The Ostomy Files: What is This?
“I’ve got something growing around my stoma! It’s bleeding, it hurts, and I’m scared it’s my cancer coming back.”
What this patient is describing is a peristomal skin condition referred to by multiple terminologies: pseudoverrucous lesions, pseudoephitheliomatous hyperplasia (PEH), human papilloma virus-negative ileostomal chronic papillomatous dermatitis,1 hyperplasia, and chronic papillomatous dermatitis. Basically, the condition is the result of chronic exposure to urine or moisture that is trapped on the skin around the stoma — a type of peristomal “dish pan hands.” The lesions are thickened epidermis. Although the condition is more common in patients with a urostomy, it is not completely uncommon in patients with a fecal stoma that produces a high volume, liquid output such as an ileostomy or jejunostomy.
Presentation
The patient may complain of blood-tinged urine in the ostomy pouching system, peristomal pain, shortening of wear time, or persistent leakage. The tendency to develop the condition can be exacerbated by a retracted or stenosed stoma,2 a peristomal hernia, suboptimal stoma citing, obesity, a high pH in the urine, extended wear times, and the presence of a pannis or any other factor known to interfere with obtaining a secure skin barrier-to-skin seal.
The lesions may be single or clustered and are white-gray to reddish brown wart-like papules or nodules. If chronic and untreated, they can protrude above skin level, further interfering with adhesion of an ostomy pouching system. The shape and location of the lesions frequently mirrors the gap on the skin between the stoma and the opening in the skin barrier that is too large or improperly shaped.
According to Lyon and Smith,3 persons with alkaline urine have a greater tendency to develop pseudoverrucous lesions around urostomies. Therefore, development of urinary crystals on the stomal mucosa or peristomal skin is often an associated complication.
Treatment and Management
The first step is to determine the source of chronic exposure of the peristomal skin to moisture and correct it. The skin barrier may be eroding too quickly or is being worn too long. Many patients believe they should wear a skin barrier for 7 days if it is not leaking. However, an inspection of the skin barrier after it is removed from the skin will likely show that it has eroded away before 7 days have passed — a phenomenon Rolstad and Erwin-Toth4 refer to as “silent leakage.” Patients experiencing silent leakage may complain about burning or itching without signs of any detachment of the skin barrier from the skin. The opening in the skin barrier should be examined to ensure it fits snugly up to the stoma-skin junction.5 Extended-wear skin barriers should replace standard skin barriers to prevent premature skin barrier erosion. Patients should be instructed to reduce wear time until the condition has been resolved. Frequently, re-evaluation of the pouching system, skin barrier, and wear time can heal the lesions and eliminate the problem.
In other situations, more drastic changes in pouching methods may be required, such as the use of moldable convexity, convex extended-wear skin barriers or the use of an ostomy appliance belt to slightly increase support on the peristomal skin, aid in enhancing the convexity, and obtain a leak-proof seal. Because they adhere to moist skin, cohesive seals (Eakin™, ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ) may be used to create an effective seal around the stoma over which the pouching system (flat or convex) may be placed.2 When placing the cohesive seal on the skin, constant contact between the stoma and the cohesive seal should be obtained.
In circumstances where urinary crystals are a problem or the lesions protrude above skin level or cause pain, more aggressive management may be indicated. Silver nitrate may be used on protruding or clustered lesions to create a flat skin surface. More severe cases may require sharp debridement by a qualified healthcare professional.
Efforts to acidify urine (lower the pH) may be achieved through increasing fluid intake, vitamin C supplementation, and cranberry juice.5 However, these approaches should be approved by a physician because vitamin C supplementation may be contraindicated in some patients. Urinary crystals also may be eliminated through direct application of vinegar soaks on the areas affected.
Summary
Once again, patient education is of paramount importance in helping to prevent stomal and peristomal skin complications. Clinicians should be vigilant and listen carefully to patient complaints and use patient cues and clues to help solve clinical problems.
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. Williams CM, Wieland U, Rodning CB, Horenstein MG. Human papilloma virus-negative ileostomal chronic papillomatous dermatitis. J Cutan Pathol. 2003;30(4):271–274.
2. Wagner VP, Osgood SB. Patient with a recessed, stenosed stoma located in an irregular pendulous abdomen and the presence of pseudo-verrucous lesions. JWOCN. 1998;25:261–266.
3. Lyon CC, Smith AJ. Infections. In: Lyon CC, Smith AG (eds). Abdominal Stomas and Their Skin Disorders: An Atlas of Diagnosis and Management. Malden, Mass: Blackwell Science;2001.
4. Rolstad BS, Erwin-Toth PL. Peristomal skin complications: prevention and management. Ostomy Wound Manage. 2004;50(9):68–77.
5. Colwell J. Stomal and peristomal complications. In: Colwell J, Goldberg MT, Carmel JE (eds). Fecal & Urinary Diversions: Management Principles. St. Louis, Mo: Mosby;2004:308–325.
