Managing Ostomy-Related Skin Irritation: Fault Tree and Fixes

Howdy gang,

Seems we deal with a lot of skin irritation issues on here, so I'm going to list the fault tree you should go through with your doc or ostomy nurse whenever you run into a skin problem. I'll also include the link to that great stoma picture book I keep referring to that shows in graphic detail all the issues you could have with your stoma. It will help you narrow down what you have going on and save you and your docs a lot of time chasing the wrong causes. It's a huge file, so it may take a few seconds to load on the site.

Ok........print this one out and hang it on your fridge for when you need it. Note that the "fixes" I listed below are what I've tried, so it's not a complete list.....but it will point you in the right direction. Feel free to add to this list any products you've tried or know about that others might want to try.

Link to Stoma Book: https://docshare.tips/abdominal-stomas-and-their-skin-disorders_5884d04fb6d87fb4298b4ac9.html

Ok, here we go

There are 5 possible causes for peristomal skin irritation, and here they are along with some ways to correct them

1) Mechanical: Damage from frequent barrier changes or tape removal causing trauma to the skin

Fixes:

Skin protectants (Marathon, Cavilon, etc)

Cold compress

Pure Aloe

Various adhesive removers

Butt Paste (40 zinc oxide)

Chlorine spray (be careful with this one)

Honey

Moisturizers

Triple antibiotic ointment

Petroleum jelly

2) Fungus

Fixes:

Nystatin liquid

Tolnaftate

Clotrimazole

Miconazole

Terbinafine

Fluconazole

Itraconazole

3) Contact dermatitis (Note – Topical steroids come in a wide variety of strengths and can permanently damage your skin if used improperly or for too long. Consult a dermatologist before using what I've listed and see the topical steroid strength list at bottom of page)

Fixes:

Stoma powders and wipes

Topical steroids (Betamethasone, Tacrolimus, Triamcinolone, Hydrocortisone, etc)

4) Allergic reaction (recommend patch testing anything in question on opposite side of abdomen for at least 72 hours)

Fixes:

Stop using the product

Flonase

Benadryl

Calamine lotion/Ivarest

5) Poly Gangrenum (this is serious and needs to be dealt with by your doc)

How to identify: Abnormal white blood count (WBC) and/or abnormal C-reactive protein (CRP) level

How to fix: Prescription drugs needed - see your gastroenterologist

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TOPICAL STEROIDS

Four topical corticosteroid foams are available which when dry won't reduce barrier adhesion very much, if at all

Clobetasol propionate (CP) 0.05 foam

Betamethasone valerate (BMV) 0.12 foam

Calcipotriol 0.005 plus betamethasone dipropionate (Cal/BD) 0.064

Desonide 0.05 foam (Table 1).

----TOPICAL STEROID STRENGTH LIST-------------------------------------------------------------------------

Topical steroid Class I

These topical steroids are considered to have the highest potency:

Clobetasol propionate 0.05 (Temovate)
Halobetasol propionate 0.05 (Ultravate cream, ointment, lotion)
Diflorasone diacetate 0.05 (Psorcon ointment)
Betamethasone dipropionate 0.25 (Diprolene ointment, gel)

Topical steroid Class II

These topical steroids are considered highly potent:

Fluocinonide 0.05 (Lidex cream, gel, ointment, solution)
Halcinonide 0.1 (Halog cream, ointment, solution)
Amcinonide 0.1 (Cyclocort ointment)
Desoximetasone 0.25 (Topicort cream, ointment)

Topical steroid Class III

These topical steroids are considered potent:

Amcinonide 0.1 (Cyclocort cream, lotion)
Mometasone furoate 0.1 (Elocon ointment)
Fluticasone propionate 0.005 (Cutivate ointment)
Betamethasone dipropionate 0.05 (Betanate cream)
Triamcinolone acetonide 0.5 (Kenalog cream, ointment)
Calcipotriol/Betamethasone contains a potent group III-steroid

Topical steroid Class IV

These topical steroids are considered moderately potent:

Fluocinolone acetonide 0.025 (Synalar cream, ointment)
Flurandrenolide 0.05 (Cordran cream, ointment, lotion)
Triamcinolone acetonide 0.1 (Triderm cream, ointment, lotion)
Mometasone furoate 0.1 (Elocon cream, lotion, solution)
Fluticasone propionate 0.05 (Cutivate cream)

Topical steroid Class V

These topical steroids are considered somewhat potent:

Hydrocortisone valerate 0.2 (Westcort cream, ointment)
Hydrocortisone butyrate 0.1 (Locoid ointment)
Prednicarbate 0.1 (Dermatop cream, ointment)
Hydrocortisone probutate 0.1 (Pandel cream)

Topical steroid Class VI

These topical steroids are considered mild:

Desonide 0.05 (LoKara lotion, Desonate gel, Desowen cream, ointment)
Fluocinolone acetonide 0.025 (Synalar cream, solution, shampoo)
Hydrocortisone butyrate 0.1 (Locoid cream, lotion, solution)

Topical steroid Class VII

These topical steroids are considered the least potent:

Hydrocortisone 2.5 (Hytone cream/lotion)
Hydrocortisone 1 (Many over-the-counter brands of creams, ointments, lotions)
Hydrocortisone acetate 0.5 and 1 (Anusol-HC, Proctocream-HC, Proctosol HC cream)

THANKS FOR THIS INFORMATIVE INFORMATION. 

I have not suffered too badly from skin condition around the stoma, but hope that admin will make sure your post  is placed in a prominent position with 'Collections', so that we can find it if need be.

Best wishes

Bill

This is great information. I have not suffered from skin complications but that doesn't mean I won't in the future, so I have saved it in a Word document and labeled it "Ostomy Rash". If I ever need it, I will remember to open it. It's so important; it should be saved here in a relevant place, I agree.

Thanks, Bob!

Thanks, Bob. That is an interesting book. One I hope never to need.

I think number five that you were looking for is actually pyoderma gangrenosum. Despite the name, it has nothing to do with traditional gangrene.

Most of us in the States just use the term pyoderma because sometimes other clinicians are ignorant of this condition, see the word gangrenosum and believe it means gangrene. It causes a lot of brouhaha during rounds, let me tell you.

Couple of caveats or just points if you will: IMHO

I would like to point out from your friendly neighborhood wound care nurse that anytime you put any kind of cream or lotion anywhere that's going to interfere with your barrier, you're just asking for leaks. I'm sorry to say it but it's true.

Sometimes you can seal the cream or lotion under hydrochloride wafer, sometimes known as a duoderm. They come even as big as 8x8" last I checked. A little over 20 cm square for our friends across the pond. But I highly recommend you have at least 2 in (5cm), preferably double that surrounding where you have placed your cream. Anything you do really only needs to be temporary to give your skin time to heal, but temporary can be a relative term when you're dealing with giving the best man speech at your brother's wedding or surrounding the birth of your first child. Their invention life you just can't miss even with a leaky ostomy.

Whatever ends up working for you this time might not even be the right solution next time. That's why that list up there was so extensive.

Lastly for those of us who are highly allergic to everything but snot...

Please consider systemic anti-allergy treatments. I know it seems like a lot on top of what you already deal with, but if you're spending this much time at the doctor's office anyway, go across the hall to the allergist office, not the dermatologist. See an allergist, consider immunotherapy. If you can think dry rather than lotion.

Powdered antifungal like Nice that one or microstatin.

Crush up Benadryl very fine or pop open a diphenhydramine capsule.

Covered with some sort of barrier wipe or spray (or even tincture of benzoin. Which stings like hell but gets the job done special thanks to Pooter who reminded me of that one).

Lastly, please, please, please take the warnings on the steroids seriously. These are not anabolic steroids, they are catabolic steroids, which means part of what they do is break tissue down.

If I could close with one final request: If some is good, more is not necessarily or even usually better, no matter what you're using. Use these products only as directed, those directions are there for a very good reason.

Okay, I'll get down off my soapbox now rofl

Thanks so much for all this information! I have short-term solutions, but because I have a large hernia under my ostomy site, it's impossible for my bag to stay on. Lots of leaks, waiting for ostomy resection and moved to the other side. Worried because I've had 13 surgeries and apparently this will be the biggest because of sewing up one side, opening up the other side for the new ileostomy! My skin is raw, itchy, and painful! I appreciate your post!

Thank you!!

Hi O A,

Yup.....typo on my part, it is Pyoderma Gangrenosum. I was copying from my scribbled notes and I tend to shorten things, as I get what I'm talking about. But yes, they are two very different things, so thanks for the correction. Never had to deal with it myself, and hope I never have to. There's a few on here that have dealt with it, and it's not fun.

Your point about creams and lotions is absolutely correct. I didn't mention that because I figure folks know that........sort of that common sense kind of thing......but thanks for mentioning it. I only used foams, but not every steroid is available that way........actually most are not, which seriously limits choices. A Dermatologist who knows their shit can be a good friend........if you can find one.

The rest of your tips are awesome. It soooo nice to have a real ostomy nurse on this site!!

;O)