The Ostomy Files: Is a Rose Always a Rose?

  Gertrude Stein immortalized the line “a rose is a rose is a rose” in the 1913 poem Sacred Emily.¹ When later interviewed, she stated that this famous line made the “rose … red for the first time in English poetry for one hundred years.” Many years before Stein’s famous quotation, Romeo and Juliet also wondered whether a name was an artificial and meaningless convention. Because they were from feuding families, Romeo challenged Juliet by saying, “What’s in a name? … that which we call a rose by any other word would smell as sweet.” In other words, Shakespeare was explaining that Romeo was Romeo regardless of his last name and that Juliet’s love was for him and should have nothing to do with his family name. Thus, a rose is a rose is a rose regardless of what you call it. Is this also true of ostomy skin barriers? Is a skin barrier a skin barrier a skin barrier?

  Earlier this year, van Rijswijk² discussed the challenges associated with classifying wound dressings based solely on the main ingredient (such as hydrocolloid, alginate, hydrogel) in the dressing, stating that modern dressings should be categorized by their function, not by their ingredients. One also could challenge these broad ingredient-based classifications for skin barriers used for peristomal skin protection.

  Baking provides another excellent corollary. Basically, flour, baking soda, salt, butter or oil, and milk or cream make biscuits. Add eggs and sugar and you have a cake. Add cheese and it becomes cheesecake. Add chocolate and you have a chocolate cake. Each one of these goodies has some of the same basic ingredients but how they are mixed together and what is added (or deleted) produces an entirely different baked good that looks and tastes different.

  The same is true for ostomy skin barriers. Colwell³ states “the most important part of the pouching system is the skin barrier, the interface between the patient’s skin and the pouch.” Ostomy skin barriers may start out with the same “ingredients,” but how they are processed, what is added to them, and in what proportion materials are mixed or assembled can directly impact the skin barrier’s function. The ultimate goal is to provide a predictable, consistent seal; protect the peristomal skin; and provide support.⁴

  Skin barriers used to protect the peristomal skin are composed of a mixture of a variety of components that can include polymers, tackifiers, softeners, plasticizers, hydrocolloids, fillers, pigment,³ adhesives, karaya, films, and carbohydrates. The processing and mixing of these ingredients impact their function on the skin and their ability to absorb and/or withstand moisture, as well as the length of time before the skin barrier erodes. The composition and manufacture of each ostomy skin barrier is unique and has a direct impact on wear time.³

  Today, ostomy skin barriers are classified two ways: standard (or regular) and extended-wear. Extended-wear skin barriers (a relative term specific to each patient’s unique situation) have delayed absorption and a higher level of adhesion that generally provides a longer wear time. Each of the two classifications is further divided into flat, convex, cut-to-fit, moldable, and precut.

  The subject of an acceptable wear time has been debated for many years. Lengthening wear time by using an extended-wear skin barrier may mean a 7-day wear time for one patient or a 2-day wear time for another person who previously had been able to maintain a seal for only 24 hours. Again, selection of the “right” skin barrier (type, size, shape) for the individual patient depends on several factors, including the abdominal topography (creation of a flat surface on which the skin barrier can adhere) and the character and quantity of stomal output. Wear time is also compromised by what Rolstad and Erwin-Toth⁵ refer to as “silent leakage.” This occurs when the skin barrier erodes and the peristomal skin is exposed to effluent even though no visible or outward signs of leakage are observed. Silent leakage can be prevented by inspecting the back of the skin barrier once it is removed from the skin to check for erosion and by conducting an assessment of the peristomal skin. At this juncture, a decision can be made whether to extend or decrease wear time or select another type of skin barrier.

  To answer the question posed earlier, is a skin barrier a skin barrier a skin barrier? The answer is that a skin barrier may always be called a skin barrier, but how it functions to protect the peristomal skin and maintain a predictable wear time will depend on the material it contains and the manner in which those materials have been combined and manufactured.

The Ostomy Files is made possible through the support of ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ. This article was not subject to the Ostomy Wound Management peer-review process.

1. Stein B. Sacred Emily. Geography and Plays. Boston, Mass: Four Seas Co.;1922 :178-188.

2. van Rijswijk L. Ingredient-based wound dressing classification: a paradigm that is passé and in need of replacement. J Wound Care. 2006;15(1):11-14.

3. Colwell JC. Principles of stoma management. In: Colwell JC, Goldbert MT, Carmel JE (eds). Fecal & Urinary Diversions: Management Principles. St. Louis, Mo: Mosby. 2004:240-262

4. Turnbull G, Colwell JC, Erwin-Toth P. Quality of life: pre, post, and beyond ostomy surgery. Ostomy Wound Manage. 2004;50(7A suppl):S1-S12.

5. Rolstad BS, Erwin-Toth PL. Peristomal skin complications: prevention and management. Ostomy Wound Manage. 2004;50(9):68-77.