, the elderly patients affected
have concomitant vulvar lesions. The lesions have a thickened white plaque-
like appearance. Lesions have been treated successfully by ensuring proper
appliance fit, reducing peristomal skin exposure, and topical application of
Peristomal Skin Conditions 391
0.05% clobetasol propionate. Regression of lichen sclerosis can be expected
in 1–12 months [28].
MALIGNANCY
Adenocarcinoma at the mucocutaneous junction is uncommon, but a num-
ber of case reports exist in the literature. Stomal polyps are more common
and can occur on both ileostomies and colostomies. The histopathology
of stomal polyps differs from those encountered on routine colonoscopy.
Histologically, they possess elongated, hyperplastic crypts with a character-
istic inflammatory infiltrate and underlying fibrosis or granulation tissue.
Both polyps and adenocarcinomas are long-term stoma complications, most
commonly occurring after 15–20 years [29]. Cold forceps biopsy followed
by electrocautery removal is effective therapy for these polyps, which are
theorized to develop as a consequence of long-term mucosal exposure to
chemical and physical trauma. Most patients presenting with adenocarci-
noma have a history of pain and bleeding associated with a mass or ulcer
at the periphery of the stoma (Fig. 8). Ileostomy adenocarcinoma is specu-
Figure 8 Primary adenocarcinoma in an ileostomy: A late complication of sur-
gery for ulcerative colitis. (From Ref. 30.)
392 Mahmoud and Bradley
lated to occur as a result of a number of factors. Of the cases described,
over half the reports note colonic metaplasia with dysplasia in the mucosa
surrounding the excised adenocarcinoma [30]. Chronic irritation, physical
and chemical trauma, and, perhaps, exposure to ileostomy effluent with
colonic flora may be responsible for this change [31].
Diagnosis of mucocutaneous adenocarcinoma is best made by biopsy.
Computed tomography of the abdomen and pelvis can help define the ex-
tent of both local and distant disease. Because reported cases are few, prog-
nosis is unclear, but wide local en bloc resection of the stoma and surround-
ing skin and abdominal wall with resiting of the stoma seems to be the best
treatment option [30].
RADIATION
Irradiated intestine should be avoided in selecting bowel for a stoma. How-
ever, it may be impossible to avoid placing the stoma through skin that has
received radiation. Radiated skin can appear thin and shiny. Radiation to
the dermis causes damage to small vessels and ischemia; moreover; the der-
mis can then easily be traumatized by removal of skin adhesives associated
with the stoma appliance. Modern high-energy radiotherapy devices mini-
mize scatter and reduce the skin damage seen in earlier times. If the stoma
is included in the treatment field however, the stoma appliance can cause
scatter and damage the underlying skin. Therefore the appliance should be
removed when radiation is being delivered. The use of lateral ports helps to
reduce the incidence of stoma involvement. It is mandatory for patients re-
ceiving radiation treatment to wear a nonadherent karaya ring between
treatments until completion, to avoid adhesives, and to be inspected closely
during treatment [7,21].
INFECTION
Candidiasis
The most common cause of peristomal skin infection and colonization is
the monilial yeast Candida albicans. Yeast infections can occur around all
types of stomas and are usually caused by leaking, poorly adherent appli-
ances, creating a warm, moist microenvironment under the stoma wafer.
Other factors contributing to the problem include the use of oral or paren-
teral antibiotics and local peristomal skin care routines and products that
violate natural barriers and extinguish the normal dermal flora. Candidal
infections are more common in debilitated, immunocompromised patients.
The affected skin appears bright red and moist and is surrounded by ery-
thematous satellite papular lesions (Fig. 9). Severe itching and burning are
commonplace. The condition is usually diagnosed and treated empirically,
Peristomal Skin Conditions 393
Figure 9 Candidal infection involving the peristomal skin.
but definitive diagnosis can be made by treating dermal scrapings with 10%
potassium hydroxide and observing them under light microscopy for bud-
ding yeast and hyphae. Treatment consists of dusting nystatin powder over
the infected skin with each pouch change [7,32].
Bacterial Infection
Peristomal cellulitis of bacterial origin is uncommon. The organisms pres-
ent are skin flora, with Staphylococcus aureus predominating. Treatment
with systemic antibiotics like dicloxacillin or amoxicillin/clavulanate (Aug-
mentin) is aimed at gram-positive organisms. Cultures of the erythematous
plaques or effluent can be taken for sensitivities if the cellulitis does not
clear with oral antibiotics alone. Occasionally, severe cellulitis may warrant
hospital admission and parenteral antibiotics, depending on the patient’s
underlying disease, comorbidities, and presentation.
Peristomal abscesses are not uncommon in patients with Crohn’s dis-
ease. Peristomal fluctuance, pain, and erythema occur and spontaneous rup-
ture at the mucocutaneous junction is common. The organisms present rep-
resent intestinal flora principally, because these abscesses result from
fistulas that may or may not be obvious at the time of incision and drainage.
All stomas that present with peristomal abscesses should be incised and
drained as close to the mucocutaneous junction as possible so as to obviate
pouching problems that can result from close approximation of the wound
and the stoma. A computed tomography scan, Gastrografin study through the
394 Mahmoud and Bradley
stoma, and mucosal biopsy are additional tests that may be useful depend-
ing on the patient’s underlying disease and symptoms [33].
These tests can demonstrate associated undrained collections, inflam-
matory masses, and fistulas, thus aiding in diagnosis and treatment.
REFERENCES
1. Hellman J, Lago C. Dermatologic complications in colostomy and ileostomy
patients. Int J Dermatology 1990; 26(2):129–133.
2. Shellito P. Complications of abdominal stoma surgery. Dis Colon Rectum
1998; 4:1562–1572.
3. Hampton B. Peristomal and stomal complications. In: Hampton B, Bryant R,
eds. Ostomies and Continent Diversions: Nursing Management. St. Louis:
Mosby, 1992:105–123.
4. Samda F, Myrvold HE. A troublesome colostomy treated with liposuction.
Eur J Surg 1992; 158:323–324.
5. Hocevar BJ, Landis-Erdman J. Pouching challenges in a patient with exten-
sive peristomal skin loss and subsequent skin graft. J Wound Ostomy Conti-
nence Nurs 1992; 26:48–52.
6. Kodner I. Stoma complications. In: Fazio V, ed. Current Therapy in Colon
and Rectal Surgery. Philadelphia: Decker, 1990.
7. Fry RD, Swatske ME. Skin problems in stoma management. In: MacKeigan
JM, Cataldo PA, eds. Intestinal Stomas, Principles, Techniques, and Manage-
ment. St. Louis: Quality Medical Publishing, 1993:329–338.
8. Convatec Connection. Preventing and Managing Peristomal Skin Problems.
www.convatec.com.
9. Ratliff R, Donovan A. Freque ncy of peristomal complications. Osto my Wound
Manage 2001; 47(8):26–29.
10. Cairns BA, Herbst CA, Sartor BR, Brigaman RA, Koruda MJ. Peristomal
pyoderma gangrenosum and inflammatory bowel disease. Arch Surg 1994;
129:769–772.
11. Brady E. Severe peristomal pyoderma gangrenosum: a case study. J Wound
Ostomy Continence Nurs 1999; 26(6):306–311.
12. Brennecke A. Peristomal pyoderma gangrenosum: review and case study.
Medsurg Nurs 1996; 5(3):195–198.
13. Erwin-Toth P. Prevention and management of peristomal skin complications.
Adv Skin Wound Care 2000; 13(4):175–179.
14. Keltz M, Lebwohl M, Bishop S. Peristomal pyoderma gangrenosum. J Am
Acad Dermatol 1992; 27:360–363.
15. Wolfsen HC, Brubacher LL, Ng CS, Kayne AL, Kozarek RA. Refractory
peristomal ulcers: a multidisciplinary approach. J Clin Gastroenterol 1990;
12:651–656.
16. Tjandra JJ, Hughes LE. Parastomal pyoderma gangrenosum in inflammatory
bowel disease. Dis Colon Rectum 1994; 37(9):938–942.
17. Vande Maele DM, Reilly JC. Bullous pemphigoid at colostomy site. Dis Co-
lon Rectum 1997; 370–371.
Peristomal Skin Conditions 395
18. Guillot B, Doassans S, Degaver B, Crozet I, Basset-Sequin N, Dandurand M.
Peristomal subepidermal autoimmune blistering disease. Eur J Dermatol
1999; 9:385–386.
19. Harries K, Owen C, Mills C, Gately CA, Stephenson BM. Case report: acute
stomal “contact” dermatitis or pemphigus. Br J Surg 1997; 84(5):685– 686.
20. Pereyo NG, Davis LS. Generalized bullous pemphigoid controlled by tetracy-
cline therapy alone. J Am Acad Dermatol 1995; 32:138–139.
21. Crohn’s and Colitis Foundation of America. Library: Surgery—Common
Peristomal Skin Conditions. www.ccfa.org.
22. Todd P, Halpern S, Kirby J, Pembroke A. Lichen sclerosis and the Ko
¨
bner
phenomenon. Clin Exp Dermatol 1994; 19:262–263.
23. Storey VM. Persistent peristomal skin reaction: a case of psoriasis. J Enteros-
tomal Ther 1982; 9:63–64.
24. Fliescher I, Bryant D, Spiegel J, Christian R, Farraye FA. Peristomal hidrade-
nitis suppurativa. J Wound Ostomy Continence Nurs 1996; 23:171–173.
25. Church JM, Fazio VW, Lavery IC, Oakley JR, Milsom JW. The differential
diagnosis and comorbidity of hidradenitis suppurativa and perianal Crohn’s
disease. Int J Colorectal Dis 1993; 8(3)117–119.
26. Shelley WB, Cahn MM. Pathogenesis of hidradenitis suppurativa in man:
experimental and histologic observations. Arch Dermatol 1955; 72:562.
27. Meffert JJ, Davis BM, Grimwood RE. Lichen sclerosis. J Am Acad Dermatol
1995; 32:393–416.
28. Ah-Weng A, Charles-Holmes R. Peristomal lichen sclerosis affecting colos-
tomy sites. Br J Dermatol 2000; 142:177–179.
29. Attanoos R, Billings PJ, Hughes LE, Williams GT. Ileostomy polyps, adeno-
mas, and adenocarcinomas. Gut 1995; 37:840–844.
30. Carey PD, Suvarna SK, Baloch KG, Guillou PJ, Monson JRT. Primary ade-
nocarcinoma in an ileostomy: a late complication of surgery for ulcerative
colitis. Surgery 1993; 113:712–715.
31. Gorbach SL, Nahas L, Weinstein L. Studies of intestinal microflora: a unique
microbial ecology. Gastroenterology 1967; 53:875–880.
32. Cameron B, Stepka A. Ileostomy stoma with a mucocutaneous separation. J
Wound Ostomy Continence Nurs 1995; 22:199–201.
33. Bubrick MP, Rolstad BS. Intestinal stomas. In: Gordon PH, Nivatvongs S,
eds. Principles and Practice of Surgery of the Colon, Rectum, and Anus. St.
Louis: Quality Medical Publishing, 1992:855–887.
20
Unusual Problems
in Stoma Management
Kerry M. Casey, Donna L. Loehner,
and David J. Schoetz, Jr.
Lahey Clinic, Burlington, Massachusetts, U.S.A.
INTRODUCTION
Challenging problems in the management of stomas vary from fairly com-
mon parastomal dermatological conditions to unusual complications related
to the stoma representing diagnostic and therapeutic dilemmas. Three of these
latter entities—parastomal pyoderma gangrenosum, parastomal varices, and
carcinoma arising in an ileostomy—are the subject of this current review.
PARASTOMAL PYODERMA GANGRENOSUM
Pyoderma gangrenosum is an indolent, painful ulcerative process of the skin
of unknown cause. In 1930, Brunsting and associates [1] first described this
entity; since then, pyoderma gangrenosum has been considered an extrain-
testinal manifestation of both ulcerative colitis [2,3] and Crohn’s disease
[4]. The estimated incidence of pyoderma gangrenosum in association with
inflammatory bowel disease varies from 0.5–5% [5–7]. Erythema nodosum
[7,8], the other serious cutaneous extraintestinal manifestation of inflamma-
tory bowel disease, may occur in patients with pyoderma but both rarely
occur at the same time.
Although these lesions may be seen in healthy persons, most are asso-
ciated with an underlying debilitating condition. In addition to inflamma-
tory bowel disease, pyoderma gangrenosum has been described in associa-
tion with blood dyscrasias, Hodgkin’s disease, other malignancies, and chronic
active hepatitis [2,8].
The cause of pyoderma gangrenosum is obscure. The original descrip-
tion [9] of the disease suggested a primary bacterial origin; it is now ac-
cepted that bacterial contamination is a secondary phenomenon. Although
397