Keep it simple: peristomal skin health, quality of life and wellbeing - EXPERT OPINION CONSENSUS DOCUMENT

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Keep it simple: peristomal skin health, quality of life and wellbeing - EXPERT OPINION CONSENSUS DOCUMENT
EXPERT OPINION CONSENSUS DOCUMENT

Keep it simple:
peristomal skin health, quality of life and wellbeing

Supported by

               This article is reprinted from the British Journal of Nursing, 2021, Vol 30, No 6, Supplement 1, Consensus Document
Keep it simple: peristomal skin health, quality of life and wellbeing - EXPERT OPINION CONSENSUS DOCUMENT
BJN

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          This supplement is supported by Hollister and Dansac

          Suggested citation for this document:
          Burch J, Marsden J, Boyles A, Martin N,Voegeli D, McDermott B, Maltby E. Keep it simple: peristomal skin health,
          quality of life and wellbeing. Best practice consensus document on skin health. Br J Nurs. 2021; 30(6, Supp 1):1–24

      This article is reprinted from British Journal of Nursing, 2021, Vol 30, No 6, Supplement 1, Consensus Document
Keep it simple: peristomal skin health, quality of life and wellbeing - EXPERT OPINION CONSENSUS DOCUMENT
BJN

                           Contents
                           Introduction5                                               Using products appropriately13
                                                                                            Convex appliances
                           Optimising patient care6                                        Colostomy irrigation
                             Early education and intervention                               Stoma care accessories
                             Personalised care
                             Therapeutic relationships                                  Making prescribing decisions15
                                                                                            Personalised prescriptions
                           Classifying skin conditions7                                    Off-label prescribing
                             Moisture-associated skin damage                                Patient advocacy
                             Medical adhesive-related skin injury
                             Other dermatological conditions                            Keeping a record of care16
                                                                                            Documentation
                           Understanding risk factors9                                     Photography
                             Surgical factors                                               Terminology
                             Comorbidities and medications
                             Age and demographic factors                                Working with evidence18
                                                                                            Staying up to date
                           Assessing peristomal skin11                                     Quality of evidence
                             Assessment tools                                               Research participation
                             Asking the right questions
                             Holistic care                                              Improving stoma care nursing19
                                                                                            Professional education
                           Finding the right routine12                                     Ongoing appraisal
                             Cleaning the skin                                              Recognition of specialist roles
                             Forming a seal
                             Changing the appliance                                     Conclusion20

                                                                                      Jenny Marsden, Stoma Care Nurse, York
                            CONSENSUS PANEL                                           Teaching Hospital NHS Foundation Trust
                            Jennie Burch (chair), Head of Gastrointestinal            Nuria Martin, Tissue Viability Nurse, St
                            Nurse Education, St Mark’s Hospital, London North         Mark’s Hospital, London North West University
© 2021 MA Healthcare Ltd

                            West University Healthcare NHS Foundation Trust           Healthcare NHS Foundation Trust
                            Anna Boyles, Stoma Care Nurse, King’s                     Benjamin McDermott, Stoma Care Nurse,
                            College Hospital NHS Foundation Trust                     Salford Royal NHS Foundation Trust
                            Emma Maltby, Stoma Care Nurse, Hampshire                  David Voegeli, Professor of Nursing,
                            Hospitals NHS Foundation Trust                            University of Winchester

                                           This article is reprinted from British Journal of Nursing, 2021, Vol 30, No 6, Supplement 1, Consensus Document
Keep it simple: peristomal skin health, quality of life and wellbeing - EXPERT OPINION CONSENSUS DOCUMENT
BJN

                                                                                                                        © 2021 MA Healthcare Ltd

      This article is reprinted from British Journal of Nursing, 2021, Vol 30, No 6, Supplement 1, Consensus Document
BJN

                           Keep it simple:
                           peristomal skin health,
                           quality of life and wellbeing

                           A
                                               person living with a stoma (ostomate)          2006). A large international survey of 4235 ostomates in
                                               can face many challenges, and one of           13 countries found that 73% had reported a PSC in the
                                               the greatest is maintaining the integrity      previous 6 months (Voegeli et al, 2020). Ostomates do
                                               and health of the skin around the stoma        not always recognise PSC or seek help for skin problems
                                               (peristomal skin). Healthy peristomal is       (Herlufsen et al, 2006; Erwin-Toth et al, 2012), which
                           best defined as intact skin that is like the skin elsewhere        suggests the possibility that the true incidence of PSCs
                           on the abdomen and does not cause distress or impair the           may be higher than reported by some studies.
                           ostomate’s quality of life (Williams, 2010), and it should also        PSCs typically occur as a result of a variety of
                           be able to support an ostomy appliance with an effective seal.     interconnected factors, including chemical irritation from
                               However, peristomal skin is vulnerable to damage, which        the leakage of stomal effluent; physical damage provoked
                           can present with a combination of symptoms, including              by applying and removing products and accessories; allergic
                           discolouration, irritation, inflammation, erosion, maceration      reactions; and pre-existing or emerging comorbidities.
                           and/or ulceration, as well as the appearance of fissures or        Consequently, an ostomate’s risk of developing a PSC is
                           papules. Damage to skin integrity can be difficult and time-       also affected by a complex variety of factors, including their
                           consuming to heal and can pose serious risks to an ostomate’s      type of stoma, body profile and comorbidities, alongside
                           general wellbeing and quality of life (Boyles and Hunt,            their age and other demographic factors, as well as the
                           2016).The presence of these peristomal skin complications          nature of their stoma-forming surgery, the time since that
                           (PSCs) can significantly complicate the process of adaptation      operation and medications they are taking.
                           to life with a stoma. A PSC can make it more difficult                 It is the role of the specialist stoma care nurse (SCN)
                           to learn the physical maintenance techniques of stoma              to help ostomates maintain healthy peristomal skin and                    INTRODUCTION

                           care, and it can exacerbate the considerable challenges of         minimise the risk of PSCs. Peristomal skin health is among
                           psychological adjustment to a changed body image.These             the most common reasons for ostomates to consult a
                           issues affect all aspects of an ostomate’s life, from activities   health professional and one of the most important clinical
                           of daily living, work and leisure, to relations with family,       objectives for SCNs. Members of the consensus panel
                           friends and sexual partners (Ang et al, 2013;Vonk-Klaassen         estimated that about two-thirds of their clinical time is
                           et al, 2016; Hubbard et al, 2017).                                 devoted to addressing PSCs. SCN support involves helping
                               Moreover, the product prescriptions and clinical               ostomates select an appropriate pouching system for their
                           interventions required to manage PSCs represent a                  individual needs; this consists of a stoma appliance (more
                           substantial economic burden on healthcare finances, as has         often referred to by ostomates as a bag or pouch), which
                           been demonstrated in a number of recent studies (Taneja            is worn against the skin to collect and contain the stoma’s
                           et al, 2017; Colwell et al, 2018; Nichols, 2018; Nichols           output, sometimes supported by additional accessories.
                           et al, 2019; Taneja et al, 2019; Salvadalena et al, 2020).         SCNs also educate ostomates on correct use of their
                           Ostomates themselves may also be financially burdened              pouching system and regular management of the stoma
                           by reduced productivity or the cost of products purchased          to maintain healthy peristomal skin, as well as safe and
© 2021 MA Healthcare Ltd

                           off prescription, although more research is required to            effective self-care should a PSC occur. If a complication
                           confirm this (Meisner et al, 2012).                                does occur, the SCN will help the ostomate identify
                               Estimates of the incidence of PSCs vary. In a study            and resolve its causes, which may include adjusting their
                           of 202 Danish ostomates who had a stoma for a mean                 pouching system and updating their self-care skills, as well
                           of 8 years, 45% had experienced a PSC (Herlufsen et al,            as providing a treatment plan to return the skin to health.

                                                This article is reprinted from British Journal of Nursing, 2021, Vol 30, No 6, Supplement 1, Consensus Document
BJN

          SCNs also have an important role as patient advocates,           including activities of daily living; their relationships
          using their expertise to promote the interests of ostomates      with intimates, family, and friends; and their professional,
          within the wider healthcare system and ensure that they          social and leisure pursuits. The needs of someone who
          have access to the most effective treatments and services.       works might be different from those of a retired person.
              This consensus document describes the fundamentals           Someone who wants to pursue an active nightlife may
          of peristomal skin care and outlines best practice in the        have different requirements from someone with more
          prevention, assessment and management of PSCs. It draws          leisurely outdoor pursuits.
          on published evidence and the clinical experience of a               SCNs should use this information to guide all decisions
          consensus panel to demonstrate how nurses at all levels of       on prevention, assessment and treatment of PSCs. This is
          experience can make the best use of their knowledge and          especially important in selecting the right pouching routine
          skills to support ostomates to maintain healthy peristomal       from the wide choice of available products. Moreover,
          skin, overcome challenges and improve their quality of life.     empowering ostomates to try different products, after
                                                                           demonstrating how they should be used correctly, can be
          OPTIMISING PATIENT CARE                                          an important part of finding the optimal pouching routine.
          Early education and intervention                                     An experienced SCN will often be able to anticipate
          Ostomates do not always recognise signs of a PSC or may be       the signs of future problems and events in the ostomate’s life
          slow to report them, and many are known to tolerate PSCs         that increase their risk of PSCs, such as diabetes, vascular
          for long periods without seeking help (Herlufsen et al, 2006;    disease, immunosuppression, cancer and chemotherapy.
          Erwin-Toth et al, 2012).When a PSC is left untreated, the        These events require proactive prevention strategies,
          skin condition is likely to worsen, become more complicated      working in collaboration with other health professionals
          to heal and more seriously impair quality of life.               involved in the ostomate’s care.
              Therefore, SCNs need to educate ostomates
          about PSCs from the outset, ideally in both pre- and             Therapeutic relationships
          postoperative patient education, as well as give ongoing         Good long-term outcomes in stoma care require that SCNs
          support throughout their life with a stoma.This education        develop strong therapeutic relationships with the ostomates
          should involve face-to-face discussions, as well as written      they care for, and relationship-building is a core skill for
          information online and in printed literature. It should          nurses in this specialism. These relationships are facilitated
          aim to teach ostomates to recognise the signs of skin            by SCNs’ rare advantage of seeing their patients over many
          deterioration and remind them that regular leaks and             years, and they can be built through proven pathways of care,
          PSCs are not normal. Ostomates should expect to be able          including annual clinical reviews.They can involve setting
          to achieve a secure seal and healthy peristomal skin. This       out the aims of care, treatment goals and expected outcomes,
          information should include guidance on when, why and             which will give ostomates an informed understanding of
          how to access specialist advice and assistance in the event      their situation and motivate them with something to work
          a complication develops.                                         towards (LeBlanc et al, 2019).
              Should a PSC be suspected, early assessment and                  In such a relationship, the SCN should have an
          intervention from an SCN is essential. This should be as         informed and evolving knowledge of the changing needs
          early as possible to achieve optimal outcomes and prevent        of the particular ostomate.This means understanding what
          the skin deteriorating further and causing wider problems,       is most meaningful for each ostomate in achieving a good
          especially as the complex and multifactorial nature of PSCs      quality of life. This understanding puts SCNs in a good
          means that they can be difficult to resolve once they take       position to provide ongoing education and advice, as
          hold (Steinhagen et al, 2017).                                   well as achieve concordance and optimal outcomes with
                                                                           prescribing and product use.
          Personalised care                                                    Therapeutic relationships need to be built on trust.
          The care provided by an SCN should be personalised               This means holding honest conversations with ostomates
          to the individual needs of each ostomate. This means             that discuss the risks of products and interventions not
                                                                                                                                            © 2021 MA Healthcare Ltd

          getting to know their clinical history, as well as their         working and the SCN’s expectations of outcomes. The
          personal priorities and preferences. Ostomates will have         panel’s consensus was that SCNs are gatekeepers, and trust
          different goals they want or need to achieve in their lives.     is needed to encourage ostomates to be independent, while
          Their experience and tolerance of discomfort will vary.          also providing a safety net that they feel able to call on
          A stoma will affect all aspects of life in different ways,       for support when needed.

      This article is reprinted from British Journal of Nursing, 2021, Vol 30, No 6, Supplement 1, Consensus Document
BJN

                                                                                                                                                                        Peter Lamb
                              The skin comprises subcutaneous tissue, the dermis
                              and the epidermis. The outer layer of the epidermis
                              is the stratum corneum, which is constituted of
                              corneocytes and intercellular lipid (ceramide) layers.
                              The stratum corneum is coated by a film of dead skin
                              cells, sweat, keratin and lipids (sebum), known as the
                              acid mantle.
                              The pH of the acid mantle, normally 4–6, is one of
                              the most important regulators of skin function. It is
                              the first line of defence for the skin’s many protective
                              functions (Darlenski et al, 2011). The skin protects
                              the body against trauma, infection and excessive
                              fluids (Woo et al, 2017), and it is thought to have four
                              distinct barrier functions: microbiological, chemical,
                              physical and immunological (Eyerich et al, 2018).
                              The skin also functions to regulate the exchange
                              of substances between the body and the external
                              environment. This includes transepidermal water loss
                              (TEWL), the process by which moisture is evaporated
                              from the skin (O’Flynn, 2019). Each layer of the skin
                              is involved in absorbing, excreting, secreting and
                              thermoregulating; the corneocytes provide resistance,
                              while the lipid layers allow for substance exchange
                              (Darlenski et al, 2011).

                           Figure 1. Anatomy of the skin

                           CLASSIFYING SKIN CONDITIONS

                                                                                                                                                                        Cheryl Thomas
                           PSCs can result from a wide variety of complex chemical,
                           physical and pathological processes. Each of these has its
                           own way of interacting with the anatomy of the skin
                           to cause breakdown in its integrity and damage to its
                           function (Figure 1). These aetiological factors are typically
                           interconnected and mutually reinforcing, and so PSCs are
                           usually classified according to which of these causative
                           factors appears to be predominant.This classification system
                           is imperfect, owing to the multifactorial nature of most
                           PSCs and variance in practice and terminology. However,
                           it is valuable, as highlighting the predominant cause of a
                           PSC will indicate the best way to treat it.

                           Moisture-associated skin damage
                           The most frequently diagnosed PSC is peristomal moisture-
                           associated skin damage (PMASD) (Figure 2). PMASD refers
                           to any PSC predominantly caused by prolonged exposure
                           of the skin to moisture, typically containing chemical
                           irritants.This moisture may comprise perspiration and/or         Figure 2. Peristomal moisture-associated skin damage (PMASD)
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                           exudate (Voegeli, 2013), but PMASD is typically caused by
                           leakage of effluent (stool or urine) from the stoma onto the     experienced leakage in the previous 6 months, and 91%
                           surrounding skin (Burch, 2014). The Ostomy Life Study            were worried about it (Claessens et al, 2015).
                           of more than 4000 ostomates from 11 countries found                 PMASD typically results in maceration, irritation
                           that leakage was very common.Three quarters (76%) had            (peristomal dermatitis) and/or breakdown of the peristomal

                                                This article is reprinted from British Journal of Nursing, 2021, Vol 30, No 6, Supplement 1, Consensus Document
BJN

                                                                                                      skin and erosion of the stoma’s mucocutaneous junction.
Peter Lamb

                                                                                                      Peristomal dermatitis acquired its own code and definition
                 Harmful substances
                 unable to penetrate                                                                  in the 11th revision of the International Classification of
                                                                                                      Diseases (ICD-11) (World Health Organization, 2020),
                                                                                                      and, for the first time, several types of MASD were classified
                 Stratum corneum                                                                      and coded. Peristomal dermatitis (code EK02.23) is defined
                 (horny layer)                                                                        as ‘Irritant contact dermatitis of skin surrounding stomas
                                                                                                      or fistulas caused by prolonged or repeated contact with
                 Skin barrier                                                                         gastrointestinal secretions, faeces, urine, pus, mucus or
                 (skin surface lipids)                       Moisture                                 cleansing materials’. ICD-11 also classified for the first
                                                                                                      time other forms of moisture-associated skin damage with
                                                                                                      its own separate codes.
                                                  Normal skin barrier function                            Output from the small bowel contains many salts and
                                                                                                      digestive enzymes (proteases and lipases) that thrive in an
                                                                                                      alkaline environment, and effluent from an ileostomy has
                 Harmful substances                                                                   a median pH of 7.2–7.4 (Fallingborg et al, 1990). This
                 penetrate stratum                                                                    allows the effluent to disrupt the pH of the acid mantle,
                 corneum                                                                              break down lipids and keratin and penetrate the stratum
                                                                                                      corneum, initiating an inflammatory response and leading to
                                                                                                      irritation (Figure 3).The process can also create an osmotic
                                                                                                      pull, drawing more moisture, enzymes and salts into the
                 Reduced skin barrier                                                                 skin and causing further disruption (Warner et al, 2003).
                 (loss of surface lipids)                  Moisture
                                                                                                          PMASD is complicated by the cycle of skin damage.
                                                                                                      Damage to peristomal skin increases the amount of
                                                                                                      moisture on the stratum corneum, which makes it harder
                                                                                                      to form a firm seal with the appliance. This increases the
                                                 Disrupted skin barrier function                      chance of leakage, which consequently exacerbates the
                Figure 3. Disruption of stratum corneum and inflammatory response                     PSC (Woo et al, 2017).
                caused by corrosive enzymes in stomal effluent
                                                                                                      Medical adhesive-related skin injury
Cheryl Thomas

                                                                                                      Peristomal medical-adhesive related skin injury (PMARSI)
                                                                                                      refers to a PSC that is predominantly caused by mechanical
                                                                                                      trauma related to use of an adhesive stoma product
                                                                                                      (Figure 4) (Fumarola et al, 2020). A stoma appliance is
                                                                                                      attached to the peristomal skin via an adhesive flange
                                                                                                      (also known as a baseplate or skin barrier), and this is
                                                                                                      sometimes secured with additional adhesive accessories.
                                                                                                      PMARSI occurs when removal of the adhesive device
                                                                                                      results in epidermal stripping (or skin tears), erythema,
                                                                                                      erosion, blisters, vesicles and/or bullae (LeBlanc et al,
                                                                                                      2019). When the outer layer of the stratum corneum is
                                                                                                      more strongly bonded to the adhesive material than to
                                                                                                      the layer below, removal of the adhesive will pull away
                                                                                                      the outermost skin cells. PMARSI typically occurs when
                                                                                                      appliance removal is traumatic, as a result of fragile skin,
                                                                                                                                                                       © 2021 MA Healthcare Ltd

                                                                                                      a strengthened adhesive or poor removal technique. It
                                                                                                      is made more likely if the appliance is removed overly
                                                                                                      frequently. PMARSI is largely avoidable with education
                                                                                                      on good appliance removal technique, potentially assisted
                Figure 4. Peristomal medical adhesive-related skin injury (PMARSI)                    with an adhesive remover.

                                 This article is reprinted from British Journal of Nursing, 2021, Vol 30, No 6, Supplement 1, Consensus Document
BJN

                           Other dermatological conditions
                                                                                             Table 1. Peristomal skin complications by appearance and cause
                           As well as PMASD and PMARSI, peristomal skin can be
                           affected by a variety of dermatological conditions that are       Complication          Appearance               Possible causes
                           not specific to stoma care (Table 1). For example, ostomates      Moisture-             Erythema, rash,          Maceration from perspiration,
                           may develop eczema or psoriasis, which is characterised           associated skin       inflammation,            exudate or stomal effluent
                           by inflammation and patches of scaly red skin. Other              damage (PMASD)        pruritus, papules,       and/or chemical irritation from
                           PSCs include:                                                                           plaques, scaling,        enzymes in effluent
                                                                                                                   fissures
                           ■ Pyoderma gangrenosum: Ostomates may also
                               experience pyoderma gangrenosum, which typically              Medical adhesive      Erythema, blisters,      Skin stripping from traumatic
                               manifests as inflamed and painful ulcers with purple          related skin          skin tears               or overly frequent appliance
                                                                                             injury (PMARSI)                                removal
                               edges. This relatively rare ulcerative inflammatory
                               skin disorder is associated with an inflammatory or           Peristomal            Inflammation, pain,      Bacteria from surgical site,
                               proliferative systemic disease, such as inflammatory          infection             swelling, folliculitis   stomal output or other source
                               bowel disease or cancer, and can be triggered by              Allergic contact      Inflammation, rash,      Allergic reaction to ingredients
                               surgical or mechanical trauma (Lyon and Smith,                dermatitis            erythema, papules        of skincare, hygiene or stoma
                               2010). Peristomal ulceration can be an outward sign                                                          products or topical medication
                               of a systemic condition.                                      Granulation           Lumpy lesions            Infection, poor wound healing,
                           ■ Peristomal infection: PSCs can result from                                            (granulomas),            Crohn’s disease or bowel
                               an infection, which may be bacterial, fungal or                                     inflammation             metaplasia
                               viral. It is likely to be a secondary infection of
                                                                                             Psoriasis             Patches of               Genetic disposition,
                               the surgical site or caused by bacteria in stomal                                   scaly red skin,          autoimmune issues, mechanical
                               output. These peristomal skin infections are                                        inflammation             stripping (Koebner reaction),
                               relatively uncommon, compared with PMASD                                                                     inflammatory bowel disease
                               and PMARSI, and can be treated with antibiotics.              Pyoderma              Inflammation,            Surgical or mechanical trauma
                               However, ostomates who present to their GP with               gangrenosum           extremely painful        and systemic inflammatory
                               a PSC are sometimes incorrectly diagnosed with                                      purple-edged ulcers      disorders
                               an infection and prescribed antibiotics. It is only         Sources: Oakley (2006); Lyon and Smith (2010); Nybaek and Jemec (2010); Blessy
                               when the antibiotics fail to resolve the condition          et al (2019)
                               and the ostomate is referred to an SCN that the
                               diagnosis is corrected to PMASD or other stoma-
                               specific cause. To avoid unnecessary contributions          UNDERSTANDING RISK FACTORS
                               to antibiotic resistance, SCNs should aim to                An ostomate’s risk of developing a PSC depends on many
                               educate GPs on the common causes of PSCs, and               factors that contribute to a more precarious peristomal
                               ostomates with a PSC should be encouraged to                environment (Blessy et al, 2019; Salvadalena et al, 2020).
                               present to an SCN first where possible. If the SCN          These are rarely isolated, and a PSC will typically be
                               does suspect a peristomal infection, this can be            triggered by a combination of factors.
                               investigated with a swab; however, a swab is not
                               always possible in practice, and so diagnosis may           Surgical factors
                               have to be made on assessment of the appearance             People with an ileostomy (ileostomates) have a higher
                               of the skin and knowledge of the ostomate and               risk of PSCs than those with a colostomy (colostomates)
                               their history.                                              (Taneja et al, 2017). One study found that the incidence
                           ■ Allergic contact dermatitis: PSCs can also result             of PSC over 1 year was 57% for people with an ileostomy,
                               from an allergic reaction to a product. Ostomates           48% for a urostomy and 35% for a colostomy (Herlufsen
                               may have or go on to develop an allergy to the              et al, 2006).Voegeli et al (2020) showed that people with
                               constituent materials of stoma appliances and               an ileostomy were nearly twice as likely to develop a
© 2021 MA Healthcare Ltd

                               accessories, as well as those of any topical treatments     PSC as those with a colostomy.This may be related to the
                               or other skincare, medical or hygiene products used         consistency and volume of the stomal output.The output
                               on their skin, including soaps and washes. The more         of an ileostomy is liquid or loose and high in volume, while
                               products an ostomate uses, the more likely they are         that of a colostomy is likely to be of a formed consistency
                               to have a reaction.                                         and lower in volume, and thus less prone to leakage.

                                               This article is reprinted from British Journal of Nursing, 2021, Vol 30, No 6, Supplement 1, Consensus Document
BJN

               The surgical formation of the stoma is an important             PSC risk is affected by the general condition of the
          factor in PSC development.A significant factor is whether        ostomate’s skin. Conditions such as psoriasis, atopic
          the stoma has been correctly sited by an SCN or surgeon,         eczema, obesity and malnutrition, whether pre-existing
          as has been highlighted by the Association of Stoma Care         or developing after surgery, exacerbate vulnerability to
          Nurses (ASCN) UK (2016). This requires the availability          breakdown of skin integrity. Skin comorbidities, such
          of an experienced SCN and is more difficult to achieve in        as atopic eczema and psoriasis, are likely to present on
          emergency surgery.An ostomate’s likelihood of experiencing       peristomal skin because it is a site of trauma. Fissures in
          a PSC if affected by the quality of the surgical construction    the epidermis from xerosis, atopic eczema or other skin
          of the stoma, particularly how well the stoma is spouted         damage can also release excess moisture onto the skin
          from the abdomen (Cottam and Richards, 2006; Koc et              surface, increasing transepidermal water loss (TEWL) above
          al, 2017; Steinhagen et al, 2017; Murken and Bleier, 2019).      normal levels.They allow the penetration of proteases and
          In addition, stomas are formed when ostomates are lying          lipases from stomal effluent. Micro-organisms in the stomal
          flat or tilted head down on the surgical table. Therefore, a     effluent have the potential to cause infection in ostomates
          stoma formed from bowel that is not under tension may            who are immunocompromised as a result of diabetes,
          appear to protrude sufficiently on the operating table but       recent weight loss, cancer treatment, malnutrition or the
          may pull inwards when the ostomate sits up.                      natural process of ageing (Oakley, 2006).
               Although PSCs are an intermittent problem that can              Many drugs can provoke dermal side effects, including
          occur at any time while a person has a stoma (Meisner            medicines for long-term conditions not directly related to
          et al, 2012), they are particularly frequent in the period       the stoma (Table 2). For example, nicorandil (Donaldson et
          after stoma-forming surgery (Steinhagen et al, 2017). A          al, 2009) can cause flushing and ulceration, and warfarin
          retrospective cohort study by Taneja et al (2017) found that     increases the risk of bleeding (Joint Formulary Committee,
          one-third of ostomates had evidence of a PSC within 90           2020). Skin that is already fissured and fragile or subject to
          days of surgery.Voegeli et al (2020) found that PSC risk         irritation is therefore more vulnerable to further damage
          was 1.5 times higher in the first 2 years compared with          and breakdown in someone using these drugs. Metformin
          people who had had their stoma for more than 2 years             (Bouchoucha et al, 2011) commonly causes diarrhoea, as
          (p=0.0002). Londono-Schimmer et al (1994) found that             can warfarin (Joint Formulary Committee, 2020), and an
          PSCs were more prevalent in the first 5 years following          increase in loose faecal output poses a high risk of leakage
          surgery than after.This is perhaps partly because these early    and PSCs.Topical treatments used on the skin may cause
          stages often see changes in the size of the stoma, the shape     skin irritation or allergic reactions in some ostomates.
          of the abdomen and the volume and consistency of the             For example, topical steroids, including steroid inhalers
          output, while these variables tend to stabilise over time. It    prescribed off-label, risk thinning the skin. Ostomates may
          may also be because it takes time for the new ostomate to
          develop proficiency in self-care skills (Salvadalena, 2008).
                                                                             Table 2. Dermal side effects of medications
          Comorbidities and medications
                                                                             Drug class                     Side effects
          A high BMI is a risk factor for PSCs. Excessive subcutaneous
          fat often results in undulating contours on the abdomen,           Corticosteroids                ■ Bruising

          which make it more difficult to achieve an effective seal                                         ■ Skin thinning

          between the skin and appliance.Those who are overweight                                           ■ Delayed healing
                                                                                                            ■ Fragile skin
          or obese present a more difficult surgical environment
          that makes it challenging to free enough bowel to make             Anticoagulants (e.g.           ■ Bruising
          it through the adipose layer without being under tension,          warfarin)                      ■ Prolonged bleeding
          potentially resulting in a poorly spouted stoma (Cataldo et
                                                                             Nicorandil                     ■ Ulceration
          al, 2008; Beck, 2011; Salvadalena et al, 2020). More research
          and guidance are required for ostomates with a high BMI.           Chemotherapy                   ■ Rash
                                                                                                                                            © 2021 MA Healthcare Ltd

               Alterations in body profile, such as the development                                         ■ Dry skin

          of a parastomal hernia, can increase vulnerability to PSCs.                                       ■ Delayed healing
                                                                                                            ■ Increased bleeding
          Likewise, an ostomate may be more vulnerable to PSCs
                                                                                                            ■ Pruritus
          if their stoma is flush with or recessed below, rather than
          spouted from, the skin.                                          Source: Boyles and Hunt (2016)

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                           be prescribed medicines to treat skin problems, such as           population, while the descendants of immigrants from the
                           infections, dermatitis or psoriasis. Usual care and caution       Caribbean, Africa and South Asia are more susceptible to
                           are required to ensure that ostomates receive and use the         long-term conditions (Evandrou et al, 2016). People with
                           right product and the right dose to treat the problem and         poor English skills also experience relatively poorer health
                           that they understand the risk of side effects and relevant        by comparison with the general population (Office for
                           interactions, as well as what to do if they occur.                National Statistics, 2015). They find it more difficult to
                              Peristomal skin health can also be affected by                 access health services and express their care needs. Many
                           recreational drugs. This includes alcohol, which may              also express concerns about the cultural and religious
                           interact with other drugs the ostomate is taking, cause           appropriateness of services (Greenwood et al, 2015).Access
                           skin flushing and irritation and/or affect faecal and urinary     to healthcare can also be impeded by discrimination on
                           output (Coleman, 2020).                                           the basis of sex, sexual or gender identity and disabilities
                                                                                             (West et al, 2015). It can be assumed that ostomates who
                           Age and demographic factors                                       face any of these health inequalities are likely to be more
                           Skin also changes with age (Haydont et al, 2019), suggesting      vulnerable to PSCs (Cooper-Gamson, 2017; Nichols, 2018).
                           that the presentation of peristomal skin problems and the         Therefore, SCNs should take particular care to ensure that
                           most suitable management will be different across the age         such people receive an equal standard of care.
                           spectrum, from neonatal to older ostomates. Pittman et al             Moreover, skin damage looks different across the
                           (2008) found that ostomates under 60 years experienced            range of skin tones. Much of the evidence on PSC comes
                           more skin complications than ostomates over 80 years,             from research on people with paler skin. Particular skin
                           but more research is needed to understand whether it              pigmentations handle and respond to TEWL differently,
                           is changes in the skin, disease or other factors that are         owing to variations in the structure and content of the skin
                           responsible for this observation.                                 layers, and may respond differently to damage (Voegeli et
                               Best management of peristomal skin in neonates is             al, 2015). In addition, observing for subtle changes in the
                           an under-researched area. The neonatal epidermis and              skin, such as erythema, may be more difficult in people
                           stratum corneum are thinner and more fragile, with smaller        with darker skin pigmentations. More research is needed
                           corneocytes in the first year of life (Blume-Peytavi et al,       in this area to understand the full implications of these
                           2016). Clinical experience shows that the skin layers can         differences for PSCs.
                           be easily separated by shearing forces, so adhesives must
                           be applied and removed with extreme caution. Moreover,            ASSESSING PERISTOMAL SKIN
                           because newborns have a skin surface area-to-weight               When an ostomate presents to an SCN, they should be
                           ratio about three-times greater than adults (Guzelian et          assessed for the presence of a PSC. If their peristomal skin
                           al, 1992), infant skin will absorb more of a substance by         is healthy, they can be assessed for risk factors for future
                           body weight than an equivalent patch of adult skin, making        PSC development. If PSC symptoms are present, they
                           correct quantities challenging to calculate. In premature         should be assessed for likely causes, which will determine
                           neonates with the most fragile skin, SCNs need to decide          the most appropriate course of treatment.
                           which intervention is likely to cause the least damage: the
                           separation of the layers that comes from adhesive removal         Assessment tools
                           (PMARSI) or the moisture damage from skin exposure                The condition of peristomal skin and the severity of PSCs
                           to stomal output (PMASD). The best course will depend             can be measured with some objectivity using a number
                           on each neonate at different points in their care (Global         of tools. The Ostomy Skin Tool is a validated method to
                           Paediatric Stoma Nurses Advisory Board (GPSNAB), 2019).           track changes in peristomal skin using standardised criteria
                               Data linking a variety of other demographic factors to        for three domains: discolouration (D), erosion (E) and
                           variable health outcomes in the general population can            tissue overgrowth (T) (Martins et al, 2010). Each domain
                           be extrapolated to ostomates (Blessy et al, 2019). Health         is assigned two scores: one for the extent of skin affected,
                           inequalities are particularly associated with socio-economic      scored 0–3, and one for severity, scored mild (0), moderate
© 2021 MA Healthcare Ltd

                           status, which restricts access to health services and financial   (1) or severe (2). Both these scores are combined to give
                           resources and has a strong geographical correlation (Nazroo,      the individual domains a score of 0–5, and all three domain
                           2003; The King’s Fund, 2020). This often overlaps with            scores are combined to provide a total score of 0–15. Other
                           people from black and minority ethnic groups, who                 available tools include the Stoma Care Ostomy Research
                           generally have poorer general health than the rest of the         Index (Williams et al, 2010) the Peristomal Lesion Scale

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                       (Menin et al, 2019) and the Peristomal Skin Assessment               However, these tools are subjective, and results may vary
                       Guide (Wound, Ostomy, and Continence Nurses Society              by practitioner. Use of tools should only be supplementary to
                       (WOCN), 2020).                                                   a specialist’s experiential and evidence-based understanding
                                                                                        of the variety of complex chemical, physical and disease
                                                                                        factors that can precipitate PSCs. SCNs must acquire this
Box 1. Questions to determine causes of a peristomal                                    knowledge of what to look for through a combination of
skin complication                                                                       clinical experience, discussion of cases with colleagues and
Appearance                                                                              reading of evidence, nurtured by habits of critical thinking
■ What is the extent and severity of discolouration?                                    and reflective practice.
■ What is the extent and severity of erosion?
■ What is the extent and severity of tissue overgrowth?                                 Asking the right questions
■ Are there any other distinct visual features on the skin?                             Example questions an SCN can ask to determine the
Potential causes                                                                        likely causes of a peristomal skin complication are given
■ Has the ostomate experienced a recent leakage?                                        in Box 1. These questions should cover patient history, as
■ What is the consistency of the stomal output?                                         insufficient history is one of most common causes of clinical
■ Is there excessive moisture under the flange?                                         misdiagnosis. Moreover, in the experience of the consensus
■ Is there discomfort or pain on appliance removal?                                     panel, apparent skin signs, such as erythema or pain, may
■ Are there signs of bacterial, fungal or viral infection?                              prompt rapid assumptions or conclusions about the cause
■ Does the ostomate have any known allergies?                                           of a PSC without consideration of factors that may be less
■ Has the abdomen been shaved in the past week?                                         obvious or less well understood to the SCN. A medication
■ Does the ostomate have particularly fragile skin?                                     review should be included, to inform the SCN of what has
Appliance leakage                                                                       been previously prescribed so they can intervene to correct
■ How frequently has leakage occurred?                                                  regimens where necessary.
■ Is the abdominal area flat or contoured?
■ Is the stoma spouted or retracted, flush or prolapsed?                                Holistic care
■ How skilled is the ostomate at forming a seal?                                        PSCs are often complex and multifactorial, and their causes
■ Are there visible leaks tracking along a crease in the flange?                        are usually not limited to the physical impact of regular
Clinical history                                                                        appliance changes and management.Therefore, assessment
■ When did the skin condition occur?                                                    should be thorough and holistic, incorporating a full clinical
■ Were there any circumstances that might have triggered this?                          history and medication review, alongside assessment of stoma
■ What measures have already been taken to improve it?                                  care regimen and technique, to consider the variety of factors
■ Is the stoma functioning differently to normal?                                       that might also play a role in the ostomate’s skin condition.
■ How long has it been since the stoma-forming surgery?                                     It is also important to consider the person’s social networks
■ What disease process or condition led to that operation?                              and access to support as part of an assessment (McMullen
■ What other health conditions does the ostomate have?                                  et al, 2011). Those ostomates who have supportive friends
Product review                                                                          and family, are better positioned and equipped to make
■ What stoma appliances and accessories are being used?                                 the many transitions necessary to adapt to living with a
■ How long does the ostomate wear their appliance before changing?                      stoma. Health professional support also affects ostomates’
■ Is the template well-fitting?                                                         ability to become more skilled in changing appliances and
■ Is there disintegration of the flange?                                                maintaining healthy skin, which can make the appliance
■ What is the rationale for any accessory use?                                          less prone to leakage.
■ Have there been any recent changes in stoma care regimen?
■ Have these changes coincided with changes in skin condition?
                                                                                        FINDING THE RIGHT ROUTINE
Medication review                                                                       Once an ostomate has undergone an assessment and been
■ What topical treatments and/or hygiene products are being used in the                 determined to have a PSC or risk of PSC development, they
                                                                                                                                                            © 2021 MA Healthcare Ltd

  peristomal area?                                                                      may benefit from education on good stoma care technique
■ What medications (prescribed or over the counter) are being taken?
                                                                                        and habits. Many problems can be prevented by appropriate
■ What recreational drugs (including alcohol) are being consumed?
                                                                                        cleaning of peristomal skin and correct technique in
■ Have there been any recent changes in medication?
                                                                                        changing the appliance, and these can be achieved through
■ Have these changes coincided with changes in skin condition?
                                                                                        good teaching of the ostomate by an SCN (Box 2).

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                           Cleaning the skin
                                                                                             Box 2. How to avoid peristomal skin problems
                           Ideally, the skin should be cleaned with water only.
                           Alcohol wipes should not be used, as these risk irritation        ■ Have the equipment available to formulate the template correctly

                           to the skin, while wet wipes should be avoided, because           ■ Wash the skin with warm tap water

                           they contain moisturisers, such as lanolin, that prevent          ■ Dry the skin gently but thoroughly
                                                                                             ■ Formulate the template precisely to achieve a good fit
                           the appliance adhesive from reaching the skin layer
                                                                                             ■ Ensure that the appliance is carefully placed and adhered around
                           sufficiently to ensure adherence (Mortz and Andersen,
                                                                                               the stoma
                           2008). Soap can be used to remove adhesive residue but
                                                                                             ■ Educate the ostomate on prevention from the outset
                           must be carefully washed off the skin, because it contains        ■ Know what risk factors to look out for
                           irritants that can damage the skin and trigger contact            ■ Address problems as soon as they occur
                           dermatitis (Black, 2007; Voegeli et al, 2019; Fletcher et         ■ Understand the rationale for correctly sizing the template
                           al, 2020; Lichterfeld-Kottner et al, 2020). After washing,
                           the skin must be thoroughly dried.
                                                                                           New ostomates should be encouraged to aim for a
                           Forming a seal                                                  consistent regimen of changes that are made around
                           A stoma appliance should be correctly fitted so that it         the same time each day. Although this routine may
                           forms an effective seal around the stoma.This requires the      occasionally be altered for special events, a consistent
                           template to be sized and shaped so that it sits close enough    approach gives ostomates a greater sense of control over
                           around the stoma to avoid exposing the peristomal skin          their lives. Regular appliance changes also provide more
                           to contact with effluent. However, the template should          opportunities for the ostomates or SCN to inspect the
                           not be so tight that the stoma is constricted. A poorly         skin and anticipate problems before they develop. As
                           fitting appliance increases the risk of damage to the           ostomates gain experience and confidence, they will be
                           stoma or skin (Chandler and Lowther, 2012). This can            better able to try different routines. Changing times should
                           be assisted with tools, such as the Fit Indicator Tool          be determined to best suit their daily routines. For example,
                           (Hollister, 2020) or Peristomal Skin Assessment Guide           an ostomate who plans to go out for the evening might
                           (WOCN, 2020); however, these are not validated and              prefer to change before they do so, as a fresh appliance can
                           should only be used with caution and to supplement              provide more confidence in a social setting, where access
                           critical clinical judgement.                                    to bathrooms is more difficult than at home.
                               If an appliance leaks, it should be changed as soon as
                           possible. Leaks cause great distress to ostomates, as well      USING PRODUCTS APPROPRIATELY
                           as damage to the skin.                                          To prevent leaks and protect their peristomal skin,
                                                                                           ostomates need to use the right products to meet their
                           Changing the appliance                                          individual needs, including the appliance that will provide
                           Stoma appliances need to be changed regularly, although         the best fit and form the most effective seal with their
                           the actual and optimal frequency of changing varies             skin.An appropriate appliance should avoid leaks and leave
                           depending on the individual’s anatomy, including type           peristomal skin intact, without discomfort or distress. A
                           of stoma, bowel function and skin. As a broad guide             number of manufacturers have recently produced stoma
                           and in line with Association of Stoma Care Nurses UK            appliances with flanges that are infused with additives.
                           (ASCN) UK (2016) guidelines, the consensus panel                SCNs should observe the emerging evidence on whether
                           recommends that:                                                these additives have a significant positive impact on
                           ■ Ileostomates use a drainable pouch, empty it as               peristomal skin health.
                              necessary and change every other day (although
                              some change it daily)                                        Convex appliances
                           ■ Urostomates use a drainable appliance, typically              Ostomates may find it difficult to form an effective seal
                              change every other day (or sometimes daily) and              with a flat appliance if their stoma is situated below skin
© 2021 MA Healthcare Ltd

                              consider a night bag when sleeping                           level (retracted), at skin level (flush), excessively protruding
                           ■ Colostomates use a closed appliance and change                (prolapsed) or off-centre, or if they have an enterocutaneous
                              whenever their bowels function, up to a maximum              fistula. When clinically necessary in order to avoid leaks
                              of around three changes per day, beyond which a              and PSCs, a convex appliance may be indicated for these
                              drainable appliance should be considered.                    ostomates regardless of the length of time they have had

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                    their stoma. An SCN should be able to anticipate those           should not lead to the assumption that all accessories
                    who might require convexity, so this contingency can be in       are optional or unnecessary. In many ostomates some
                    place should problems arise. However, convexity presents         products, such as skin barriers, are absolutely essential
                    a risk of pressure damage, which may result in ulceration        to maintaining a functional seal and healthy peristomal
                    and bruising, and therefore it should only be used under         skin. However, the consensus panel agreed that accessory
                    the direction of an SCN (Hoeflok et al, 2017). These             use can be inefficient, ineffective or liable to cause more
                    ostomates should be advised to be vigilant for problems and      problems than it solves. Therefore, it is generally better
                    seek assistance from the SCN if any occur. SCNs should           to keep the use of accessories simple and to a minimum,
                    understand the variations in appliance convexity and when,       and the panel recommends that an accessory should only
                    for example, soft convexity might be more appropriate.           be prescribed if it has been determined to be necessary
                                                                                     for the individual (Box 3). Moreover, ostomates must be
                    Colostomy irrigation                                             taught correct and careful application of these accessories.
                    Some colostomates can use colostomy irrigation, which            For example, if the skin has not been thoroughly dried,
                    involves instillation of water through the colostomy, where      adhesive products can lock in moisture and make the skin
                    it stimulates the large bowel and causes it to empty. This       more vulnerable to maceration.
                    provides control over bowel movements, and can achieve               There are cases where stoma accessories can have a role
                    regular emptying of the colon, particularly if it is performed   in improving the seal between appliance and skin, but they
                    at the same time each day.As a result, the ostomate generally    should be only used when appropriate for the ostomate.
                    only needs to wear a small appliance, such as a cap or plug,     Accessories should not be prescribed if the ostomate
                    and this can be worn for longer and more regular periods         cannot use them because of dexterity issues. Products
                    between changes. Colostomy irrigation may also reduce            used on the peristomal skin carry risks of disrupting the
                    the risk of leakage and consequent PSCs. Ostomates who           pH of the acid mantle (Cressey et al, 2017), leaving a
                    find irrigation suitable report improvements in quality of       residue that impedes the adherence of the appliance or
                    life (Carlsson et al, 2010; Kent et al, 2015). Ostomates may     triggering an allergic reaction to the product itself, while
                    benefit from irrigation if they have an end colostomy, skin      adhesive accessories that have to be pulled off increase the
                    problems and/or issues with bowel function. Irrigation           risk of skin stripping and PMARSI (Grove et al, 2019;
                    is contraindicated in the presence of large parastomal           LeBlanc et al, 2019). The more accessories are used, the
                    hernias or active bowel disease, such as Crohn’s disease,        greater these risks become.
                    and consideration should be given to other health issues,        ■ Fillers and seals: Fillers are pastes that can be
                    such as renal dysfunction (Colostomy UK, 2019).Where                 shaped into abdominal contours to provide a flat
                    appropriate, it is important that ostomates are offered              surface for an appliance to adhere to, reducing
                    irrigation as an option, and that those who opt for to use           the risk of leaks and PMASD. Meanwhile, seals
                    it are given good support to learn the technique.                    (sometimes referred to as washers, rings or discs)
                                                                                         are small adhesive circles that sit around the stoma,
                    Stoma care accessories                                               helping form an effective seal with the appliance.
                    A stoma accessory is defined as any product designed to be           Where possible, it is more cost-effective and time-
                    used in addition to a stoma appliance (NHS Supply Chain,             efficient to create a seal with the optimal appliance
                    2018).The consensus panel emphasised that this definition            alone. However, both fillers and seals can be useful
                                                                                         for those with especially challenging body profiles
                                                                                         marked by dips or creases or with a retracted or
Box 3. Less is more: questions to ask before using an accessory                          flush stoma. Some fillers contain alcohol, making
Before considering a range of accessories, it is necessary to ask:                       these inappropriate for damaged or infant skin,
■ Was the skin dried thoroughly after cleaning?                                          although many recent products are alcohol-free
■ Has the appliance been applied correctly?                                              (Boyles, 2010; GPSNAB, 2019).
■ Are there gaps between the appliance and the skin?                                 ■ Adhesive removers: Adhesive remover wipes
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■ Does the patient have the dexterity to use any prescribed products?                    and sprays are designed to provide effective, pain-
■ Does the appliance need to be changed? If the appliance is well                        free adhesive removal without risking PMARSI.
  adhered and there are no signs of leaks, could it be left another day and              Silicone-based removers are recommended over
  progress charted, to help prevent skin stripping, for example?
                                                                                         those with an oil or alcohol base (Boyles, 2010).
■ Would an accessory or a convex appliance work achieve a better seal?
                                                                                         They can be useful in certain cases and should be

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BJN

                               prescribed for ostomates with evidence of PMARSI            MAKING PRESCRIBING DECISIONS
                               or risk factors, such as fragile or damaged skin.           The available selection of appliances and accessories
                               However, they should not be prescribed by default,          is wide enough that ostomates should be able to find
                               as many ostomates will not need them. Adhesive              something suitable for them. However, the range is so
                               removers do pose risks for PSCs, so the SCN                 wide that ostomates and GPs will typically require support
                               prescribing them should educate the ostomate on             and advice from a specialist SCN to make an educated
                               correct technique (LeBlanc et al, 2019).                    choice on what works, what to avoid and why. Likewise,
                           ■   Barrier films: Barrier wipes, creams and sprays             the consensus panel recommends that non-specialist
                               create a film over the skin that acts as a barrier          practitioners using stoma-related products should first
                               protecting it from contact with corrosive stomal            discuss these with a specialist SCN.
                               output, thus reducing the risk of PMASD (Metcalf,
                               2018). This additional protective layer can increase        Personalised prescriptions
                               appliance wear time for some ostomates, such as             Prescribing decisions should be based on knowledge of
                               those with cystic fibrosis, whose skin is less able         evidence regarding the products available and which work
                               to reabsorb excreted salt and can become oily               better for particular skin conditions and the ostomate’s
                               (GPSNAB, 2019). However, the ADVOCATE trial                 needs. Decisions should always be informed by a
                               found that this protective film had the potential to        comprehensive assessment undertaken by an SCN. This
                               impede the adhesion between the appliance and               process should include a careful assessment of the dexterity
                               skin, particularly for ileostomates and urostomates,        of the ostomate or carer who will take responsibility
                               and therefore updating the ostomate’s appliance             for regular appliance and accessory change, because it
                               was usually a more effective solution in terms of           is counterproductive to prescribe a product that the
                               cost, time and clinical outcome (Colwell et al,             ostomate will not be able to use appropriately (LeBlanc
                               2018). Barrier films may mask an underlying PSC,            et al, 2019). No product should be prescribed unless the
                               so, when considering a barrier, it is important to          SCN knows the ostomate or carer is able to apply and
                               determine what is causing the complication and              remove it correctly with minimal harm to the skin.
                               address it. Most ostomates will not require a barrier           Before a product is to be prescribed, it is important
                               film; however they can offer valuable protection for        to check the instructions for use about its risks. Nurses
                               those whose body profile or stoma shape makes it            should resist the temptation to change approaches too
                               hard to form a seal that prevents stomal output from        quickly. If a new product is tried, sufficient time should
                               reaching any part of the skin.                              be allowed for it to work and skin damage to heal before
                           ■   Flange extenders: Flange extenders, including               determining whether it has been effective or another
                               strips and tapes, are attached to the outer edge of         product should be tried.
                               the appliance flange to extend its adhesive area and            Prescribing should aim to provide the most appropriate
                               thus provide extra security. This can be helpful for        products in the most appropriate quantity.This should be
                               ostomates whose body profile makes it difficult to          based on careful assessment of what each individual needs
                               secure an appliance, such as those with a parastomal        to perform their daily activities and realise their social
                               hernia (Black, 2016). Flange extenders can also be          and professional goals. Some ostomates will require more
                               used to provide additional security and peace of            expensive and/or a greater number of products than others.
                               mind on occasions where the risk of a leak is of            Too many, too few or the wrong products can increase the
                               particular concern, such as at a swimming pool or           risk of comorbidity, anxiety and/or PSCs, with associated
                               a party. However, in many cases, flange extenders           costs for health and social care.The most clinically efficient
                               provide little benefit and are another thing to             stoma care routine is typically the most cost-effective, as
                               be removed from the skin, increasing the risk of            it will promote the ostomate’s health, quality of life and
                               PMARSI (LeBlanc et al, 2019). Flange extenders              capacity to contribute to wider society.
                               should never be used to resolve leaks, because they
© 2021 MA Healthcare Ltd

                               do not treat the underlying issue and merely extend         Off-label prescribing
                               the time the output takes to leak from the stoma            Some products used to treat PSCs are used off-label,
                               to the edge of the adhesive area. This increases the        meaning for a use that is not described in the product’s
                               time the effluent is in contact with the skin and thus      license. Some ostomates seek out off-label products on
                               perpetuates the skin issue.                                 the basis of their own research or recommendations from

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BJN

          friends or family. It is important for SCNs to initiate a        stoma prescribing might be lacking in CCGs. For example,
          discussion of ostomates’ use of such products to prevent         in the British National Formulary, stoma care products are
          them exacerbating skin damage.                                   not given their own category and are instead listed under
              A common example is Gaviscon liquid, which some              wound care devices, although the Drug Tariff part 9 does
          ostomates apply to the peristomal skin to soothe erythema        group stoma products together. As a result, spending on
          and pruritus, although there is no stronger evidence for this    tissue viability items are sometimes inaccurately allocated
          use other than anecdotes from SCNs and ostomates, which          to stoma care.
          have been shared in commercial patient literature and at             Moreover, as the community prescribing spend on
          conferences.Accessories with a pH-buffering technology           stoma care is substantial, it is often a focus for cost-cutting.
          can also be used for this purpose (Dansac, 2020).As another      These cuts must be informed by an up-to-date knowledge
          example of off-label prescribing, a corticosteroid inhaler       of best practice. A collaborative discussion between the
          is sometimes used topically to reduce a flare-up of an           SCN and CCG medicines-management team can help
          existing condition, such as eczema, on the peristomal            ensure that the right products are available to prescribe
          skin (Nicholson et al, 2014).Alternatively, a corticosteroid     for ostomates and can be used cost-effectively. Savings on
          lotion is applied instead of a cream or ointment for the         waste can be redirected to enhancing patient pathways and
          same purpose. If used correctly, corticosteroids can be very     education. There is also guidance for stoma care nurses
          effective at treating short-term problems, but they cannot       on recommendations for product usage published by the
          be used continuously, because their side effects include         Patient Industry Professionals (PIPs) Forum (2014).
          skin thinning, which will undermine the integrity of the
          skin in the long term.                                           KEEPING A RECORD OF CARE
              Although off-label prescribing occurs for adult              Documentation
          ostomates, it is particularly common in neonatal and             After each patient assessment, the SCN should make
          paediatric ostomates.These products are often prescribed         precise and detailed notes on the condition of the
          by weighing up the risks and benefits. However, there            peristomal skin, mentioning any evidence, protocols or
          is insufficient evidence on neonatal skin’s absorption of        tools used to make that assessment, with critical reflections
          certain product ingredients, such as alcohol, and so some        and observations from the SCN. It is also important to
          SCNs may avoid using them. Summaries of product                  record any changes to pouching routine and product
          characteristics provide little guidance. Off-label treatments    use, including the precise date of and rationale for these
          can be used with caution in ostomates who might benefit          changes. Thorough documentation will record the
          from them, but the SCN who prescribes a product off-             ostomate’s progress over time.This allows the SCN to track
          label is accountable and responsible for that decision. In       whether the peristomal skin is healing or deteriorating,
          such cases, SCNs should use their clinical judgement             which can help identify possible causes of a PSC, review
          and experience, as well as collaborate with medical,             the efficacy of an intervention and decide whether a new
          dermatology and tissue viability colleagues, where available.    approach is needed.
                                                                              This information can be used to develop a detailed
          Patient advocacy                                                 and individualised care plan, which can be added to an
          Prescribing is an area in which SCNs can exercise effective      inpatient’s notes. Care plans can be shared with other health
          patient advocacy. Financial pressures on health services have    professionals working with the ostomate, for example,
          led to cuts to and limits on prescribing budgets, which can      emailed to community nurses or sent with a referral to
          have serious consequences for ostomates’ quality of life and     another hospital. Care plans can also be an opportunity
          outcomes. Nurses can use their access to decision-makers to      to educate less-experienced colleagues by explaining
          advocate on behalf of ostomates’ interests.A greater patient     the rationale for decisions, demonstrating good practice
          voice in healthcare policy is also desirable—for example,        and modelling correct techniques, such as how to size a
          greater inclusion on NICE panels, patient partnerships in        template around a stoma.
          research and lobbying by patient groups.                            Documentation should be exact, thorough and updated
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              Part of an SCN’s responsibility is to act in an advisory     regularly. To aid communication, it is important that all
          capacity at an organisational level. SCNs need to reach out      terminology used is clear and consistent. Standards for
          to clinical commissioning groups (CCGs) and inform the           documentation are available from the Royal College
          medicines-management teams about what products are               of Nursing (2017) and Nursing and Midwifery
          appropriate to stoma care. Knowledge of the specifics of         Council (2018).

      This article is reprinted from British Journal of Nursing, 2021, Vol 30, No 6, Supplement 1, Consensus Document
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