UROLOGICAL PERISTOMAL SKIN PROBLEMS

Transcription

1 ASCN UROLOGY MASTERCLASS BIRMINGHAM May 21 st 2018 UROLOGICAL PERISTOMAL SKIN PROBLEMS Liz Davis Urology Stoma /Continence CNS

2 Presentation Aim Brief overview of the anatomy and functions of skin Explore the predisposing factors which contribute to peristomal skin damage in urostomy patients Role of ph in peristomal skin conditions Case study examples

3 Skin facts The skin is the largest organ in the body An average persons skin covers an area of 2 m² Skin accounts for 15% of body weight The skin renews itself every 28 days Your skin is home to more than 1000 species of bacteria!! More than 50% of dust within the home is dead skin!

4 Peristomal skin facts Peristomal skin complaints are common with a reported rate of 60% 9% - Pre existing skin conditions 6% - Infections, bacterial, viral or fungal 4% - Pyoderma gangrenosum > 1% - ALLERGIC REACTION TO HYDROCOLLOIDS

5 Skin structure

6 Skin ph and the Stratum Corneum The normal ph of human skin is fairly acidic at between 4.5 and 6.2. The Acid Mantle of the skin is critical in maintaining Stratum Corneum integrity, barrier function and antimicrobial activity. It is a fine, slightly acidic film on the surface of the skin made from natural lipids, sweat and dead skin cells

7 Importance of the Acid Mantle and Stratum Corneum

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9 Common causes of raised urinary ph in Urostomy patients Chronic renal failure or Chronic Kidney Disease - Main causes include: UTI Reflux nephropathy Infection Stenosis of the uretero-ileum anastomosis Hydronephrosis. Renal calculi > risk in patients with ileal conduits Renal tubular acidosis secondary to metabolic changes caused by chloride reabsorption within the ileal loop stimulating bicarbonate loss in the urine - bicarbonaturia.

10 Bacterial causes of raised ph in Urostomy patients GUT BACTERIA PROTEUS, MORGANELLA, KLEBSIELLA, E COLI, UREASE ALKALINE URINE ph > 7 CO2 AMMONIA NH3 UREA CH4N2O

11 Most common causes of peristomal skin complications Hyperkeratinisation secondary to alkaline urine MARCI Medical adhesive related skin injury PMASD Peristomal moisture associated skin damage Infection

12 PERISTOMAL HYPERKERATINISATION SECONDARY TO ALKALINE URINE CPD (Chronic Papillomatous Dermatitis)

13 Clinical Features of CPD Hyperkeratosis of the peristomal skin secondary to prolonged irritation and inflammation Nodular papules, grey or white in appearance secondary to the moistening of the hyperkeritonised skin gritty texture Hyperpigmentation of the peristomal skin Florid stenosed flat tethered stoma bleeds easily to the touch.

14 Resolving CPD at 6 weeks

15 Management of CPD Appropriate appliance choice fit and formulation most commonly found in patients who are using flat appliances when a convex would be indicated and who change one piece appliances infrequently when a two piece would be more appropriate. White vinegar soaks method and concentrations vary from author to author. Calum Lyon in Abdominal Stomas and their Skin Disorders advocates ratio vinegar : water Oral antibiotics Where appropriate a course of oral antibiotics may be necessary to reduce over all bacterial load within the conduit. Particularly if the patient reports any of the following: blue staining in the overnight bag: gas in the overnight bag: acrid strong odour associated with ammonia. Increased oral fluid intake dehydration concentrates urine

16 Purple bag syndrome COMPLEX METABOLIC PROCESS - LIVER!! INDOXYL SULPHATE KLEBSIELLA Providencia stuartii INDIGO INDIRUBIN INDOXYL PHOSPHATASE

17 Peristomal Moisture - Associated Skin Damage (PMASD) Inflammatory response to any damage to the waterprotein-lipid matrix of the skin due to prolonged exposure to urine (effluent) PMASD leads to irritant dermatitis Increases the Transepidermal Water Loss (TEWL) Signs of irritant dermatitis include; erythema, oedema, blistering, weeping, skin erosion, itching and pain

18 PMASD

19 Resolving PMASD at 8 weeks

20 Medical adhesive related skin injury (MARSI). Frequent adhesive removal results in the detachment and disruption of the Stratum Corneum Repeated injury prompts a wound healing response and inflammation - dermatitis Allows opportunistic bacterial ingress into the skin leading to infection most commonly Staphylococcus Aureus Streptococci, Pseudomonas

21 Staphylococcus dermatitis secondary to MARSI

22 Staphylococcal Impetigo

23 Characteristic denuded skin and honey coloured crusting Distinctive honey coloured crusting

24 Staphylococcus dermatitis

25 Staphylococcal Folliculitis

26 Staphylococcus dermatitis

27 Management of Staphylococcus Aureus peristomal skin infections Skin Swab for C&S essential! Oral antibiotics Flucloxacillin, Clarithromycin Topical steroid Betnovate Scalp Lotion Consider two piece appliance to reduce skin trauma Adhesive remover spray Patience!!

28 Skin is surprisingly complex! Conclusion Urinary ph and the Bacterial interactions with the components of urine play a significant part in contributing to peristomal skin conditions in Urostomists Peristomal skin conditions are unfortunately common Understanding and diagnosing the mechanisms that cause the skin problem are essential to resolving it saving time and money What takes weeks to develop can takes weeks to resolve!

29 THANK YOU FOR LISTENING