Download Get the Skinny: Common but Seldom Discussed Skin Issues in Long

“Get the Skinny: Common but Seldom Discussed Skin Issues in Long Term Care
Donna Sardina, RN, MHA, WCC, DWC, CWCMS, OMS
Wound Care Education Institute
Upon completion of this session, participants will be able to:
1) Recognize different types of skin lesions based upon their clinical characteristics.
2) Describe types and characteristics of 3 common traumatic wounds frequently seen in the
geriatric population.
3) Describe types and characteristics of 3 common inflammatory skin conditions frequently
seen in the geriatric population.
4) Differentiate types of moisture associated skin damage and list interventions for treatment.
I.
II.
Basic Anatomy of Skin
A. Skin Facts1
1. 3000 square inches
2. Weighs 6 lbs.
3. Receives 1/3 of the body’s blood volume
4. Has about 100,000 bacteria per sq cm, and that 10% of human dry weight is attributed
to bacteria
5. Outer Skin cells shed and re-grow about every 27 days – That is almost 1000 new skins
in a lifetime.
B. Layers of the Skin
1. Epidermis (external skin surface)
a. The layers are made of mostly DEAD CELLS.
b. Thickness varies in different regions of the body but is usually 0.1 mm thick (given
ranges are from 0.07 to 0.12 mm)1
c. Avascular
2. Dermis
a. Supports & nourishes epidermis
b. Thick dense, fibroelastic connective tissue
c. Highly vascularized
d. Contains: Nerves, sweat glands, sebaceous glands, and hair follicles
e. Made up of proteins i.e. collagen & elastin
3. Subcutaneous
a. Loose connective tissue lying under the dermis, which binds skin loosely to
subjacent tissues.
b. Function: Channels nutrients and oxygen to the Dermis via capillaries that have
branched out from arteries
C. Changes with Aging
1. Dermal layer thins as we age
2. Reduction in: connective tissue, vascular components, sweat glands, sense receptors,
mast and Langerhans cells, elastin
3. Graying, thinning and loss of hair
4. Decrease rate of: epidermal turnover, wound repair, and collagen deposition
5. Wound Healing 13
a. Delayed inflammatory response
b. Capillaries are fragile
c. Reduced collagen syntheses
d. Reduced angiogenesis
e. Slower epithelialization
6. Most consistent age-related change in the epidermis is the “flattening of the basement
membrane. In aging skin, this junction flattens out which diminishes the amount of
surface between the layers, reduces nutrient transfer and resistance to shearing forces
that tend to separate the layers.
Types of Wounds
A. Acute wound – a disruption in the integrity of the skin and underlying tissues that progress
through the healing cascade in a timely and uncomplicated manner.2
B. Chronic wound – defined as a wound that has failed to proceed through an orderly and
timely process to produce anatomic and functional integrity. 2
1. Pressure Ulcers
2. Lower Extremity Ulcers – Venous, Arterial and Diabetic
C. Classification of Tissue Destruction
1. Full thickness - destruction of epidermis, dermis, subcutaneous and or deeper
2. Partial Thickness – destruction of epidermis and part of the dermis; superficial dermal
layers not through the dermis
3. Classification Systems
a. Pressure Ulcers – National Pressure Ulcer Advisory Panel Staging Guidelines
b. Diabetic Foot Ulcers – Wagner Scale
c. Venous & Arterial Ulcers – Full or partial thickness
d. Skin Tears – Payne Martin Skin Tear
III. Types of Lesions
A. Assessment and documentation of skin lesions should include number, size, color, location,
sensation, duration, distribution, morphology, and configuration.
B. Primary Lesions 3– present at initial onset of problem. Primary lesions are physical changes
in the skin considered to be caused directly by the disease process. Types of primary lesions
are rarely specific to a single disease entity.
1. Vesicle – circular, free fluid filled, Up to 1 cm
2. Bulla – circular, free fluid filled, greater than 1 cm
3. Macule – a change in the color of the skin, circular, flat discoloration, brown, blue, red or
hypo-pigmented, less than 1 cm
4. Patch – same as a macule but larger than 1 cm
5. Papule – superficial, solid, less than 1 cm, color varies
6. Nodule – circular, elevated, solid, greater than 1 cm, may be seen in the epidermis,
dermis or subcutaneous tissue
7. Pustule – circular, collection of leukocytes, free fluid filled, varies in size
8. Wheal – firm, edematous plaque, infiltration of dermis, may last few hours
9. Plaque – superficial, elevated, solid, flat topped lesion greater than 1 cm
C. Secondary Lesions3 – may result from primary lesions, or may be caused by external forces
such as: scratching, trauma, infection, and healing process.
1. Scale – consists of flakes or plates that represent compacted desquamated layers of
stratum corneum. Desquamation occurs when there are peeling sheets of scale
following acute injury to the skin.
2. Crust – the result of the drying of plasma or exudate on the skin
3. Fissure – crack or split in the skin
4. Erosion – loss of epidermis, superficial; part or all of the epidermis has been lost
5. Ulcer – loss of epidermis and dermis and sometimes underlying subcutaneous tissue
6. Lichenification – refers to a thickening of the epidermis seen with exaggeration of
normal skin lines. It is usually due to chronic rubbing or scratching of an area.
7. Atrophy – loss of substance; thinning
8. Scar – thickening; permanent fibrotic changes following damage to the dermis. May
have secondary pigment characteristics.
9. Excoriation – linear erosion; destruction of the skin by mechanical means
10. Denuded - loss of epidermis, caused by exposure to urine, feces, body fluids, wound
exudate or friction
IV. Trauma Wounds
A. Bruise
1. AKA contusion, results from leakage of blood from vessels into the tissues after
sufficient blunt force has been applied to distort the soft tissues and tear one or more
vessels.
2. Usually resolves on its own in a matter of 2 weeks.4
3. Color
B.
C.
D.
E.
4. Starts reddish color of oxygenated blood, may have blue appearance as blue light
bounces and red penetrates more deeply, then becomes Purplish.5
5. As blood pigments break down, the sequence of colors passes through those of a
ripening banana, through greens, yellow and browns and the coloration fades. 5
6. Skin is intact
7. Damage may be both superficial and deep
8. Tissue may be swollen or painful
Purpura
1. Purpura is a general term for reddish-purple skin lesions produced by bleeding in the
dermis or subcutaneous tissues.
2. True purpuric lesions do not blanch as blood is fixed in the skin (due to erythrocyte
extravasation it retains its red color)
3. Classified by the size of bleeding
a. Petechia
1) Small, nonblanching, erythematous macules, less than 0.5 cm up to 3mm
(pinpoint to pinhead size)
b. Ecchymosis
1) Non-blanching, purpuric macules or patches of greater than 3mm
2) Irregular shape, and appear as blue or purplish patches.
3) Found in skin and mucous membranes.
4) Often misused by clinicians, Ecchymosis is not a synonym for bruise or
contusion. 5,6,7,8 Caused spontaneously by hematological complications, such as
thrombocytopenia. NOT trauma. 5,6,7,8
4. Purpura are a common and nonspecific medical sign however the major causative
factors are:11
a. Increased intravascular venous pressures
b. Inflammatory skin diseases
c. Vascular abnormality (from vasculitis)
d. Blood flow abnormality (e.g., hypergammaglobulinemia, which often accompanies a
systemic disease)
e. Decrease or functional abnormality of platelets
f. Coagulopathy
g. Etiology is unknown in many cases
Hematoma
1. A localized collection of blood from a broken blood vessel (s); extravasated blood
trapped in the tissues of the skin, usually clotted.
2. Hematoma is not a synonym for a bruise or a contusion.7,8
3. Hematoma may be imbedded within a bruise as a palpable mass; hematomas can be
caused by non-traumatic means i.e., a spontaneous blood clot to the brain.
sDTI
1. In most cases, DTIs occur over bony prominences.
2. Patients have history of immobility in one position.
3. Deteriorate rapidly
4. The skin over and around a DTI site may be cooler than the surrounding skin and tissue.
The usual assessment includes boggy, nonblanchable tissue that is deep purple in color,
may be painful, has a blistered top layer, and may present with a mirror image
bilaterally.10
5. Seven day Principle9
a. For the purposes of deep pressure injuries that present as a demarcated red/purple
area, clinicians can count back 7 days to pinpoint when the actual pressure damage
occurred. 9
b. Deep pressure injuries take 7 days from the early signs of redness to demarcate; by
day 9 to 11 spontaneous “skin slippage” occurs and 14 to 15 days are required to
form a mature brown/black eschar to form. 9
6. If unsure if it is a sDTI or a bruise….. Document sDTI, Protect yourself, Revise later.
Skin Tears - a traumatic wound.
1. Definition - A skin tear is a wound caused by shear, friction, and/or blunt force17
resulting in either:
a. Partial thickness-separation-epidermis from the dermis; AKA - Epidermal stripping –
Removal of epidermis by mechanical force; tape/bandage removal, electrode
removal. 17
b. Full-thickness-separation of both from underlying structures17
2. In the late 1980s, the Payne-Martin Classification18 System for Skin Tears was developed
to provide a common language for severity of skin tears. The classification system is
divided into 3 categories.
a. Category I - skin tears without tissue loss.
1) A - Linear skin tear: Full-thickness wound that occurs in wrinkle or furrow of skin.
Both epidermis and dermis are pulled apart as if an incision has been made,
exposing tissue below.
2) B - Flap - type skin tear: Partial-thickness wound in which the epidermal flap can
be completely approximated or approximated so that no more than 1 millimeter
of dermis is exposed.
b. Category II - skin tears with partial tissue loss
1) A - Scant tissue loss. Partial-thickness wound in which 25% or less of the
epidermal flap is lost and at least 75% or more of the dermis is covered by the
flap.
2) B - Moderate to large tissue loss. Partial thickness wound in which more than
25% of the epidermal flap is lost and more than 25% of the dermis is exposed.
c. Category III - skin tears with complete tissue loss.
1) A partial thickness wound in which an epidermal flap is absent.
3. There is no gold standard or Clinical Practice Guideline available for the ideal treatment
of skin tears. Goal promote moist wound healing principles and protection of the
wound and surrounding skin from further trauma & infection.
F. Lacerations
1. A torn or jagged wound; tear lacerations tend to be caused by blunt trauma (such as a
blow, fall, or collision).
2. Little or profuse bleeding; the tissue damage is generally greater and the wounds ragged
edges do not readily line up
3. TX – Clean the wound, remove/flush away any foreign debris, and apply adhesive strips,
tissue adhesive, transparent dressing, or antibiotic ointment with gauze covering.
4. Lacerations that involve the face, are longer than 1/2 inch, are deep, or are bleeding
heavily; may require stitches.
G. Abrasions
1. Caused by shearing of skin by rough surface, superficial, aka road rash
2. Appears as lines of scraped skin with tiny spots of bleeding
3. TX - Thorough cleaning/ flushing of wound with normal saline, remove all foreign debris,
apply protective dressing, antibiotic ointment may be used
H. Puncture Wounds
1. An injury caused by a sharp, object deeply penetrating the skin
2. Little bleeding around the outside of the wound and more bleeding inside, causing
discoloration.
3. TX- Irrigate wound, cover with protective dressing. For deep wounds - possible sharp
debridement, exploration, and placement of drain may be indicated.
I. Burns
1. Older adults at high risk for burns due to:16
a. changes in physical and mental capacity
b. sensory loss or impairment
c. decreased mobility
d. slowed reaction time
2. Burn Classification
a. Revisions of burn-depth estimations are often necessary in the first 24 to 72 hours
and may be required through the first two or three weeks. 14
b. Categories14
1) Superficial partial thickness burns (also known as first and second degree)
- Superficial/epidermal (also known as superficial first degree)
- Superficial dermal (also known as superficial partial thickness)
- Deep dermal (also known as deep partial thickness)
2) Full thickness burns (also known as third degree)
3) Severe full thickness burns (fourth degree) extend into muscle and bone
3. Overall management goals for non-complex burns: 14
a. Preventing or reducing the risk of wound infection
b. Applying moist wound care
c. Optimizing pain relief
d. Providing patient education
1) Free - http://www.usfa.fema.gov/prevention/outreach/older_adults.html
J. Incisions
1. Covered with a sterile dressing for 24 to 48 hours. 15
2. Use sterile technique for dressing changes first 48 hours. 15
3. Purpose of dressing to incision
a. absorb drainage
b. provide sterile environment
c. barrier to further trauma
d. non-adherent
e. absorptive
4. After 48 hours, incisions can be cleansed with mild soap and water. 15
5. When there is no drainage or chance of infection on suture line, may leave open to air. 15
V. Inflammatory
A. Eczema
1. General term of various inflamed skin conditions
2. Most common atopic dermatitis which is an allergic condition that makes skin dry and
itchy
3. Characteristics: dry, red, extremely itchy patches on the skin, “bubbly" rash
4. Location: In older children and adults, eczema appears less often on the face and more
commonly on the hands, neck, inner elbows, back of knees, and ankles. In younger
children, eczema usually appears on the face, elbow, or knees, and possibly on other
areas.
5. Treatment goal
a. Relieve discomfort by controlling the signs and symptoms. Dryness and itching
b. Emollient Moisturizers - free of additives, fragrances, perfumes; lotions have higher
water content and tend to evaporate quickly.19
1) Emollients should be used at least twice a day all over the skin. They are best
applied within three minutes after a shower or bath to maximize their moistureretaining effect.
c. Corticosteroid creams - tend to rapidly and effectively reduce inflammation, which
relieves itching
d. Researchers have found that using both a topical corticosteroid and a moisturizer
decreases the signs and symptoms of atopic dermatitis better than use of a topical
corticosteroid alone. Studies also have found that proper use of a moisturizer along
with a topical corticosteroid can reduce the amount of corticosteroid needed. 19 This
suggests that using an appropriate moisturizer may reduce the need for long-term
corticosteroids.
B. Xerosis
1. AKA Dry skin
2. Dry skin is often the result of a combination of etiologic factors, in particular genetic
abnormalities, but also metabolic and environmental triggers20
3. Severe xerosis can lead to the onset of atopic dermatitis
4. Common problem in the elderly
a. It is estimated that generalized or diffuse xerosis affects 75% of individuals over 75
years of age. 20
b. Most common predisposing factor is a lower rate of epidermal proliferation than
that of younger skin. 20
5. Characteristics
a. Rough, flaky dry skin with fine scaling
b. May itch
6. Treatment
a. Goals
1) Restoring moisture to the skin
2) Stopping the itch-scratch cycle so irritated skin can heal
b. Topical20
1) Apply moisturizer frequently. Do not use lotions, colognes, perfumes, or similar
products that contain alcohol.
2) A thin film of Cortisone cream BID may alleviate itching
3) For severely dry skin, apply an oil to moist skin then apply a moisturizing cream
BID
4) Minimize the number of showers and baths per week
5) Avoid very hot water
6) For daily hygiene use soaps that have an acid pH and contain humectants
c. General20
1) Drink sufficient water
2) Eat a varied and balanced diet including plenty of fruit and vegetables
3) Avoid smoking, alcohol consumption, and direct exposure to sunlight
4) Take regular moderate exercise
C. Candida
1. AKA: Candidiasis, Candida albicans, Localized transient cutaneous candidiasis
2. A fungal infection of any of the Candida (yeast) species
3. Overgrowth of Normal flora in intestines related to stress, antibiotics, poor hygiene, high
humidity, Diabetes and other causes and thrives in warm moist environment
4. Characteristics12
a. Location - most commonly in intertriginous areas such as the axillae, groin, body
folds, gluteal folds, in digital web spaces, in the glans penis, and beneath the breasts.
b. Distribution - consolidated or patchy
c. Shape - Diffuse differential areas; small round erythematous papules and pustules,
plaques, and/or satellite lesions
d. Depth – Partial thickness; superficial
e. Wound Bed - Pink/Beefy Red; associated crusting or scaling with cheesy white
exudate.
f. Margins – Diffuse and irregular edges, satellite lesions (outside the advancing edge
of candidiasis) most important diagnostic feature12
g. Surrounding Skin – Varies; may be white (maceration)
h. Associated Findings
1) Key indicator is Itching and/or burning12
2) White skin - presents as bright to dull red central area with peripheral red
vesicles (satellite lesions)
3) Dark skin - presents as a darker skin tone, may develop into dark red or purple
hue
D. Rashes
1. Breaking out (eruption) of the skin.
2. A rash can be caused by an underlying medical condition, hormonal cycles, allergies, or
contact with irritating substances. 23
3. Treatment depends on the underlying cause of the rash.
4. Exanthem is the medical name given to a widespread rash that is usually accompanied
by systemic symptoms such as fever, malaise and headache.22
5. A simple rash is called dermatitis, meaning inflammation of the skin.
6. Contact dermatitis
a. Inflammation of the skin caused by direct contact with an irritating or allergycausing substance
b. Caused by things the skin touches, such as: Dyes and other chemicals in clothing
Chemicals in elastic, latex, and rubber products Cosmetics, soaps, and detergents
Poison ivy, oak, or sumac
c. Treatment
1) Remove the cause
2) Treat symptoms
3) Cortisone cream
4) Antihistamines
E. Seborrheic Keratosis
1. Hyperkeratotic epidermal lesion; lesions usually are multiple and arise in the face, chest,
and shoulders. They appear as black or brown, slightly elevated skin lesions; most
common non-cancerous skin growths in older adults.
2. Develop from the proliferation of epidermal cells. No specific etiologic factors have been
identified.24
3. Characteristics24
a. Early (Flat lesions)
1) Small (<3mm)
2) Slightly elevated
3) Variable hyperpigmented coloration
b. Late (Raised pigmented lesions)
1) Large Plaque (1 to 6 cm)
2) Keratotic (warty) appearance
3) Appears "stuck-on" like clay
4) Rough surface
5) Tan, brown or black pigmentation
6) Sharp well-circumscribed border
4. Occurs in patients over age 30; Number of lesions increase with age.
5. Treatment24
a. Generally, no treatment is required unless the growth becomes irritated from
chafing against clothing.
b. Methods of removal:
1) Cryosurgery, which freezes off the growth using liquid nitrogen.
2) Curettage, in which the doctor scrapes the growth off the surface of the skin.
3) Electrocautery, used alone or in conjunction with curettage to burn off the
tissue and stop the bleeding.
F. Scabies
1. Infestation of the skin by the human itch mite (Sarcoptes scabiei var. hominis). The
microscopic scabies mite burrows into the upper layer of the skin where it lives and lays
its eggs. Symptoms appear when it digs a little tunnel (burrow) below the skin & causes
an allergic reaction.
2. Spread by direct, prolonged, skin-to-skin contact with a person who has scabies. Scabies
sometimes is spread indirectly by sharing articles such as clothing, towels, or bedding
used by an infested person. Mite can survive no longer than 2 days when not in contact
with a human.
3. Characteristics25,26
a. Itching (pruritus), especially at night, and a pimple-like (papular) itchy rash.
b. Location: between the fingers or toes, the buttocks, the elbows, the waist area, the
genital area, or under the breasts in women. In geriatric patients, scabies
demonstrates a propensity for the back, often appearing as excoriations.
c. Appearance: short elevated S-shaped track in the superficial epidermis; a small
vesicle or papule may appear at the end of the burrow. One- to 3-mm erythematous
papules and vesicles are seen in typical distributions in adults. The vesicles are
discrete lesions filled with clear fluid, although the fluid may appear cloudy if the
vesicle is more than a few days old.
4. Treatment25,26
a. Scabies treatment includes administration of a scabicidal agent (eg, permethrin,
lindane, or ivermectin), as well as an appropriate antimicrobial agent if a secondary
infection has developed.
b. Machine wash and dry bedding and clothing of scabies patients using the hot water
and hot dryer cycles.
c. Patients should be reexamined 2 weeks after treatment to evaluate effectiveness.
d. Contact Local and/or state health departments for specific guidelines for preventing
and controlling scabies outbreaks in your facility.
G. Pemphigus27
1. Chronic, autoimmune, subepidermal, blistering skin disease
2. Bulla/blisters noted on the abdomen, back, arms, and legs
3. Refer to dermatologist for treatment
4. Treatment
a. Topical steroids
b. Systemic corticosteroids (prednisone)
c. Blisters should generally be left intact if possible as this may help prevent secondary
bacterial infection.
d. If open blisters, use moist wound healing management.
H. Neurotic excoriation28
1. Self-induced skin lesions caused by picking, rubbing, scratching or repetitive itching.
2. No known physical problem of the skin, this is a physical manifestation of an emotional
problem. Patients have poor impulse control and cannot avoid the desire to scratch.
Depression, anxiety and OCD are the most common psychiatric disorders leading to
neurotic excoriations.28
3. Appearance
a. Excoriations appear in areas that are easily reachable to the patient.
b. Classic butterfly sign; areas free of lesions where the patient cannot reach resemble
the shape of butterfly wings.
c. Excoriations appear as erosions, crusting and scabbing. Hypopigmented or
hyperpigmented scars may also be evident.
4. Treatment
a. Treatment of underlying psychotic diagnosis
b. Steroid creams; Anti-Itch medications, moist wound healing, bandages or dressing
that restrict access to areas.
c. Anti-anxiety medication - SSRI’s
I. Cellulitis
1. Rapidly spreading bacterial infection; involves the deep dermis, extending into the
subcutaneous tissue and fat. Legs are the most common location. 29
2. Typically unilateral (usually affects only one leg)
3. Symptoms29
a. Skin is hot, red, and edematous
b. Localized skin redness or inflammation that increases in size as the infection spreads
c. Tight, glossy, "stretched" appearance of the skin
d. Pain or tenderness of the area
e. Sudden Onset
f. Vesicles and bullae may develop and rupture, occasionally with necrosis of the
involved skin.
4. Cellulitis with rapid spread of infection, rapidly increasing pain, hypotension, delirium, or
skin sloughing, particularly with bullae and fevers, suggests life-threatening sepsis.
5. Treatment29
a. Intravenous antibiotics, oral antibiotics
b. Treatment is focused on control of the infection and prevention of complications
c. Mark off the extent of erythema present on admission
d. Measurement of the limb
e. Elevation of the limb
f. Use of a bed cradle
g. Topical Treatment29
1) Products used for management of wound exudate should be considered and
selection will depend on the site and size of area to be covered.
2) Topical antibiotics should not be used in the management of cellulitis.
3) Once the critical stage of swelling and redness has subsided and the patient is
reasonably pain free, compression bandaging can resume or be initiated.
VI. Moisture Associated Dermatitis
A. Incontinence associated dermatitis (IAD)
1. Other names: Perineal Dermatitis, irritant dermatitis, and diaper rash when noted in
children.
2. Causes:
a. Inflammation of the skin from prolonged exposure to urine or stool.
b. Regular use of an absorptive containment device such as an incontinence brief or
pad, which raises the pH of the underlying skin and increases production of
perspiration. The use of an absorptive or containment device may exacerbate
irritation when it creates prolonged occlusion and hyperhydration of the skin.34
3. Characteristics30,31,32
a. Location - Often occur over the fatty tissue of the buttocks, Perineum, inner thigh,
groin; May occur over bony prominence.
b. Distribution - consolidated or patchy
c. Shape - Diffuse differential areas/spots; kissing ulcer (a mirror-image manner on
each side of the skin fold); Anal cleft-linear.
d. Depth – Partial thickness; superficial
e. Wound Bed - Non uniform redness; Pink/white surrounding skin (maceration); Perianal redness, NO NECROSIS
f. Margins – Diffuse and irregular edges
g. Surrounding Skin – Varies
h. Associated Findings
1) Moisture must be present.
2) A full-thickness wound (tissue destruction into the subcutaneous tissue or
deeper), with or without necrosis (slough or eschar), reflects ischemic tissue
damage and would be classified as a pressure ulcer not as perineal dermatitis.33
4. Prevention
a. Clean
1) Gentle motion using pH balanced cleanser.
2) A no-rinse formulation should be used for frequent bathing; as towel-drying
has been shown to compromise the skin’s moisture barrier. No-rinse options
include incontinence or perineal cleansers, disposable wipes, or 3-in-1 sprays.
3) NO SOAP - Soap can strip the skin of natural oils and puts it at risk of secondary
infection from fungus and bacteria.38
b. Moisturize
1) Maintain skin’s barrier function
c. Application of skin protectant or moisture barrier
1) Petrolatum-based
2) Dimethicone-based
3) Zinc oxide-based
4) Liquid acrylate
B. Intertriginous Dermatitis (ITD)
1. Causes - skin damage caused by trapped perspiration and skin-on-skin friction and
typically presents as inflammation and linear lesions occurring at the base of skin folds.
34,35,36
2. Characteristics34,35,36
a. Location – Intergluteal cleft; Skin folds; beneath the pannus, underneath pendulous
breasts, or in the groin crease.
b. Distribution - typically in a mirror-image manner on each side of the skin fold
c. Shape- linear
d. Depth – Partial thickness
e. Wound Bed - Initially mild erythema and may progress to more intense
inflammation with erosion, oozing, exudation, maceration, and crusting.
f. Surrounding Skin - Frequently macerated, secondary bacterial and fungal
infections; candidiasis
g. Associated Findings
1) Pain, itching, burning, and odor.
2) Perspiration with or without friction.
3) ITD can coexist with IAD.
C. Peri-stomal Dermatitis37
1. Appearance Red, weepy, possibly bleeding, painful
2. Caused by skin barrier or pouch leakage, allergies, infection, radiation, skin stripping
when too strong an adhesive is used.
a. If caused by allergy: The peristomal skin presents with erythema and the patient
complains of itching, erythema has less distinct, more blurred margins that may
correspond to the shape of the contact surface.
b. Other causes include poor technique, wearing the pouching system too long,
chronic leakage, inappropriate use of tape, adhesives, or skin care products.
c. Some patients may have difficulty in lining up the aperture with the stoma, and may
be placing it off-center, thereby exposing the skin to effluent on one side.
3. Management
a. Check for pouching system leakage.
b. Compare size of stoma and opening in the pouching system.
c. Observe technique in removing and applying pouching system and in cleaning the
skin.
d. Revise pouching system to ensure that the peristomal skin is protected from the
drainage from the stoma.
e. Consider correct sizing of pouching system, using convexity or belt, or modification
of pouching system.
f. Management of allergic contact dermatitis requires the elimination of the offending
product. Attempt to identify the product causing the allergic reaction. Stop using
this product.
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