prevention and management of pseudoverrucous lesions: a

NSW_210053 461..471Prevention and Management of Pseudoverrucous Lesions: A Review and Case Scenarios Luanne Brogna, MSN, RN, CWOCN, Certified Wound Ostomy Continence Nurse, Hackensack University Medical Center, Hackensack, New Jersey
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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.
ABSTRACT Pseudoverrucous lesions are a late peristomal complication that occurs most commonly in people with urinary stomas. Impairment of the peristomal skin can result in pouching system leaks that can translate into odor, embarrassment, and diminished quality of life. Prevention is key tomaintaining smooth, dry skin and intact psyche. Treatment revolves around outpatient postoperative follow-up, refitting the pouching system to eliminate moisture impacting the peristomal area, modification of pouching system wear time, acidification of the urine, and intensive education. This review includes three case scenarios to support early, intermediate, and late-stage intervention guidelines. Some interventions were successful; one case remains unresolved. KEYWORDS:moisture-associated skin damage, ostomy, peristomal complication, peristomal skin, pseudoverrucous lesions, quality of life, urinary stoma
ADV SKIN WOUND CARE 2021;34:461–71.
DOI: 10.1097/01.ASW.0000758620.93518.39
d planners, in any position to control the content of this CME/N l companies relevant to this educational activity. st read the CME article and complete the quiz online, answeri gust 31, 2023, and for nurses September 6, 2024. All tests are E/ASWC for nurses. Complete NCPD/CME information is on th
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INTRODUCTION According to the United OstomyAssociation of America, there are 750,000 to 1,000,000 people living with ostomies in the US—roughly one in every 500 people.1 The American Cancer Society reported an estimated 81,400 new cases of bladder cancer in 2020. Although this rep- resents only 4.5% of all new cancer cases, there is a 76.9% 5-year survival rate (2010–2016), and many of these survivors require stoma surgery.2 Urinary stomas can also be constructed for individuals with neurogenic problems such as multiple sclerosis, spinal cord injury, and birth defects. As a result, there are a significant number of individuals who can potentially develop peristomal complications. Pouching system leaks and peristomal skin complica-
tions are themost common reason individualswith ostomies seek outpatient ostomy care.3,4 The creation of an ostomy itself is amajor alteration that impacts functional elimination, body image, and self-esteem. A recent cross- sectional study examined the prevalence of anxiety and depression in people with ostomies. With a sample size of 120 adults, researchers found that the prevalence of depression was 26.7%, whereas anxiety was 52.5%.5 Com- bine the ostomy with a peristomal skin complication, and the mental health impact is magnified. In a review of the literature, the overall incidence of
peristomal skin complications ranges from 10% to 70%.6
Unfortunately, a different study identified that the ma- jority of persons living with a stoma do not consider
CPD activity have disclosed that they have no financial relationships with, or financial
ng at least 7 of the 10 questions correctly. This continuing educational activity will now online only; take the test at http://cme.lww.com for physicians and e last page of this article.
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alteration in skin integrity to be a disorder, but rather a normal part of life with a stoma. Consequently, 80% of them failed to seek advice from a practitioner.4,6 The combined work experience of two experts in the field of wound, ostomy, and continence (WOC) nursing, Rolstad and Erwin-Toth3 found that “most patients livingwith a stomawill experience peristomal compromise and require treatment.”More recently, Spencer et al7 found that COVID-19 pandemic fears prevented many people with ostomies from seeking professional help when experiencing peristomal skin complications. This evidence emphasizes the value of systematic surveillance. There are a variety of stoma and peristomal complica-
tions that can occur in the early and late postoperative period. A quick reference for these may be found in the WCET Ostomy Pocket Guide.8 Although the focus of this article is a single complication (pseudoverrucous lesions), it is essential to consider postoperative healing and stoma complications as well because they affect the peristomal contours for the pouch landing zone. Nor- mally, abdominal distention and stoma edema subside in 6 to 8 weeks following surgery. However, stoma complications such as retraction, prolapse, and hernia increase the risk for peristomal skin complications. Further, changes from aging, activity, and weight shifts may occur. Gaps in the skin barrier seal enable effluent to contact intact skin, resulting in moisture-associated skin damage.6 Any alteration therefore necessitates a pouching system reassessment. Having worked many years as a WOC nurse in both
acute and home care, this author has seen a variety of early postoperative stoma complications. Currently, at an 850-bed acute care trauma center, outpatient services are a part of the WOC’s role responsibilities, leading to increased exposure to more late-term complications. In the past 2 years, three women have presented for the management of peristomal pseudoverrucous lesions. Standard interventions were effective for two of these cases. The third scenario has been challenging and prob- lematic for both the author and the family who bears the burden of care, which prompted exploration of the literature in search of an appropriate solution. Accordingly, this article discusses the associated risk factors, prevention measures, and assessment and management of pseudoverrucous lesions specific to the surgically created ileal conduit, as well as the three clinical scenarios illustrating this condition.
ETIOLOGY AND INCIDENCE Peristomal moisture-associated dermatitis is inflammation and erosion of skin related to moisture that begins at the mucocutaneous junction and can extend outward up to a 10-cm radius.6,9 Thismoisture is a product of bodily fluids: stool, urine, and perspiration. In the case of the ileal
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conduit urinary diversion, the moisture source is urine. When the skin barrier seal is inadequate, the urine that is in constant contact with the skin causes maceration. Skin injury from excessive exposure to urine may result in inflammation, erosion, and secondary infections.6
Pseudoverrucous lesions, alsoknownas chronicpapilloma- tous dermatitis, hyperkeratosis, and pseudoepitheliomatous hyperplasia, is a benign condition.10 It is a thickening of the epidermis that appears as warty white, gray, brown, or dark red papules or nodules in areas chroni- cally exposed to moisture.4,11 The lesion pattern can be partial (Figure 1) or circumferential (Figure 2). These lesions are often associated with crusts on the stoma and skin related to alkaline urine output.5,12 In some cases, they have been known to cause hemorrhage andpain.4,10 Given compromised skin integrity, the cycle of pouch leakage, further skin erosion, and more leakage occurs. Epidermal resurfacing is necessary to restore a secure seal.3
Few studies focus specifically on the incidence of pseudoverrucous lesions. Although the data are dated, they do support a significant incidence of this peristomal complication. Borglund et al9 identified pseudoverrucous lesions in 13 of 57 patients (an incidence of 23%). A second study by this group12 of 66 patients with ileal conduits reported a 21% incidence. Cheung13 examined 316 patients, 123 of whom had ileal conduits; alkaline encrustations were present in 23.6% of the participants. Given
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Table 1. RISK FACTORS CONTRIBUTING TO PSEUDOVERRUCOUS LESION DEVELOPMENT 1. Improper sizing and/or placement of skin barrier 2. Poorly positioned stoma 3. Poorly constructed stoma, eg, flush or retracted 4. Irregular peristomal landing zone 5. Obesity 6. Early postoperative stoma complications, eg, mucocutaneous separation, stoma necrosis 7. Late postoperative complications, eg, hernia 8. Stoma placed outside the patient’s visual field
Table 2. INTERVENTIONS THAT MAY PREVENT PSEUDOVERRUCOUS LESIONS 1. Preoperative stoma site marking and education 2. Well-sited stoma 3. Stoma protrusion of 1 to 3 cm 4. Stoma placement within the rectus muscle, away from scars and folds 5. Aperture cut or molded to size and shape of stoma 6. Adjustment of aperture as stoma edema decreases 7. Adjustment of aperture with fluctuations in weight 8. Use of an antireflex pouch 9. Connecting to gravity drainage at night 10. Measures to keep urine acidic, eg, drink eight 8-oz glasses of noncaffeinated fluids each day including water and cranberry juice 11. Regular outpatient surveillance with an ostomy nurse at 2, 3, and 6 mo postoperation and annually thereafter
the frequency of pseudoverrucous lesions, this peristomal skin complication poses significant risk to patients with urinary stomas, and providers should assiduously imple- ment prevention efforts for this patient population.
RISK FACTORS Those at risk of developing peristomal skin complications may have issues related to stoma siting and construction.3
Irregularities on the abdomen create areaswhere urine can pool, disintegrate the skin barrier, and begin the process of peristomal maceration, inflammation, and erosion.4,10
Obesity makes it more difficult to construct a protruding stoma, and even if it does project above skin level, the peristomal contours are most likely irregular.10 Wound complications adjacent to the stoma, as well as recurrent conditions such as urinary tract infection, can create diffi- culty securing a seal (Table 1).3 Further, age can be a fac- tor given thinning of the epidermis and flattening of the rete pegs.6
PREVENTION There are a variety of interventions that may prevent pseudoverrucous lesions (Table 2). Creation of a well- sited, protruding stoma is key. Preoperative education and stoma site marking lay the foundation for a patient who is well-prepared and eager to engage in prevention activities. An experiencedWOC nurse will take the time to examine the abdomen and mark the site within the rectus muscle at the apex of the abdominal bulge. There should be a flat, 5- to 8-cm area surrounding the mark. Scars, skin folds, and/or redundant flesh, as well as clothing (ie, waistbands and belt placement), need to
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be taken into consideration.4 The nurse should also ensure that the site works for the patient in multiple positions and is within their visual field.3,14 In two retrospective studies that included patients with fecal and urinary stomas, a preoperative visit with a WOC nurse who provided education and marking decreased postoperative ostomy complications by 25% to 43%.4 A more recent meta-analysis15 found that stoma site marking alone did not significantly reduce peristomal complications in patients with urostomies; however, results were limited by a small sample size. Surgical technique is critical to preventing peristomal
skin complications. Flush or retracted stomas result in the discharge of urine below skin level (Figure 3). From the start, this exposes the patient to additional risks such as maceration. A stoma protrusion of 1 to 3 cm is recommended (Figure 4).3,12
Postoperative education should address what normal peristomal skin looks like and the basic skin care tomain- tain it. Inform patients and caregivers that it should look just like the skin on the other side of the patient’s abdomen.
Use of water for cleaning is most appropriate, thereby elim- inating exposure to multiple chemicals that could cause sensitization. Keeping pouching system reapplication procedures simple will make it easier and safer for
Figure 4. THE IDEAL STOMA IS ROUND, MODERATELY PROTRUDING, AND VIABLE, WITH A SMOOTH, FLAT PERISTOMAL LANDING ZONE The black arrow indicates the direction of the head of the patient. The red dot on the silhouette identifies the location of the stoma on the abdomen.
patients with a limited ostomy skill set. Adjunct products need only be added as required (eg, the use of an adhesive remover for those who experience skin stripping).3
The pouching system fit impacts the health of the peristomal skin. The aperture needs to be cut or molded to the size and shape of the stoma, so all of the peristomal skin is protected. As the stoma edema from surgery re- solves, the size of the skin barrier aperture needs to be ad- justed accordingly (Figure 5). Instruct patients to resize their stoma at least weekly in the first 8 weeks. A cut-to-fit or moldable barrier works best, initially. Other standard interventions include using an antireflex pouch, connecting to gravity drainage at night, and using an extended-wear barrier.9 Once the stoma size stabilizes, a precut barrier may be considered. Just as clothing sizes change over time, patients need to understand that their pouching system will need to be resized as well.6
The 2018–2019 Ostomy Life Study Review16 qualified different body profiles and their influence on a secure ostomy seal and intact peristomal skin. Three overall cate- gories were recommended to standardize terminology and communication: “regular,” “inward,” and “outward”. This international study included 4,000 people with ostomies from around the globe. In this sample, 27% were found to have an inward body profile, and 21% were outward; together, these account for nearly half of all stomas created. Those who had inward and outward body profiles had an increase in leakage on a daily or weekly basis.17
Figure 5. ROUND PROTRUDING STOMA WITH CIRCUMFERENTIAL PSEUDOVERRUCOUS LESIONS FROM A LACK OF POSTOPERATIVE RESIZING White arrows indicate pseudoverrucous lesions. The black arrow indicates the direction of the head of the patient. The red dot on the silhouette identifies the location of the stoma on the abdomen. Curved black lines are actual hairs.
Reprinted from Drake RL. Anatomy of the kidneys, ureter, and bladder. Fischer’s Mastery of Surgery. Volume 1. Fischer JE, ed. 7th ed. Philadelphia, PA: Wolters Kluwer; 2018.
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Table 3. MANAGEMENT OF PSEUDOVERRUCOUS LESIONS 1. Assess back of skin barrier for overhydration 2. Increase frequency of pouching system change 3. Consider use of extended-wear skin barrier 4. Evaluate need for convexity and/or double-faced adhesive rings 5. Add snug belt to support convex seal and prevent urinary undermining 6. Use skin barrier strips to fill any peristomal irregularities 7. Apply acetic acid soaks for 20 min for each pouching system change until lesion is resolved 8. Routine follow-up with an ostomy professional
Developing a routine schedule for skin barrier changes is helpful for maintaining intact peristomal skin. Wear time should never bemore than 3 to 7 days and is depen- dent on the stoma size, shape, protrusion, and location. Encourage patients to assess the posterior of the skin barrier at the skin stoma interface to determine if urine has been undermining the seal and eroding the barrier protection. This is referred to as “silent leakage” because the urine has contact with the skin but has not yet pene- trated the outer edge of the seal. Patients may report burning or itching at the site. Both silent and obvious leaks require refitting of the pouching system (as opposed to reinforcing it with waterproof tape).3
Last, and probably most important, is regular surveillance. Just as patients are required to follow up with their surgeons, they should be given an opportunity to visit a WOC nurse on a routine basis. Routine intervals are recommended at 2 to 4 weeks, 3 months, 6 months, and annually thereafter.4 In rural areas, this may not be feasible, which makes thorough postoperative teaching even more important. Although face-to-face visits are ideal and confer many additional benefits, virtual visits may be required in more remote areas. In addition, pro- fessionally developed websites with patient education and peristomal skin care guidance can be a substitute for technology-savvy clients.
MANAGEMENT The first step to manage pseudoverrucous lesions caused by peristomal moisture-associated skin damage is to assess the skin barrier for the extent of softening and whitening which indicates overhydration. To mitigate overhydration, consider increasing the frequency of pouching system change. Next, ensure that the skin barrier is of the appropriate size and shape to match the stoma. Assess stoma height, the direction of the stoma os, and peristomal contours. It is most helpful to examine patients in various positions to pinpoint contributing factors. Consider using an extended-wear convex skin barrier and adding a belt to support the convex seal (Table 3).3,4,6,10,11,18
Intermediate Management As previously stated, some patients do not even recognize that altered peristomal skin is abnormal. With exposure to urine over time, the once white/gray peristomal skin develops papules and/or nodules. The pseudoverrucous lesions continue to grow and rise above the level of the stoma, creating greater irregularities. There are frequent pouching system leaks; symptoms of itching, burning, and pain may be reported. In addition to increasing the frequency of reapplication and switching to a convex skin barrier, other interventions are necessary. If the pouching system always leaks in the same location, providers can
add skin barrier strips or paste to fill the gap.3 The application of hydrocolloid powder followed by barrier film spray will aid in drying the skin for better adhesion.4
Acetic acid soaks (50% white vinegar/50% water) used at the time of skin barrier change will help to flatten the raised lesions.4,6,16 The importance of standard interventions that apply to all people with urostomies, including the use of an antireflux pouch, connection to gravity drainage at night, and drinking plenty of fluids, cannot be overemphasized (Table 3).
Late Management If an inadequate urostomy seal is left unaddressed, the condition of the peristomal skin will continue to deteriorate. Other contributing factors such as the lack of a gravity drainage bag and inadequate fluid intake can worsen the situation. In addition to pseudoverrucous lesions, inadequate fluid intake creates alkaline, con- centrated urine output. Alkaline encrustations can be deposited on the stoma and exposed peristomal skin, resulting in bleeding. Interventions at this late stage include those mentioned
previously, as well as silver nitrate application to control the bleeding; several applications may be required.11 In- creasing fluid intake (2–3 L per day), including cranberry juice, will help to maintain a urine pH of 6.11 If additional fluids are inadequate, administration of vitamin C to acidify the urinemay be helpful. Citrus juices create an alkaline ash residue and should be eliminated. The ideal dosage of vitamin C is 250 mg four times daily; if this frequency is too cumbersome for the individual, it can be taken as 500 mg twice per day. Vitamin C intake should not exceed more than 1 g a day because of an increased risk of kidney stones.4 If applicable, the appropriate an- tibiotic should be prescribed to treat urinary tract infection. Further, patients should use a barrier ring as the initial layer in contact with the skin.4,6,16,18–20
Two recently published case reports2,21 are worth men- tioning here because the reports present interventions that vary from the accepted ones noted above. The 2010 case had a culture taken that was negative for any infectious
has stalled was recommended by Steinhagen et al10: intralesional corticosteroid injection and surgical exci- sion may be required.
CASE SCENARIOS These three case scenarios are provided to reinforce the basic principles of managing pseudoverrucous lesions. All three patients were women with central obesity, which often results in an “inward” body profile. The resulting irregular abdominal contours created a higher risk for this peristomal skin complication. In all cases, anxiety and/or depression affected their coping styles. Two of the ileal conduits were created because of bladder cancer; the third was a result of chronic cystitis following treatment of an unrelated cancer. The most challenging and unresolved case was the eldest of the groupwho suffered fromdementia andwas nonadherent to the recommended interventions. Written permission was obtained from each case subject to reprint the case details and associated images.
Patient 1 A65-year-oldwoman status posthysterectomy and radiation therapy for endometrial cancer developed severe radiation cystitis as evidenced by persistent urinary incontinence, poor bladder compliance, limited bladder capacity, and frequent infections. After years of diapers, antibiotics, and failure of conservative measures, she contemplated alternatives. After meeting the urologist, she made an educated decision to pursue urinary diversion surgery. Hermedical history is inclusive of endometrial cancer, hypertension, hyperlipidemia, diabetes, and obesity. There was a smoking history, although the patient had stopped 15 years prior. All preexisting conditions were under control with medical management. Laboratory data indicated renal compromise with a blood urea nitrogen (BUN) of 36 mg/dL and creatinine of 2.9 mg/dL. Socially, she is widowed and working as a customer service representative and enjoys being a part-time caregiver for her 9-month-old grandson. On July 27, 2020, this patient was admitted to the hos-
pital 1 day prior to surgery for administration of antibi- otic therapy. The urology resident referred the patient to the WOC team for preoperative stoma site marking
and education; the stoma was placed in the right lower quadrant within the rectus muscle, in an area free from scars and skin folds and within the patient’s visual field. She was anxious but in good spirits, highly motivated, and eager to put her past behind her. In addition, she had done her own research online about urostomies and care and maintenance of an ileal conduit and was well-educated on what to expect postoperatively. The next day, the patient underwent robotic-assisted laparo- scopic cystectomy, extensive lysis of adhesions from prior surgery and radiation, and an extracorporeal creation of ileal conduit. On postoperative day (POD) 1, the patient experienced
a leak from her pouching system. She reported that the staff nurse had refit the urostomy skin barrier overnight. Upon examination, urine was found to be undermining the seal. Although the stoma was viable and well-sited, it was oval and flush with the skin. Because of her central obesity, she had an “inward” bodyprofile. Themucocuta- neous junction and peristomal skin were intact, although there was a depression at the 9-o’clock position, provid- ing an avenue for urine to pool and thereby affect the skin barrier adhesion. The WOC nurse refit the pouching system with the addition of a double-faced adhesive ring to fill the irregularity while the procedure and its rationale were explained and demonstrated. On POD 2, the pouching system seal was found to be
secure. On POD 3, in preparation for discharge, the patient was given an opportunity to demonstrate refitting of the selected pouching systemwith professional super- vision. Upon removal, there was no erosion of the barrier in the area of the depression, which was brought to the patient’s attention. This patient successfully completed the procedure and repeated the signs and symptoms of urinary tract infection as well as methods of prevention and treatment. On POD 4, the patient was discharged home with a referral to home care services. After 9 weeks, patient 1 made an appointment with
the outpatient ostomy office because she noted a change in the color of her periwound skin. She had been managing ostomy self-care and denied problems with leakage of urine under the seal. She recalled being taught that the peristomal skin should reflect the color of the skin on the opposite side of her abdomen. Upon removal of the skin barrier, some overhydration of the adhesive seal was noted, and there was a 1-cm ring of gray discoloration of the skin at the mucocutaneous junction. Fortunately, she had followed up prior to the development of erosion or nodules. It was evident that postoperative edema had subsided, and there was an “inward” body profile. This was easily rectified by switching to an extended-wear convex skin barrier and adding a snug 1-inch belt. At 1-month follow-up, her skin had returned to its normal tone.
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Author’s photograph printed with patient permission.
Patient 2 A64-year-oldwoman status postcystectomy and creation of a neobladder for bladder cancer in 2017 experienced recurrent urinary tract infections, urinary incontinence, hydronephrosis, and chronic renal failure in the year following bladder removal. The plan was to transition from the neobladder to an ileal conduit. Her extensive medical history included anemia, atherosclerosis, deep vein thrombosis, gastroesophageal reflux disease, in- flammatory bowel disease, hypertension, hyperlipidemia, Lyme disease, bladder cancer, chemotherapy, and obesity, as well as anxiety and depression. Surgically, she had undergone a cystectomy, appendectomy, hyster- ectomy, and nephrostomy. Renal insufficiencywas demonstrated by a BUN of 39 mg/dL and creatinine of 2.5 mg/dL. Socially, she is married (supportive spouse hada temporary colostomy) and retired and enjoys reading. On July 13, 2018, this patient was admitted directly to
theOR; extensive lysis of adhesions, removal of neobladder, bilateral partial urethrectomy, and creation of an ileal conduit were performed. Because of the timing of admis- sion, this patient did not have preoperative stoma site marking and education. On POD1, the patientwas in significant pain, which increased her anxiety. As a result, she was not open to any education. The stoma was viable, and the pouching system intact with good urine output. With pain better controlled on POD 2, the patient was
out of bed and ambulating. A nasogastric tube remained in place because of a lack of gastrointestinal function. Her spouse reported two pouching system leaks overnight. Thenursewho refitted thepouch addedanadhesive ring so the seal was intact. The patient was given emotional support, and other pouching options were discussed. Upon removal of pouching system on POD 3 for os-
tomy teaching, the adhesive ring was overhydrated and lighter in color. Her stoma was slightly protruding, yet circumferentially recessed into abdominal fat, creating an “inward” body profile (Figure 6). In addition, the stoma was located on the underside of her abdominal curvature; the patient could not visualize the stoma when sitting. The mucocutaneous junction and peristomal skin were intact. Patient was immediately fitted with a convex skin barrier with adhesive ring (Figure 7) and ostomy belt. (The use of a firm, convex skin barrier in the initial postoperative period is controversial. It has been this author’s experience that no adverse effects have occurred with the early use of convexity. Obtaining a secure seal is of paramount importance in terms of preserving the peristomal skin and the patient’s well-being.) In the absence of leaks all weekend, the patient was in
better spirits and could demonstrate refitting of the pouching system with minimal assistance aside from centering the skin barrier because of the less visible stoma location. She was advised to use a mirror when
performing the procedure at home. On POD 6, the patient was discharged with home care services. Two years later (August 2020), after a 25-lb weight
gain, this patient arrived at the ostomy outpatient office with complaints of peristomal discomfort and rash, along with intermittent leaks. Upon removal of her two-piece pouching system, a deeply recessed stomawas surrounded by a 2-cm area of moist, white, raised hyperplasia in a circumferential pattern, followed by an erythematous ring. When sitting, the stoma receded into her abdominal fat, and a prominent skin fold was noted at the 3- and 9-o’clock positions (Figure 8). The patient was educated about the nature and cause of the pseudoverrucous lesion, as well as the anticipated course of treatment. She agreed to sample a variety of soft convex one-piece urostomy pouching systems. This patient was instructed to begin acetic acid soaks twice weekly with each pouching system change and to return to the outpatient office in 2 weeks. Patient 2 neglected to make a follow-up appointment.
After a few follow-up phone calls, the patient did return to the ostomy outpatient office in September. The patient
Author’s photograph.
Figure 8. WHEN SITTING, STOMA RECEDES FURTHER, AND PROMINENT SKIN FOLDS NOTED BILATERALLY (SKIN CONDITION WAS RESOLVED AT THIS TIME) The black arrow indicates the direction of the head of the patient. The red dot on the silhouette identifies the location of the stoma on the abdomen.
Author’s photograph printed with patient permission.
did not bring the sample one-piece pouches. She stated that she had tried them and had leaks, as well as diffi- culty with application, so she returned to her original two-piece system. This negative outcome contributed to increased depression and isolation. Her peristomal skin was essentially unchanged despite the acetic acid soaks. Because the patient preferred to stay with her original
two-piece system, a joint decision was made to add a convex double-faced adhesive ring. The proper application was demonstrated, and additional samples were provided.With each pouching system change (2 to 3 times aweek), shewas advised to apply acetic acid soaks using a soft paper towel or washcloth for 15 minutes, applying a fresh pad every 5 minutes to maintain the effectiveness of the solution. The importance of cleansing the peristomal skin of any urine that may have dripped onto the area and drying it thoroughly prior to application of the pouching system was explained to the patient. On her follow-up visit in October, the patient was in
good spirits. There were no pouching system leaks; she wasproud to report that shehad lost 4 lb in thepast 2weeks. Upon removal of skin barrier, all of the pseudoverrucous lesions had resolved. The peristomal skin was still red,
but intact and without discomfort. At this juncture, a mutual decision wasmade to follow up in 6months, un- less problems arose.
Patient 3 An81-year-oldwomanpresented to her physician’s office in 2018 with a complaint of hematuria. During workup, she was found to have a lesion at the bladder dome, which led to a diagnosis of bladder cancer. The patient completed a course of chemotherapy and was referred for surgical intervention to remove her bladder. Thyroid- itis, hypertension, and osteoporosis were of note in her medical history. Surgically, she had undergone tonsillec- tomy and cholecystectomy. She had smoked one-half of a pack of cigarettes a day for most of her adulthood; she quit upon receiving her cancer diagnosis. Her renal function was at the upper limit of normal (a BUN of 19 mg/dL), and she had a creatinine of 1.33 mg/dL. Men- tally, she was completely oriented and extraordinarily strongwilled. She livedwith her elderly spouse, for whom she was a secondary caregiver, because of his dementia. Her two adult children were incredibly supportive and an essential part of her care. On January 30, 2019, this patient was admitted directly
to the OR for robotic-assisted radical cystectomy, bilateral pelvic lymph node dissection, creation of an ileal conduit, and placement of bilateral ureteral stents. She received preoperative ostomy education and stoma site marking as an outpatient. During initial assessment on POD 1, the pouching systemwas intact, and bloody urine output was flowing. Within 2 hours, the primary nurse reported that there was a leak. Upon examination, the stoma was
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Photograph taken by patient’s son; printed with patient/son’s permission.
viable, oblong, and protruding in her right lower quadrant. Her abdomen contributed to irregular peristomal contours, and she had an “inward” body profile. In addition, therewas a deep depression from the 8- to 10-o’clock position. A convex skin barrier, with an added strip of double-faced adhesive to fill the depression, was applied. Both the patient and her son looked on as the step-by-step procedure was explained. In less than 2 hours, a second leak occurred. A muco-
cutaneous separationwas noted on the distomedial edge from the 4- to 5-o’clock position where serosanguineous fluid was draining. The surgical resident was notified, came to the bedside, and placed a catheter inside the stoma to redirect the urinary flow. The urostomypouching system was refit with a convex wafer, double-faced adhesive ring, an additional strip of adhesive to fill the lateral depression, and stoma paste to seal any minute gaps. The seal was found to be secure on POD 2. Unfortunately, the slow return of gastrointestinal func-
tion heralded gas pains that limited her motivation to ambulate. Her recovery was further thwarted by episodes of atrial fibrillation; generalizedweakness ensued. When it came time for discharge, she was too debilitated to go home. Therefore, she decided with her family to transfer to a subacute facility for rehabilitation. During her rehabilitation stay, she was readmitted to the hospi- tal twice (February 9 and 17, 2019) for abdominal pain and vomiting. Fortunately, both episodes were resolved with conservative measures. However, multiple admissions, many procedures, and
various medications took a toll on this patient’s physical and mental status. When she finally returned home, she could not care for herself, had intermittent episodes of confusion, and exhibited signs of depression. The management of her ileal conduit became her daughter’s responsibility. Because this patient lived 100 miles away from the fa-
cility and was no longer a licensed driver, she could not follow up for some time. In addition, during the height of the first wave of the COVID-19 pandemic, ostomy outpatient services were suspended. As this patient’s peristomal skin condition began to deteriorate, her son reached out through email and sent along photographs (Figure 9). Providers gave basic advice, including using a snug belt to maximize the effectiveness of the convex skin barrier, increasing fluid intake, using the gravity drainage bag overnight, and applying acetic acid soaks. When her son brought her to the outpatient office in
August 2020, he seemed frustrated and reported that his mother had gained 40 lb, had a confirmed diagnosis of dementia, refused to drink water at all, failed to wear the ostomy belt, and disconnected fromgravity drainage sometime during the middle of the night. Consequently, the pouching systemwas leaking approximately twice a
week. Upon examination, her urine output was concen- trated and amber in color and had a strong odor. The stoma was viable but deeply recessed into her abdominal fat, with a deeper depression tracking toward the umbilicus when she sat upright. Pseudoverrucous lesions occu- pied a 1.5-cm ring circumferentially with scattered, pinpoint areas of bleeding. After cleaning the peristomal skin, the patient was
instructed that silver nitrate application was necessary. (Some patients report that the treatment burns; however, the sensation most often lasts about 60 to 90 seconds. Educating the patient prior to administration assists in decreasing anxiety and increasing trust.) The topical medication was applied to the raised lesions in an ef- fort to address the bleeding and leveling of the peristomal skin.10
The patient’s son was instructed in application of a deep soft convex one-piece urostomy pouch with an additional convex ring. Samples of this new pouch, stoma powder, and sting-free barrier filmwere provided
along with written instructions to pass on to the patient’s daughter. An in-depth conversation took place with this patient; she was agreeable at the time and left with a snug belt in place. Her plan was to remain con- nected to gravity drainage at least until the sun rose and hydrate consistently. At 1-month follow-up (an interval chosen by the son
because of distance), the patient’s son reported that the new one-piece pouch leaked after 2 days, and the patient could not handle the spout closure. This patient had not been adherent to any of the prevention/intervention measures that she had previously agreed to. Her fluid intake consisted of 4 cups of caffeinated coffee over the course of her waking hours. Beyond the 1.5-cm area of pseudoverrucous lesions, therewas a new area ofmacer- ation extending 2 cm. Urine crystals were noted on the stoma, as well as the affected skin; bleeding occurred with cleansing (Figure 10). A different brand of a deep flexible convex one-piece
pouch was applied so this patient could manage the spout closure at the bottom. Providers and the patient had a discussion regarding the importance of fluids, the
Figure 10. VIABLE STOMA SURROUNDED BY PSEUDOVERRUCOUS LESIONS, MACERATION, ERYTHEMA, AND URINARY CRYSTALLIZATION ON THE STOMA ITSELF White arrows indicate pseudoverrucous lesions. The black arrow indicates the direction of the head of the patient. The red dot on the silhouette identifies the location of the stoma on the abdomen.
Photograph taken by patient’s son; printed with patient/son’s permission.
addition of vitamin C, and a suggested follow-up with her urologist and/or with a WOC nurse closer to her home. All options were rejected. The son shared that he had been able to get his mother to a psychologist, and he was hopeful that if she could get stabilized on an antidepressant she might be more amenable to the outlined interventions. Unfortunately, this patient has not returned for follow-
up, nor has she been to any other recommended special- ist. Her sonwill communicate through email on occasion, sharing the overwhelming impact his mother’s condition has had on the family.
CONCLUSIONS Pseudoverrucous lesions are a late peristomal skin complication that occurs when there is an inadequate urostomy seal, allowingurine to contact theperistomal skin, resulting inmaceration, inflammation, and erosion. Early intervention is the most effective at reversing this alteration in skin integrity. Prevention includes (1) preoperative stoma site marking and education, (2) location of the stoma within the rectus muscle above the apex of the abdominal bulge, (3) 1- to 3-cm stoma protrusion, (4) an adjustable pouching system with an antireflex mechanism, (5) connection to gravity drainage at night, and (6) drinking at least 2 L of fluid each day. Treatment interventions revolve around (1) obtaining
a secure ostomy seal with pouching system modifica- tions, (2) maintaining dry peristomal skin, (3) acetic acid soaks with each pouching system change, (4) considering convexity and a supportive belt, and (5) the use of silver nitrate if bleeding is present. Follow-upwith a surgeon is recommended if there is evidence of a urinary tract infection. Referral to a registered dietitian may be helpful for guidance regarding vitamin C and an acid ash diet. Last, regular surveillance with a certified ostomy nurse at 2, 3, and 6 months and annual follow-ups thereafter can help ensure intact peristomal skin, a secure ostomy pouching system seal, and an enhanced quality of life.
PRACTICE PEARLS • Peristomal skin conditions, including pseudoverrucous lesions, affect patients’ physical and emotional quality of life. • Themajority of people livingwith ostomies consider leakage and peristomal skin complications to be the norm. • Early identification of peristomal skin conditions and prompt interventions result in more successful outcomes. • Regular surveillance by an ostomy nurse can prevent peristomal skin conditions and supports healthy adjustment to life with a stoma.•
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REFERENCES 1. United Ostomy Association of America. What is an ostomy? www.ostomy.org/what-is-an-ostomy.
Last accessed June 2, 2021. 2. American Cancer Society. Key Statistics for Bladder Cancer. www.cancer.org/cancer/bladder-
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Wound Manage 2004;50:68-77. 4. Szymanski KM, St-Cyr D, Alam T, Kassouf W. External stoma and peristomal complications following
radical cystectomy and ileal conduit diversion: a systematic review. Ostomy Wound Manage 2010; 56:28-35.
5. Moraes JT, Borges EL, Fernandes Santos C, et al. Prevalence of anxiety and depression in persons with ostomies: a cross-sectional study. J Wound Ostomy Continence Nurs 2020;47:595-600.
6. Colwell JC, Ratliff CR, Goldberg M, et al. MASD part 3: peristomal moisture-associated dermatitis and periwound moisture associated dermatitis: a consensus. J Wound Ostomy Continence Nurs 2011;38:541-53.
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15. Hsu MY, Lin JP, Hsu HH, etal. Preoperative stoma site marking decreases stoma and peristomal complications. J Wound Ostomy Continence Nurs 2020;47:249-56.
16. Coloplast Ostomy Forum. Ostomy Life Study 2015/16. Minneapolis, MN: Coloplast Corp; 2016. 17. Almutari D, LeBlanc K, Alavi A. Peristomal skin complications: what dermatologists need to know.
Int J Dermatol 2018;57:257-64. 18. Salvadalena G. Chapter 15: Peristomal skin conditions. In: Carmel JE, Colwell JC, Goldberg MT, eds.
Wound Ostomy Continence Nurses Society Core Curriculum: Ostomy Management. Philadelphia, PA: Wolters Kluwer Health; 2016:301-8.
19. Wound, Ostomy, and Continence Nurses Society. Peristomal Skin Assessment Guide for Clinicians. https://psag.wocn.org. Last accessed June 2, 2021.
20. Wound, Ostomy, and Continence Nurses Society. Stoma Complications: Best Practice for Clinicians. August 2013. https://cdn.ymaws.com/member.wocn.org/resource/resmgr/document_library/stoma_ complications_best_pra.pdf. Last accessed June 2, 2021.
21. Fernandez IS, Moreno C, Vano-Galvan S, Olasolo PJ. Pseudoverrucous irritant peristomal dermatitis with an histological pattern of nutritional deficiency dermatitis [letter]. Dermatol Online J 2010;16:16.
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