Wound, Ostomy and Continence Nurses Society™

Peristomal Skin Assessment Guide for Consumers

Funded through an educational grant from Hollister Incorporated

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Images & Definitions

Resources

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How to Use This Guide

This Peristomal Skin Assessment Guide is for teens and adults with an ostomy. It is designed to help you identify some common skin problems, things you should do, and when you should visit a wound, ostomy and continence (WOC) nurse or nurse specialized in wound, ostomy and continence (NSWOC) for additional support.

This guide is not meant to replace advice from a medical professional.

Examine Your Skin:

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Acknowledgement

Thank you to the dedicated developers of the Peristomal Skin Assessment Guide for Consumers:

Janice C. Colwell, MS, RN, CWOCN, FAAN
Advanced Practice Nurse – Ostomy Care Services
University of Chicago, Chicago, Illinois

Dorothy Doughty, MN, RN, CWOCN, FNP, FAAN
Emory University Hospital, Atlanta, Georgia

Margaret Goldberg, MSN, RN, CWOCN
Clinical Nurse Specialist/WOC Nurse,
Delray Wound Treatment Medical Center, Delray Beach, Florida

Jo Hoeflok, RN, BSN, MA, CETN(C), CGN(C)
Consultant in Enterostomal Therapy Nursing
Campbell River, British Columbia, Canada

Christine Kim
Ileostomate since 1994 and founder of OstomyConnection.com
Texas, USA

Andrea Manson, RN, BSN, ET
Ostomy Care & Supply Centre,
New Westminster, British Columbia, Canada

Laurie McNichol, MSN, RN, CNS, GNP, CWOCN, CWON-AP, FAAN
Clinical Nurse Specialist/WOC Nurse,
Cone Health, Wesley Long Hospital, Greensboro, North Carolina

The WOCN Society does not endorse any specific brands or products.

How to Use This Guide

This Peristomal Skin Assessment Guide is for teens and adults with an ostomy. It is designed to help you identify some common skin problems, things you should do, and when you should visit a wound, ostomy and continence (WOC) nurse or nurse specialized in wound, ostomy and continence (NSWOC) for additional support.

This guide is not meant to replace advice from a medical professional.

Examine Your Skin:

  • Remove your pouching system.
  • Look at your skin and stoma in both the sitting and lying positions.
  • Answer a series of questions, choosing the answer that best matches what you see.
  • Follow the instructions provided within this guide.
Start

Where is the skin damage?

  • There is no damage
  • Next to the stoma
  • Away from the stoma
  • An area of solid rash with scattered dots at the outer edge
  • Bumps or pimples at hair follicles

What color is the skin damage?

  • No skin damage; no lasting redness; change in skin tone under the skin barrier may occur
  • Red
  • White/gray
  • Red AND White/Gray

How does the skin look?

  • Skin intact
  • Shallow skin loss (open and moist)
  • Deep skin loss (crater)
  • Skin overgrowth (raised tissue)
  • Waterlogged (soggy)
  • Blisters
  • Drainage (pus)
  • Shallow skin loss AND skin overgrowth (raised tissue)

What other information can you report?

  • No pain, no lasting itching or burning, able to maintain pouch seal
  • Lasting itching or burning
  • Pain or sensitivity in the area of skin damage
  • Unable to maintain pouch seal for 24 hours
  • Sensitivity to touch or pressure

 

Healthy Peristomal Skin

Definition: Skin free of any damage or rash; no breakdown or discoloration; no burning or persistent itching; mirrors skin on the other side of abdomen. Images below illustrate persons with light and dark skin tones.

Tips for Better Skin Care

Techniques to Maintain Healthy Peristomal Skin

  • Check Barrier/Pouching System Fit
    Routinely measure your stoma and check that the skin barrier opening is sized to fit closely around stoma base.
  • How to Measure your Stoma:

  • Change skin barrier immediately if experiencing burning, itching, or leakage.
  • Assess adhesive side of skin barrier at each pouch change for evidence that stool/urine is leaking under the barrier. If there is evidence of leakage, change pouching system more often.

Skin Barrier and/or Tape (Adhesive) Removal Technique

  • Starting at the top, with one hand, gently lift the edge of the adhesive product; with the other hand, gently push the skin away from the adhesive.

Before putting on the pouching system, some people find it helpful to remove hair in the peristomal area. This helps to prevent trauma to the hair follicle upon the next pouching system change. Clipping with scissors or use of disposable or electric razors are recommended; frequency dependent on rate of hair growth.

Avoid Wetness Under Pouching System

  • Thoroughly dry the tape border and pouch backing after bathing, swimming, etc.
  • Consider a pouch cover to manage perspiration and/or moisture under plastic pouch.

 

Peristomal Moisture Associated Skin Damage (PMASD – Maceration)

The softening and breaking down of the skin around the stoma resulting from prolonged exposure to moisture (urine or stool). Image below illustrates person with darker skin tone.

Manage Probable Causes

Check Barrier for Overhydration (softening and whitening)

Remove pouching system and assess adhesive side of skin barrier; if there is significant overhydration of the barrier, change pouching system more frequently.

Check Barrier/Pouching System Fit

Ensure skin barrier opening is sized to fit closely around stoma base.

How to Measure your Stoma:

Ensure Barrier Provides Good Fit for Stoma and Abdominal Surface

  • Examine your stoma and the skin around your stoma in the standing and sitting positions. Check to see if your stoma sticks out in those positions. Check to see if you have creases or folds in the skin around your stoma in either position.
  • If your stoma does not stick out AND/OR you have creases or folds in the skin around your stoma, consider a convex pouching system and/or ostomy belt.
  • Consult a WOC nurse/NSWOC or product manufacturer should you wish to discuss these options.

Peristomal Skin Care for Waterlogged Skin

Dust waterlogged skin with stoma powder; brush off excess (if too much powder remains on the skin, the barrier may not stick). Do this during each pouching system change until the skin recovers.
Assess adhesive side of barrier and skin at each pouch change. If the barrier appears overhydrated or the skin is waterlogged, change pouching system more often.

Discontinue use of stoma powder when problem resolves/skin recovers.

Seek Help

Consult a WOC nurse/NSWOC and/or product manufacturer:

  • If no improvement after 7 days of management
  • Probable contributing factors unclear or not identified

Tips for Better Skin Care

  • Change pouching system on a consistent schedule.
  • Change pouching system if there is peristomal itching and/or burning.
  • Change pouching system if the skin barrier leaks or loosens.

 

Peristomal Moisture Associated Skin Damage (PMASD – Irritant Dermatitis)

Areas of skin loss and irritation due to contact with stool and/or urine.

Manage Probable Causes

Check Barrier/Pouching System Fit

Ensure skin barrier opening is sized to fit closely around stoma base.

How to Measure your Stoma:

Ensure Barrier Provides Good Fit for Stoma and Abdominal Surface

  • Examine your stoma and the skin around your stoma in the standing and sitting positions. Check to see if your stoma sticks out in those positions. Check to see if you have creases or folds in the skin around your stoma in either position.
  • If your stoma does not stick out, consider using a convex pouching system and/or ostomy belt.
  • If you have creases or folds in the skin around your stoma, consider a barrier ring, convex pouching system, and/or ostomy belt.
  • If your stoma does not stick out AND you have creases or folds in the skin around your stoma, consider a barrier ring, convex pouching system, and/or ostomy belt.
  • How to use ostomy belt:

  • If you have liquid stool, consider adding a barrier ring.
  • How to use barrier rings:

Frequency of Pouching System Change

  • Change pouch when leaking; do not reinforce with additional tape.
  • Assess adhesive side of skin barrier at each pouch change for evidence that stool/urine is leaking under the barrier. If there is evidence of leakage, change pouching system more often.
  • If you experience burning, itching or leakage, change barrier immediately.

Peristomal Skin Care for Irritated Skin

Dust irritated skin with stoma powder; brush off excess (if too much powder remains on the skin, the barrier may not stick). Do this during each pouching system change until the skin recovers.

Discontinue use of stoma powder when problem resolves/skin recovers.

Seek Help

Consult a WOC nurse/NSWOC and/or product manufacturer:

  • If no improvement after 7 days of management
  • Probable contributing factors unclear or not identified

Tips for Better Skin Care

  • Change pouching system on a consistent schedule.
  • Change pouching system if there is peristomal itching and/or burning.
  • Change pouching system if the skin barrier leaks or loosens.

 

Peristomal Moisture Associated Skin Damage (PMASD – Fungal)

An area of solid rash with scattered dots at the outer edge.

Manage Probable Causes

Check Barrier for Overhydration (softening and whitening)
Remove pouching system and assess adhesive side of skin barrier; if there is significant overhydration of the barrier, change pouching system more frequently.

Check Barrier/Pouching System Fit
Ensure skin barrier opening is sized to fit closely around stoma base.

How to Measure your Stoma:

Wetness Under Pouching System
Thoroughly dry the tape border and pouch backing after bathing, swimming, etc.
Consider a pouch cover to manage perspiration and/or moisture under plastic pouch.

Peristomal Skin Care for Fungal Rash

Antifungal Powder Dust powder on affected area with each pouch change. Brush off excess (if too much powder remains on the skin, the barrier may not stick). Avoid using antifungal cream or ointment under the barrier.

Change pouching system and use antifungal powder at least every 3-4 days for 2 weeks.

Discontinue use of antifungal powder when problem resolves/skin recovers.

Seek Help

Consult a WOC nurse/NSWOC and/or product manufacturer if no improvement after 14 days of treatment.

Tips for Better Skin Care

  • Change pouching system on a consistent schedule.
  • Change pouching system if there is peristomal itching and/or burning.
  • Change pouching system if the skin barrier leaks or loosens.
  • Dry pouching system well after bathing, swimming, or contact with water or steam

 

Peristomal Medical Adhesive Related Skin Injury (PMARSI – Adhesive Damage)

Skin injury related to use and/or removal of adhesives. Images below illustrate persons with light and dark skin tones.

Manage Probable Causes

Skin Barrier and/or Tape (Adhesive) Removal Technique

  • Starting at the top, with one hand, gently lift the edge of the adhesive product; with the other hand, gently push the skin away from the adhesive.

Peristomal Skin Care for Adhesive Related Skin Injury

Treatment of open areas (if any)
Dust open areas with stoma powder; brush off excess (if too much powder remains on the skin, the barrier may not stick). Do this during each pouching system change until the skin recovers.

Trim adhesive border of pouching system to avoid injured skin.

Discontinue use of stoma powder when problem resolves/skin recovers.

Seek Help

Consult a WOC nurse/NSWOC and/or product manufacturer:

  • If no improvement after 7 days of treatment

Tips for Better Skin Care

  • Change pouching system on a consistent schedule.
  • Change pouching system if there is peristomal itching and/or burning.
  • Change pouching system if the skin barrier leaks or loosens.

 

Peristomal Medical Adhesive Related Skin Injury (PMARSI – Folliculitis)

Bumps or pimples at hair follicles

Manage Probable Causes

Skin Barrier and/or Tape (Adhesive) Removal Technique

  • Starting at the top, with one hand, gently lift the edge of the adhesive product; with the other hand, gently push the skin away from the adhesive.

Hair Removal
Before putting on the pouching system, some people find it helpful to remove hair in the peristomal area. This helps to prevent trauma to the hair follicle upon the next pouching system change. Clipping with scissors or use of disposable or electric razors are recommended; frequency dependent on rate of hair growth.

Peristomal Skin Care for Folliculitis

Skin Cleansing
Clean with mild antibacterial soap at each pouching system change. Rinse thoroughly. Continue using mild antibacterial soap until bumps/pimples have resolved.

Treatment of open areas (if any)
Dust open areas stoma powder; brush off excess (if too much powder remains on the skin, the barrier may not stick). Do this during each pouching system change until the skin recovers.

Discontinue use of stoma powder when problem resolves/skin recovers.

Seek Help

Consult a WOC nurse/NSWOC and/or product manufacturer if no improvement after 14 days of treatment.

Tips for Better Skin Care

  • Change pouching system on a consistent schedule.
  • Change pouching system if there is peristomal itching and/or burning.
  • Change pouching system if the skin barrier leaks or loosens.

 

Referral

Referral

Interim Interventions

If unable to maintain pouch seal for 24 hours:

Ensure Barrier Provides Good Fit for Stoma and Abdominal Surface

  • Examine your stoma and the skin around your stoma in the standing and sitting positions. Check to see if your stoma sticks out in those positions. Check to see if you have creases or folds in the skin around your stoma in either position.
  • If your stoma does not stick out, consider using a convex pouching system and/or ostomy belt.
  • If you have creases or folds in the skin around your stoma, consider a barrier ring, convex pouching system, and/or ostomy belt.
  • If your stoma does not stick out AND you have creases or folds in the skin around your stoma, consider a barrier ring, convex pouching system, and/or ostomy belt.
  • How to use ostomy belt:

  • If you have liquid stool, consider adding a barrier ring.
  • How to use barrier rings:

Change pouch when leaking; do not reinforce with additional tape.

If you have an ulcer or full thickness skin loss (crater):

  • Rinse open area with saline or tap water.
  • Fill area with stoma powder. Dust powder on area of skin loss and brush away excess.

  • Cover powder with a flattened piece of skin barrier ring, if available. If not, follow steps below.
  • Ensure skin barrier opening is sized to fit closely around stoma base.
  • Apply pouching system on top of open area treated with stoma powder.

If your ulcer or full thickness skin loss (crater) has purulent (pus) drainage:

  • Evaluate for other signs of infection (for example, elevated temperature, chills, decreased appetite, nausea or vomiting) and include in report to the physician or other provider.
  • Rinse open area with saline or tap water.
  • Fill any open areas with stoma powder. Dust powder on area of skin loss and brush away excess.
  • Ensure skin barrier opening is sized to fit closely around stoma base.
  • Apply pouching system on top of open area treated with stoma powder.
  • Report this information to physician or other provider.
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Images & Definitions

Blisters

Deep skin loss (crater)

Drainage (pus)

Healthy peristomal skin (person with darker skin tone)

Healthy peristomal skin (person with lighter skin tone)

Overhydration of skin barrier

Overhydration and erosion/breakdown of skin barrier

Peristomal Medical Adhesive Related Skin Injury (PMARSI) – Adhesive Injury
Skin injury related to use and/or removal of adhesives.

Peristomal Medical Adhesive Related Skin Injury (PMARSI) – Folliculitis
Inflammation of hair follicles.

Peristomal Moisture Associated Skin Damage (PMASD) – Fungal Rash
Characterized by a rash that is solid in the center with distinct dot-like lesions at the edge; rash appears red in people with light colored skin and appears lighter than normal skin in people with dark skin tones.

Peristomal Moisture Associated Skin Damage (PMASD) – Maceration
The softening and breaking down of skin resulting from prolonged exposure to moisture.

Shallow skin loss (open and moist)

Skin overgrowth (raised tissue)

Variety of convex pouching systems

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Resources

Services

Products

The WOCN Society does not endorse any specific brands or products.

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Patient Education

Manage current pouching system regime.

  • Characteristics of normal peristomal skin
  • Findings that would suggest evaluation by WOC/ET nurse or physician
  • How to ensure the skin barrier is sized to fit closely around stoma base
  • Change pouch for burning, itching, and leakage
  • Change pouching system at intervals that provide predictable and reliable wear time and help maintain healthy skin
  • Cleanse with warm tap water
  • Routine hair removal if indicated
  • How to gently remove pouching system:
    • Loosen edges of adhesive product
    • With fingers of opposite hand, push skin down and away from adhesive
    • Gently remove adhesive product back over itself in the direction of hair growth, keeping it close to the skin surface
    • As product is removed, continue moving fingers of opposite hand as necessary to support newly exposed skin