Classification of peristomal skin changes in patients with urostomy

Perianal Pseudoverrucous Papules and Nodules in an Elderly Patient

Pseudoverrucous papules and nodules is a reaction to irritation usually associated with urostomies. We report a case of perianal pseudoverrucous papules and nodules in an elderly patient who developed a characteristic diaper dermatitis after infrequent diaper change. The perianal papulonodular lesions improved after saline wet dressing and topical steroid application. These perianal pseudoverrucous papules and nodules indicate a unique type of irritant diaper dermatitis, which can be distinguished from Jacquet erosive diaper dermatitis and granuloma gluteale adultorum. Identifying this condition is important because pseudoverrucous papules and nodules can resemble more serious dermatoses, leading to unnecessary investigations being carried out.

Prevention and Management of Pseudoverrucous Lesions: A Review and Case Scenarios

GENERAL PURPOSE

To present the associated risk factors, prevention measures, and assessment and management of pseudoverrucous lesions specific to a surgically created ileal conduit, as well as three clinical scenarios illustrating this condition.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Define pseudoverrucous lesions.2. Identify the risk factors for stoma complications such as pseudoverrucous lesions.3. Select the appropriate routine care procedures to teach patients following stoma creation to help prevent pseudoverrucous lesions.4. Choose the recommended treatment options for patients who develop pseudoverrucous lesions.

Design and validation of a "Peristomal Lesion Scale" for peristomal skin assessment

Many people in Italy undergo ostomy because of illness, and this can have negative psychological and physical effects. It is estimated that 15%-43% of ostomates suffer from skin complications in the peristomal area. During their life, many ostomates experience at least one peristomal lesion, and they turn to stomal therapy centres where trained nurses provide patient care and manage skin complications. To ensure a good quality of life for patients, and to take prompt action for the prevention and treatment of stomal lesions, it is essential to use appropriate assessment tools. The aim of this study was to develop a reliable peristomal skin assessment tool (Peristomal Lesion Scale [PLS]) for classifying lesions based on their severity; and to compare its validity with the most widely used peristomal tool in Italy, SACS. The new tool was designed by a team of experts, focusing on patients' demographics, clinical characteristics, and classification of the lesions by severity and topography. The results of this comparative validation study indicate that the PLS better discriminates lesions by their severity because of its level of detail, using a standardised terminology, and its completeness. The PLS is a valid tool for use in the daily work of stomal therapists.

Instrumentos de avaliação das complicações na pele periestoma: revisão integrativa

Objetivo: identificar y analizar las herramientas utilizadas para evaluar las complicaciones de la piel periestoma a través de revisión integradora de la literatura. Materiales y método: la búsqueda se dio en estas bases y portales de datos: Biblioteca Virtual de la Salud (BVS), PubMed/MEDLINE, CINAHL, Scopus y Web of Science, de enero a febrero de 2018. Durante la búsqueda en las bases de datos, se utilizaron los descriptores: ostomía, colostomía, dermatitis y las palabras clave: instrumentos, complicaciones de la piel periestoma y evaluación de la piel periestoma. Se incluyeron estudios que cumplieron los siguientes criterios: que estén disponibles en su totalidad, que estén publicados en español, inglés y portugués, no se tuvo en cuenta el rango de tiempo y tenía que ser acerca de las herramientas de evaluación de las condiciones de la piel periestoma. Resultados: el análisis identificó la existencia de nueve instrumentos con diferentes parámetros para describir la piel periestoma. En general, los instrumentos describen los cambios basados en la clasificación de la complicación, en la causa del daño a la piel o en las características clínicas presentes. Los estudios evidenciaron, además, que la mayoría de los instrumentos no poseen propiedades de medida probadas. Conclusión: de los nueve instrumentos de evaluación identificados, solo cuatro tienen propiedades de medidas probadas. El enfermero debe conocer los instrumentos existentes confiables y válidos para describir y clasificar la gravedad de los problemas de la piel periestoma, lo que aporta a la sistematización de un diagnóstico más preciso y mejora, por lo tanto, la calidad del cuidado.

A vesicular variant of pseudoverrucous papules and nodules in the genital area of an incontinent 4-year-old

Irritant contact dermatitis is a common cause of chronic vulvitis in patients wearing diapers and incontinence garments. In most cases the diagnosis is obvious; however, atypical presentations may mimic more serious dermatoses. We present a 4-year-old girl who presented at birth with cloacal atresia corrected surgically and resulting in chronic incontinence requiring full-time diapers. She presented with crops of herpetiform vesicles and bullae on a base that ranged from normal skin to severe erythema and oedema. A histological examination revealed a well-demarcated lesion showing a thickened epidermis with hyperkeratosis and parakeratosis, acanthosis and an abrupt transition to pallor of the upper half. Focal full thickness epidermis necrosis and small areas of spongiosis, acantholysis and apoptotic keratinocytes were seen. Immunofluorescence was negative. The lesions improved with the treatment of secondary infection and minimal topical therapy with an emollient only. This case represents an unusual vesicular variant of pseudoverrucous papules and nodules, which has been reported only once previously.

Vulvar pseudoverrucous papules and nodules secondary to a urethral--vaginal fistula

Irritant contact dermatitis is a common cause of genital eruptions representing at least one-fifth of presenting anogenital symptoms. A spectrum of inflammatory reactions have been identified, some of them with features severely mimicking more serious dermatoses, which may lead unnecessary workup and treatments. We report a case of a 10-year-old girl who presented at birth with cloacal atresia involving the rectum and the urethra. A diverting colostomy and a urethral-vaginal fistula were created to correct the deformity. Physical examination reveals numerous shiny, white-gray, pseudoverrucous papules and nodules coalescing into plaques over the vulva and its surrounding skin. Histological examination showed psoriasiform epidermal hyperplasia with a marked reactive acanthosis and altered cornification with parakeratosis, hypogranulosis, and pale keratinocytes in the upper reaches of the epidermis. The lesions regress when the irritating factor was removed. This case represents a peculiar form of presentation of perianal pseudoverrucous papules and nodules, usually secondary to urinary incontinence or encopresis (inability to control the elimination of stool) after surgery for Hirschsprung disease. Because similar findings have not been previously observed in patients with urethral-vaginal fistula, we attempt to extend the spectrum of presentations for a better knowledge of this condition.

Stoma-related complications and stoma size - a 2-year follow up

AIM

The purpose of the study was to prospectively describe stoma configuration and evaluate stoma-related complications and their association with possible risk factors.

METHOD

All elective patients (n = 180) operated on with a formation of colostomy, ileostomy or loop-ileostomy between 2003 and 2005 were included in the study. Follow up took place on the ward postoperatively and five times during 2 years after discharge. On these occasions the diameter and height of the stoma were recorded. Complications such as peristomal skin problems, necrosis, leakage caused by a low stoma, stenosis, granuloma formation, prolapse and peristomal hernia formation were evaluated.

RESULTS

Most complications occurred 2 weeks after discharge; 53% of patients with colostomies, 79% with loop-ileostomies and 70% of patients with end-ileostomy had one or more complications. The most common complication was skin problems and it was most common in patients with end-ileostomies (60%) and loop-ileostomies (73%). Postoperatively at ward review, the most common complication was necrosis, which occurred in 20% of patients with a colostomy. Granuloma formation was most frequent in colostomies. Almost all patients with an end-ileostomy and loop-ileostomy with a height lower than 20 mm had leakage and skin problems as had half of the patients with a colostomy height lower than 5 mm.

CONCLUSION

To prevent stoma-related complications, it is important to produce an adequate height of the stoma, with early and regular follow ups and adjustment of the appliance. To work closely in collaboration with the colorectal surgeons is of utmost important to provide feedback and in turn, to improve stoma outcome.

Erosive papulonodular dermatosis associated with topical benzocaine: A report of two cases and evidence that granuloma gluteale, pseudoverrucous papules, and Jacquet's erosive dermatitis are a disease spectrum

Granuloma gluteale infantum/adultorum, pseudoverrucous papules, and Jacquet's erosive diaper dermatitis are fairly uncommon manifestations of irritant contact dermatitis historically thought to be distinct clinical entities. Here we report two informative cases of an erosive papulonodular dermatosis in the genital and suprapubic area associated with topical benzocaine. We review granuloma gluteale infantum, pseudoverrucous papules and nodules, and Jacquet's erosive diaper dermatitis, and propose that these disorders may all be variants of genitocrural irritant dermatitis.

Pseudoverrucous papules: an aspect of incontinence in children

Pseudoverrucous papules and nodules can be observed on skin surrounding urostomies and colostomies. These lesions appear to be uncommon, and sometimes can be misdiagnosed, even leading to surgical removal. We report the case of a 12-year-old boy whose lesions appeared in crops in an area subjected to urine leakage and spontaneously regressed in time. In this patient, anogenital warts had to be ruled out, but many skin diseases must be considered in the differential diagnosis of these misunderstood lesions. We stress the importance of a skin examination by a trained professional aware of these problems to avoid unnecessary investigations and treatments.

The spectrum of skin disorders in abdominal stoma patients

BACKGROUND

Skin integrity is essential for the normal usage of a stoma appliance. However, there is little published on the prevalence, nature or management of stoma-related skin disorders. Objectives To document stoma-related skin disorders in a large cohort of patients.

METHODS

We sent a postal questionnaire to all surviving patients who had had abdominal stoma surgery at Hope Hospital, Salford, U.K. in the 10 years from 1 January 1989. Those reporting skin disease were invited to attend a clinic run by a dermatologist and a stoma-care specialist nurse. All lesions were categorized and swabs taken for microbiological examination.

RESULTS

Of 525 surviving patients, 325 (62%) replied to the questionnaire. Of these, 73% reported a skin problem that had affected normal stoma bag use. Dermatoses included irritant reactions, particularly from leakage of urine or faeces (42%); pre-existing skin diseases, principally psoriasis, seborrhoeic dermatitis and eczema (20%); infections (6%); allergic contact dermatitis (0.7%) and pyoderma gangrenosum (0.6% annual incidence). A further 15% of patients with skin problems had persistent or recurrent dermatitis not explained by allergy, frank infection or faecal irritation. This responded to short-term treatment with topical corticosteroids. Further investigation is under way into its pathogenesis.

CONCLUSIONS

Skin disorders are common in stoma patients, and various patterns can be recognized and effectively treated.

Peristomal dermatoses: a novel indication for topical steroid lotions

BACKGROUND

Dermatoses that interfere with the normal use of a stoma appliance are common. When preventable causes, such as infection or allergy, are not identified, barrier preparations or topical steroids have been used. However, topical medicaments formulated in a cream or ointment base will cause stoma bags to detach, resulting in leaks.

OBJECTIVE

Our purpose was to investigate the efficacy and suitability of corticosteroids in aqueous/alcohol lotions in the management of peristomal dermatoses.

METHODS

A clinic run by a dermatologist and 2 stoma nurses was created. Patients with a variety of noninfective, inflammatory dermatoses were treated with topical corticosteroid lotions up to a maximum of 4 weeks, with occasional use thereafter in some cases.

RESULTS

Topical, aqueous/alcohol, corticosteroid lotions have been used in 60 patients and have proved particularly useful for the treatment of irritant dermatitis, pyoderma gangrenosum, psoriasis, and constitutional eczema. After the initial treatment course, occasional applications, approximately every 2 weeks, may be necessary to control the skin disorder. This low frequency of application minimizes the risk of side effects so that we have not identified local or systemic side effects in any of the patients treated so far.

CONCLUSION

Topical corticosteroids formulated in aqueous alcohol lotion are effective and acceptable treatments for peristomal dermatoses. If used appropriately, the risk of side effects is low.

Health-related quality of life after cystectomy: bladder substitution compared with ileal conduit diversion. A questionnaire survey

OBJECTIVE

To compare the health-related quality of life after bladder substitution with that following ileal conduit diversion.

PATIENTS AND METHODS

Sixty-seven male patients with bladder cancer completed the questionnaire; 38 had undergone bladder substitution and 29 ileal conduit diversion; the median follow-up was 1.0 year (range 0.5-3.0) and 4.8 years (range 1.1-15.2), respectively. Semi-structured qualitative interviews were conducted and analysed, and the questionnaire was developed based upon these results.

RESULTS

Both day- and night-time urinary leakage occurred more frequently following bladder substitution (18% against 10%, and 21% against 3%). Nevertheless, urinary leakage affected conduit patients more severely and they scored higher on a leakage distress scale. Furthermore, 58% of the ileal conduit but only 21% of the bladder substitution patients gave urinary leakage as their main concern (P = 0.04). Ileal conduit patients did not retain their body image as well as those with bladder substitution. The frequency of both sexual and non-sexual physical contacts decreased in the majority of the conduit patients but only in a minority of the bladder substitute patients. Global satisfaction was high and similar in both groups.

CONCLUSION

These results show that the health-related quality of life is retained to a higher degree after bladder substitution and supports the use of this procedure as the standard method of diversion after cystectomy for bladder cancer.

Perianal pseudoverrucous papules and nodules after surgery for Hirschsprung disease

We report two patients with Hirschsprung disease in whom severe diarrhea and a distinctive diaper dermatitis developed after delayed ileoanal anastomosis. The perianal papulonodular lesions cleared in months or years without specific treatment after resolution of the diarrhea. These perianal pseudoverrucous papules and nodules represent a peculiar form of primary irritant diaper dermatitis, distinct from Jacquet erosive diaper dermatitis and granuloma gluteale infantum.

Urostomy appliances and stoma care routines. The relation to peristomal skin complications

The aim of the study was to describe types of appliances and stoma care routines and evaluate their relation to peristomal skin complications. Sixty-six patients with a cutaneous uretero-ileostomy were interviewed and the peristomal skin was assessed according to Classification of Peristomal Skin (CPS). The results show a conservatism regarding the types of appliance and the stoma care routines. More than half of the patients used the same product at follow-up as they were initially fitted with three to 14 years earlier. The routines adopted by the patients were often inadequate, resulting in skin complications. Continuous exposure of the skin to urine by creation of a too wide opening in the face-plate and infrequent changing of the appliance resulted in development of pseudoverrucose skin lesions.

Local status of the urinary stoma--the relation to peristomal skin complications

Sixty-six patients with uretero-ileostomy were investigated with special regards to local status of the urinary stoma, i.e. stomal site, length, size/shape, and peristomal skin. Each variable was defined. In reports from other centres there has been a lack of definitions making it difficult to compare results from different studies. One fifth of our patients had inadequately located stomas and 85% had stomas shorter than 1 cm. The peristomal skin status was assessed according to CPS, Classification of Peristomal Skin. Eight per cent of the patients exhibited severe erythematous/erosive lesions and one fifth pseudoverrucose lesions. The relation between skin lesions and local status of the urinary stoma was analyzed. Patients with inadequately located stomas were more likely to show severe erythematous/erosive lesions and there was a tendency towards patients with stomas shorter than 1 cm, more frequently exhibiting pseudoverrucose lesions.