Stoma and Peristomal Skin Care: a Clinical Review Early Intervention in Managing Complications Is Key

Home , Epidermis (botany), Stoma

WOUND WISE 1.5 HOURS CE Continuing Education A series on wound care in collaboration with the World Council of Enterostomal Therapists Stoma and Peristomal Skin Care: A Clinical Review Early intervention in managing complications is key.

ABSTRACT: Nursing students who don’t specialize in ostomy care typically gain limited experience in the care of patients with fecal or urinary stomas. This lack of experience often leads to a lack of confidence when nurses care for these patients. Also, stoma care resources are not always readily available to the nurse, and not all hospitals employ nurses who specialize in wound, ostomy, and continence (WOC) nursing. Those that do employ WOC nurses usually don’t schedule them 24 hours a day, seven days a week. The aim of this article is to provide information about stomas and their complications to nurses who are not ostomy specialists. This article covers the appearance of a normal stoma, early postoperative stoma complications, and later complications of the stoma and peristomal skin.

Keywords: complications, ostomy, peristomal skin, stoma

n 46 years of clinical practice, I’ve encountered article covers essential information about stomas, many nurses who reported having little educa- stoma complications, and peristomal skin problems. Ition and even less clinical experience with pa- It is intended to be a brief overview; it doesn’t provide tients who have fecal or urinary stomas. These exhaustive information on the management of com- nurses have said that when they encounter a pa- plications, nor does it replace the need for consulta- tient who has had an ostomy, they are often un- tion with a qualified wound, ostomy, and continence sure how to care for the stoma and how to assess (WOC) nurse. It will address the normal stoma and various problems of the stoma and the surround- peristomal skin as well as early and late postopera- ing skin. This lack of knowledge can contribute to tive stoma complications and peristomal skin prob- the nurse’s stress and may cause the patient and fam- lems. Recommendations are also provided for nursing ily members to lose confidence in the nurse. This management of stomas and peristomal skin.

38 AJN ▼ June 2019 ▼ Vol. 119, No. 6 ajnonline.com By Susan Stelton, MSN, RN, ACNS-BC, CWOCN

THE NORMAL STOMA Nurses need to know the expected appearance—as well as other characteristics—of the normal stoma before they can recognize stoma complications (see Figure 1). Ideally, the stoma should be “budded,” meaning that it protrudes about 1 to 3 cm above skin level.1 Because the stoma is constructed of bowel mucosa, and the mucosa contains many small blood vessels, the stoma should be dark pink to red in color. The surface of the stoma is a mucous membrane and therefore should be warm and moist.1 To the touch, the stoma should have a tissue consistency similar to the lips. The skin around the stoma should look like the skin on the rest of the abdomen. It shouldn’t be dis- colored. In patients with lighter skin tones, the peristomal skin shouldn’t be reddened; in patients with darker skin tones, it shouldn’t have darker discolor- ations. The peristomal skin should also be clear of lesions of any kind. Remember that the stoma is part of a patient. Therefore, factors that affect the general health of the patient may also affect the color of the stoma. Patients experiencing significant hypoxia may have a bluish stoma. This should not be confused with a lack of blood flow to the stoma. When oxygen lev- els return to normal, the stoma will return to a pink- to-red color. Similarly, when a patient is extremely anemic, the stoma may be a dull-looking light pink.

When the hemoglo- Amelie-Benoist by Photo / BSIP Alamy. bin count returns to normal, the stoma re- sumes its dark pink- peristomal skin complications may cause pouch leak- to-red color. These age, pain, problems adjusting to the stoma, increased color differences are equipment expense, higher postsurgical care costs, related to the overall and diminished quality of life.4, 8 Prompt recognition health of the patient and management of stoma and peristomal skin prob- and are not consid- lems is essential to the care of these patients. ered stoma complications. EARLY POSTOPERATIVE STOMA COMPLICATIONS Figure 1. Normal Stoma. For a review of the In the first few days after the surgery to create the Photos are courtesy of different types of sto- stoma, complications including edema, bleeding, and the WOCN Image Library, mas and pouch sys- ischemia of the stoma as well as mucocutaneous sep- except where noted. tems, see Stoma Care aration may occur.3, 4, 9 Basics.2 Stoma edema is quite common immediately after surgery. The stoma takes on a lighter pink color STOMA AND PERISTOMAL SKIN COMPLICATIONS and has a translucent, fluid-filled appearance. Edema According to a 2017 study, between 100,000 and normally subsides over a period of six to eight weeks.1 130,000 new stomas are created in the United States Edematous stoma tissue is fragile and can be easily each year.3 However, the incidence of stoma and scraped or lacerated during skin cleansing and pouch peristomal skin complications varies widely, with application and removal. It’s important to accom- studies reporting rates as low as 10% and as high modate the edematous stoma by cleansing very gen- as 82%.4-6 Therefore, it’s difficult to say with any tly and cutting the skin barrier slightly larger than certainty what the percentage of patients who will the usual one-eighth of an inch in diameter to ac- experience complications might be.7 Stoma and commodate any additional edema that may occur. [email protected] AJN ▼ June 2019 ▼ Vol. 119, No. 6 39 The stoma appears a darker pink to red when the receiving high-dose edema has subsided. steroid therapy or Stoma bleeding. Minor stoma bleeding after chemotherapy before surgery is common owing to the abundant vascular surgery.1 In minor supply to the bowel. In my experience, the presence separations, the gap of a few drops of sanguineous drainage is normal between stoma and right after surgery, and this generally subsides in a skin can be filled with day or two. The application of a cool cloth with light pectin-based stoma pressure to the bleeding area will normally stop mi- Figure 3. Mucocutaneous powder or a small bit nor bleeding. A steady drip, trickle, or flow of blood Separation of absorbent dress- from the stoma is not normal and requires prompt ing, such as calcium physician notification. alginate (silver alginate may be used if there’s inflam- Stoma ischemia. Blood circulation to the stoma mation or if infection is suspected), and the pouch can become impaired for many reasons. A stoma applied directly over the separated area.10 The surgeon with impaired circulation appears less shiny than should be notified promptly of any mucocutaneous usual and more burgundy or purple in color than separation. The most serious separations involve most the normal red. This is usually a temporary condi- or all of the perimeter of the stoma and can lead to tion and is likely to serious complications such as retraction of the stoma occur more often in below fascia level and leakage of effluent into the those who have ab- abdominal cavity. dominal distention or a smaller-than- EARLY PERISTOMAL SKIN COMPLICATIONS optimal opening in The most frequent postoperative complications after the fascia or muscle; stoma surgery involve the peristomal skin, the most it may also occur in common being peristomal skin irritation.1, 12 The in- those with a high cidence rates of peristomal skin complications may body mass index, be nearly as high as 45%.1 Peristomal skin compli- which is associated cations can be both a short- and a long-term problem. with thicker abdomi- The most common early complications include irri- nal walls and corre- tant dermatitis, mechanical injury, and candidiasis. spondingly greater (Peristomal skin complications that are likely to oc- tension exerted on cur after the immediate postoperative period include Figure 2. Stoma Ischemia the bowel.5 Pro- folliculitis, peristomal hyperplasia, allergic dermati- longed impaired cir- tis, and uric acid crystal deposition; these will be ad- culation to the stoma can lead to stoma ischemia, dressed later in the article.) tissue death (necrosis), and sloughing of the stoma Irritant dermatitis is the most common peristomal (see Figure 2).1, 10, 11 In the first few days after sur- skin complication.2, 6, 11, 13 This is skin irritation caused gery, it’s important to assess the viability of the stoma by stoma output (feces or urine) coming into contact daily by examining the color, temperature, and moist- with the skin (see Figure 4).14 The severity of peris- ness of the surface of the stoma as well as its tissue tomal dermatitis can range from minor erythema to turgor.2 The surgeon should be notified immediately blisters to open skin. The longer the stomal output of suspected impaired circulation to the stoma. Care- is in contact with the skin, the greater the degree of ful application of a transparent two-piece pouch will skin damage.14 Peristomal dermatitis is commonly protect the fragile stoma from harm and facilitate associated with ileos- ongoing stoma assessment.10 Tissue that is peeling tomies. The digestive or sloughing from a stoma should not be pulled on enzyme and electro- or cut away. lyte content of ileos- Mucocutaneous separation. The edges of the tomy output can be stoma are secured to the surrounding skin with su- extremely corrosive tures. Mucocutaneous separation, also called stoma and, therefore, dam- dehiscence, is the pulling away of the stoma from aging to the peristo- the peristomal skin. The separation may involve only mal skin.13 one or two sutures or the sutures around the entire To prevent peristo- stoma (see Figure 3). Mucocutaneous separation is mal dermatitis, stoma seen more often in patients who are diabetic, who Figure 4. Irritant Derma- output must be kept have poor nutritional status, or who have been titis off the skin. Cut the

40 AJN ▼ June 2019 ▼ Vol. 119, No. 6 ajnonline.com pouch skin barrier to a diameter one-eighth of an nonantibacterial soap inch larger than the stoma. As the stoma reduces in and rinse thoroughly.14 size for several weeks after surgery, the opening cut in Management of peri- the skin barrier should be adjusted with each pouch stomal candidiasis in- change.12 A leaking pouch should not be taped at the cludes cleansing with leaking edge, keeping output in contact with the skin; water and thoroughly it must be changed to protect the skin from contact drying the skin. Spray with the output. Irritant dermatitis can be managed antifungal medication by application of pectin-based ostomy powder that can be applied to the is sealed to the skin with a protective barrier wipe infected area and al- or a water-dampened cloth to make the skin sticky. lowed to dry before Approximately three months after the surgery to cre- Figure 6. Candidiasis. pouch application. ate the stoma, the size of the opening should stabi- ConvaTec © 2009. Used In instances where lize; at that time a patient may choose to purchase with permission. antifungal spray is precut skin barriers. Mechanical injury (skin stripping). Skin stripping is a particular kind of mechanical skin injury that Stoma Care Basics can happen when the adhesive parts of the pouch system are removed (see Figure 5).13, 14 When a nurse The stomas discussed in this article result from removes the tape from three types of surgery: colostomy, ileostomy, and the skin, the epidermis urostomy. may adhere to the tape A colostomy is “a surgically created opening in and separate from the the abdomen where part of the colon is brought dermis, causing an to skin level to allow passage of stool waste.”2 open wound.14 These An ileostomy is “a surgically created opening superficial wounds where the small intestine (ileum) is brought to can be managed with skin level to allow passage of stool waste.”2 application of pectin- A urostomy is “a surgically created opening in based ostomy powder the abdomen, created after bladder removal, to on the open skin prior allow drainage of urine.”2 to placement of a new Appropriate stoma care is a key component of Figure 5. Mechanical 14 pouch. Prevention the care of any patient who has had one of these Injury (Skin Stripping) of skin stripping in- surgeries. Stoma care includes the selection and volves careful removal application of a pouch system to contain the of the adhesive portions of the pouch system. Appli- stoma output and maintenance of the pouch cation of a non-alcohol-based skin protectant wipe system by emptying and changing the pouch at or spray before pouch placement and use of an ad- regular intervals. Pouches are available in both hesive remover wipe to aid pouch removal may be one- and two-piece systems. A one-piece pouch helpful.13, 14 When skin stripping is present, manage- combines the protective adhesive skin barrier ment is the same as for irritant dermatitis, with ap- and the pouch in a single product. A two-piece plication of pectin-based powder made sticky with pouch has a separate adhesive skin barrier, and a non-alcohol-based adhesive wipe or damp cloth. the pouch snaps onto it. A clear pouch is used Candidiasis. Fungal skin infections may occur initially to allow for assessment of the stoma under the ostomy skin barrier because of the dark, without removal of the pouch. The center open- warm, moist skin environment.13, 14 Candida species ing of the skin barrier is usually cut one-eighth of are a common type of fungal organism that causes an inch larger than the stoma. Because the stoma these infections.13 Candidiasis presents as scattered size often changes in the postsurgical period, papules, pustules, or redness of the skin (see Figure 6). sizing may need to be adjusted each time the Patient complaints include “burning” or itching skin. pouch is changed. Pouches should be emptied Fungal rashes can result from the reduction of nor- when one-half to two-thirds full to prevent leak- mal skin flora under the skin barrier portion of the age. Pouches are initially changed every few pouch system.13, 14 The administration of broad spec- days; later, the amount of time the pouch system trum systemic antibiotics or cleansing of the skin with can be worn without changing can be adjusted antibacterial soaps can reduce the normal flora.13, 14 based on the type, frequency, and consistency of To maintain normal skin flora, nurses should cleanse the output. the skin with water or, if grossly soiled, a mild [email protected] AJN ▼ June 2019 ▼ Vol. 119, No. 6 41 unavailable or the cost for the patient is prohibitive, that convex pouches or ostomy appliance belts a very small amount of antifungal (water-based) should be avoided because they can increase the cream or antifungal powder can be applied to the prolapse. skin and rubbed in thoroughly until the skin feels Stoma stenosis. A stenosed stoma is one in which dry prior to pouch application.13, 14 the opening has shrunk to an extremely small diameter (see Figure 9).4 Stoma stenosis can result from LATER-ONSET STOMA COMPLICATIONS complete mucocutaneous separation or stoma ne- Some complications, including stoma retraction, pro- crosis, with resultant sloughing down to the skin lapse, and stenosis, as well as peristomal hernia, de- level or below.11 Stoma stenosis can also result from velop after the first postoperative month. repeated placement Stoma retraction. A stoma indented below skin of ill-fitting pouches level is referred to as a retracted stoma (see Figure 7).1 with openings that Retracted stomas may result from tension on the have been cut too stoma (because of obesity or abdominal distension), large for the stoma, mucocutaneous sepa- leaving peristomal ration, stoma ischemia skin unprotected for and sloughing, or a long period of time. extreme weight gain If the stoma is still after stoma surgery.1 functioning, stenosis To correct for the is not an urgent prob- retracted stoma con- lem.11 Urostomies can tour, it may be neces- Figure 9. Stoma Stenosis be stenosed and still sary to use a pouch function well because system with a convex of their fluid output; however, stenosis may adversely (curved) skin barrier affect stool evacuation, especially in colostomies, or an ostomy appli- because of the diameter and consistency of the stool. ance belt or both to Efforts to keep the stool looser by increasing fluid Figure 7. Stoma Retraction maintain pouch secu- and fiber intake may be effective.10 In some instances, rity.10, 15 if ordered by the surgeon, gentle digital dilation of Stoma prolapse is the protrusion of additional the stoma may be required to maintain patency of bowel tissue through the stoma (see Figure 8).4 the stenosed ileostomy or colostomy stoma.10, 11 This Stoma prolapse is most common in loop stomas approach is controversial because dilation may be (created by elevating a loop of bowel above the skin effective for only a brief time.10 Also, if not performed level and kept in place with a supportive rod or carefully, dilation of the stoma may traumatize the bridge device, with- walls of the bowel and cause the stoma to become out internal and ex- narrower. ternal sutures) and Peristomal hernia. A peristomal hernia presents as stomas in patients a bulge or bump around the stoma (see Figure 10).11 who have abdominal Peristomal hernias occur when additional intestinal muscular weakness, tissue protrudes through the muscle layer.4 If the including the ex- stoma is pink-to-red in color and still functioning, tremely young, the the hernia is not an emergent problem.11 However, elderly, and those a peristomal hernia often affects the fit of the pouch who are malnour- system and the ished.1 If the bowel amount of time one tissue is pink-to-red system can be worn Figure 8. Stoma Prolapse and moist, and the without changing to stoma is functioning another. A two-piece well, a prolapse is not an urgent situation; however, pouch may need to stoma prolapse presents a pouch application chal- be changed to a one- lenge. In my experience, the pouch is most easily piece pouch to pro- applied when the stoma prolapse is less prominent vide a more flexible and with the patient lying supine. The prolapse can fit over the bulge of often be reduced in size by application of a cool the hernia.10, 11 A cloth.10 The pouch opening should be enlarged to Figure 10. Peristomal stoma hernia sup- accommodate the prolapsed stoma.11 I’ve found Hernia port belt may also be

42 AJN ▼ June 2019 ▼ Vol. 119, No. 6 ajnonline.com fitted.10 Patients who irrigate the stoma should stop irrigation and resume natural evacuation.10, 11 If the Patient Resources patient is experiencing abdominal pain, lack of stool output, or vomiting, or if the stoma is bluish Several resources are available to patients who in color, which could indicate that the circulation is have a new or ongoing ostomy. compromised, the patient should see a physician or •• Patients may contact the nearest large hospi- go to the ED.11 tal to see if they employ a wound, ostomy, and continence (WOC) nurse who sees stoma LATER-ONSET SKIN COMPLICATIONS patients. Folliculitis is an inflammation of the hair follicles •• The Wound, Ostomy and Continence Nurses under the adhesive of the pouch system.13, 14 Follicu- Society can be contacted for a list of nearby litis presents as pustules at the hair follicles (see Fig- WOC nurses (go to www.wocn.org). ure 11), and is caused by repeated pulling on the •• Patients who travel may contact the World hairs surrounding Council of Enterostomal Therapists to see if the stoma when the there are WOC nurses in countries they plan pouch system is re- to visit (see www.wcetn.org). moved.11, 13, 14 Folliculi- •• The United Ostomy Associations of America is tis is more common for patients who have an ostomy; it has a in men because they website and a magazine and can inform the typically have more patient of the nearest ostomy association (see abdominal hair.14 This www.uoaa.org). inflammation can be prevented by periodic hair removal, either bleeding) can be applied to the lesions to help re- Figure 11. Folliculitis by plucking or shav- duce them in size. The surfaces of the peristomal ing with an electric skin can be evened with the application of ostomy razor or trimmer.10, 13, 14 Blade razors are not recom- powders or flexible skin barrier wafers prior to at- mended because of the potential for scraping the taching the pouch. skin or the stoma.13 Allergic dermatitis is skin inflammation resulting Peristomal hyperplasia, also known as pseudover- from an allergy to one or more components of the rucous lesions, is a buildup of epithelial tissue around skin barrier component of the pouch system.11, 14 Al- the stoma. Hyperplasia presents as tissue that ap- lergic dermatitis is a much less frequently observed pears “warty” or bumpy around the stoma (see Fig- complication than irritant dermatitis. Skin barrier ure 12).13, 14 Hyperplasia is a response to chronic materials used in stoma pouches are normally well inflammation of the peristomal skin caused by tolerated by the patient’s skin. Often it is the adhe- chronic exposure to sive substance on the tape border of the pouch that stoma output from causes the allergic reaction. This presents as redness, leaking pouches or blisters, or weeping tissue that is the same size and from pouch barriers shape of the pouch component to which the patient that are repeatedly is sensitive.2, 14 The unaffected skin is the same hue as cut too large in diam- the rest of the abdomen. The affected skin will be eter.11 Hyperplasia reddened and possibly blistered in patients with lighter can be prevented by skin (see Figure 13). In patients with darker skin, the changing the pouch affected skin will be before leakage occurs darker than the sur- and cutting a smaller rounding skin and opening in the skin may show blisters or barrier to fit snugly seepage. This inflam- Figure 12. Peristomal around the stoma as mation is managed Hyperplasia it decreases in diam topically with appli- eter.10, 13 When peris- cation of a steroid tomal hyperplasia lesions have already developed, spray that should be applying a pouch can be challenging because of allowed to dry before the uneven skin surface. A silver nitrate applicator pouch placement. (a thin stick with a cotton tip, similar to a Q-tip, Figure 13. Allergic In instances where containing silver nitrate, usually used to cauterize Dermatitis steroid spray is [email protected] AJN ▼ June 2019 ▼ Vol. 119, No. 6 43 unavailable or cost prohibitive for the patient, a small the possibility of bleeding. If minor bleeding occurs, amount of (water-based) steroid cream can be rubbed it can be managed with application of calcium algi- into the skin until the skin feels dry prior to pouch nate or silver nitrate.10 More extensive bleeding that placement. To prevent further skin irritation, the skin cannot be managed with these interventions requires barrier should be changed to a product that is better more aggressive therapy10 and collaborative practice tolerated by the patient (for example, a barrier with with a physician who may order coagulant materi- no border tape).10, 14 als to be applied. Uric acid crystal deposits. Over time, uric acid Pyoderma gangrenosum presents as a painful crystals may build up on the skin around an ileal ulceration with a bluish-purple discoloration at the conduit urostomy wound edges (see Figure 16).2, 14 Pyoderma gangreno- stoma.13, 14 This pre sum is not the result of contact with stoma output sents as whitish-gray or mechanical injury; rather, it’s symptomatic of an macerated (wet- exacerbation of a systemic chronic inflammatory looking) peristomal physical condition skin (see Figure 14).11, 14 such as Crohn’s dis- The crystal deposits ease, rheumatoid ar- can be removed by thritis, or lupus.2, 10, 16 applying a dilute Healing pyoderma acetic acid solution gangrenosum ulcers Figure 14. Uric Acid (consisting of one requires nursing Crystal Deposits. part vinegar to four care, including local ConvaTec © 2009. Used parts water) with a wound care using with permission. small cloth or gauze topical steroid prepa- pad to the skin for a Figure 16. Pyoderma rations and ostomy few minutes to loosen the crystals, then cleansing the Gangrenosum powder as well as skin with water at the time of a pouch change.11, 14 physician- or NP- ordered systemic disease management using oral DISEASE-RELATED SKIN COMPLICATIONS steroids.2, 10, 16 Disease-related peristomal skin complications are not related to the creation of the stoma or exposure to AN OVERVIEW stoma effluent. They occur as a symptom of an exacer- Any patient who undergoes surgery to create a stoma bation of a chronic medical condition experienced by may experience problems involving the stoma or the patient such as liver disease, Crohn’s disease, rheu- the peristomal skin or both. Ideally, patients with matoid arthritis, or lupus. The two disease-related stomas and the nurses who care for them should conditions discussed here are peristomal varices and have ready access to a stoma therapy specialist. In pyoderma gangrenosum. the real clinical world, this is not always possible. Peristomal varices (caput medusae) are promi- Before patients go home from the hospital it is im- nent veins present in the peristomal skin.2 They portant that they and their family, if present, can present as a purple demonstrate basic ostomy care, including knowing discoloration, often what the stoma should look like, emptying the in a “sunburst” pat- pouch, changing the pouch, and managing minor tern around the stoma skin irritation. See Patient Resources for a list of (see Figure 15). These sources of information and assistance. varices occur because This article has briefly outlined the more com- of portal hypertension mon stoma and peristomal complications that the related to liver pa- nonspecialist nurse might encounter in clinical prac- thology.2 Peristomal tice. Knowledge of the appearance of the normal skin with varices may stoma and peristomal skin is paramount in recog- be fragile and bleed nizing complications. Knowledge of the basics of very easily.16 Gentle stoma care can help to make nonspecialist nurses Figure 15. Peristomal pouch removal using more confident in the care of patients with stomas. Varices (Caput Medusae) an adhesive remover Some peristomal skin complications, such as irri- wipe and gentle skin tant dermatitis, can be prevented through basic stoma cleansing should be performed to prevent trauma management techniques. This includes correct pouch to the fragile skin. Additionally, less frequent pouch selection and application and pouch changes at the changes and the use of skin barrier wipes may reduce appropriate interval to prevent stoma leakage. The

44 AJN ▼ June 2019 ▼ Vol. 119, No. 6 ajnonline.com skin barrier opening should be adjusted with each 4. Carlsson E, et al. The prevalence of ostomy-related compli- pouch change to be one-eighth of an inch larger cations 1 year after ostomy surgery: a prospective, descriptive, clinical study. Ostomy Wound Manage 2016;62(10): than the stoma. The skin should be cleaned with 34-48. water and allowed to dry. Antibacterial soaps are 5. Koc U, et al. A retrospective analysis of factors affecting not recommended because they can affect the nor- early stoma complications. Ostomy Wound Manage mal flora of the skin. The pouch should be placed 2017;63(1):28-32. on dry skin. To prevent leakage, pouches should 6. Ratliff CR. Early peristomal skin complications reported by be emptied when one-third to one-half full and WOC nurses. J Wound Ostomy Continence Nurs 2010; changed every few days before effluent seeps under 37(5):505-10. the skin barrier. A pouch that is leaking under the 7. Beitz JM, Colwell JC. Stomal and peristomal complications: prioritizing management approaches in adults. J Wound Os- skin barrier must be changed promptly, not taped at tomy Continence Nurs 2014;41(5):445-54. the edges. Minor skin irritation such as irritant der- 8. Taneja C, et al. Clinical and economic burden of peristomal matitis can be managed with application of pectin- skin complications in patients with recent ostomies. J based stoma powder as described above. ▼ Wound Ostomy Continence Nurs 2017;44(4):350-7. 9. Lindholm E, et al. Ostomy-related complications after emergent abdominal surgery: a 2-year follow-up study. J Wound For 11 additional continuing nursing education Ostomy Continence Nurs 2013;40(6):603-10. activities related to stomas, go to www. 10. Beitz JM, Colwell JC. Management approaches to stomal nursingcenter.com/ce. and peristomal complications: a narrative descriptive study. J Wound Ostomy Continence Nurs 2016;43(3):263-8. 11. Stelton S, Homsted J. An ostomy-related problem solving guide for the non-ostomy therapist professional. WCET Susan Stelton is a certified wound, ostomy, and continence Journal: Official Journal of the World Council of Enterosto- nurse and adult health clinical nurse specialist living in Niles, mal Therapists 2010;30(3):10-9. MI. She is also the immediate past president of the World Council of Enterostomal Therapists. Contact author: notlets@ 12. Meisner S, et al. Peristomal skin complications are common, aol.com. The author and planners have disclosed no potential expensive, and difficult to manage: a population based cost conflicts of interest, financial or otherwise. modeling study. PLoS One 2012;7(5):e37813. 13. Woo KY, et al. Peristomal skin complications and management. Adv Skin Wound Care 2009;22(11):522-32. REFERENCES 14. Stelton S, et al. Practice implications for peristomal skin as- 1. Butler DL. Early postoperative complications following os- sessment and care from the 2014 World Council of Enteros- tomy surgery: a review. J Wound Ostomy Continence Nurs tomal Therapists International Ostomy Guideline. Adv Skin 2009;36(5):513-9. Wound Care 2015;28(6):275-84. 2. World Council of Enterostomal Therapists (WCET). WCET international ostomy guideline. Washington, DC; 15. Hoeflok J, et al. Use of convexity in ostomy care: results of 2014. an international consensus meeting. J Wound Ostomy Con- 3. Maydick-Youngberg D. A descriptive study to explore the tinence Nurs 2017;44(1):55-62. effect of peristomal skin complications on quality of life of 16. Ayello EA, Stelton S, editors. WCET ostomy pocket guide: adults with a permanent ostomy. Ostomy Wound Manage stoma and peristomal problem solving. Perth, Australia: 2017;63(5):10-23. World Council of Enterostomal Therapists; 2016.

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