PRODUCT FOCUS

Peristomal sore skin: assessing

the effect of an alginate wafer
Louise Taylor

ealthy peristomal skin is an essential aspect in the

quality of life as an ostomist and yet, recent studies
have highlighted that complications are significant
(Herlufsen et al, 2006; Williams et al, 2010).
There are approximately 102000 people in the UK who
have a stoma at any one time (Herlufsen et al, 2006); of these,
around 65% will be permanent (Black, 1997).

The skin
The skin consists of three layers: the epidermis (the outer
layer), the dermis and the subcutaneous layer. It is the
bodys largest organ. It has many functions including
thermoregulation, sensation and excretory functions and
serves as protection from many things including bacteria
(Timmons, 2006). The skin needs to remain intact in order
to perform these vital functions. The skin also contains sweat
glands, hair follicles and sebaceous glands, all of which can
create problems for the ostomist (Burch and Sica, 2011).

Peristomal skin problems

Literature has shown that of those people with stomas,
peristomal skin problems affect approximately one third of
colostomy patients and over two thirds of ileostomy and
urostomy patients (Lyon and Smith, 2000). A recent study by
Herlufsen et al (2006) identified an even higher incidence of
skin complications. They reported that 57% ileostomists, 48%
urostomists and 35% colostomists experienced skin problems
around their stoma. The United Ostomy Association
conducted a survey in 2000 and found that peristomal skin
complications were the most common reason patients visited
a Wound Ostomy Continence nursing service (Rolstad and
Erwin-Toth, 2004). Butler (2009) reports peristomal skin
complications accounted for the most frequent early (within
2years of surgery) complication.
Stomal surgery is known to have a profound impact on
many patients ideas of their body image and, therefore, their
psychological adaption of having a stoma. Experiencing
peristomal skin complications can compound any negative
feelings and make it harder for patients to fully adapt to life
with a stoma (Whitley and Sinclair, 2010).
One of the goals of good stoma management is to
maintain healthy peristomal skin to the point where there

Louise Taylor, Stoma Care Nurse Specialist, Oakmed Ltd

Accepted for publication: July 2012

British Journal of Nursing, 2012 (Stoma Care Supplement), Vol 21, No 16

Abstract

Peristomal skin problems affect a significant number of ostomists

leading to problems with skin integrity and pouch adherence. This
can begin to have a very negative impact on an ostomists quality of
life. The case studies within this article look at the use of an integral
skin healing dressing, alginate, within the flange of a stoma bag and
its effect on skin healing and patient quality of life. The patients and
stoma care nurses have kindly agreed to allow their experiences to be
publishedall patients are anonymous.
Key words: Peristomal skin care
Stoma care n Faecal leakage

Skin excoriation

Alginate

should be no difference between the peristomal skin and the

surrounding abdominal skin (Boyles, 2010; Williams et al,
2010). However, the peristomal skin is extremely vulnerable
and, once damaged, can be hard to treat, particularly when
faced with affixing a skin barrier adhesive (Thompson et al,
2011). As the skin becomes damaged, adhesion of the ostomy
bag is reduced and this can cause further leakage, resulting
in further skin damage, appliance adherence problems, pain
and anxiety. This can become a cyclical process (Rolstad
and Erwin-Toth, 2004; Herlufsen et al, 2006; Whitley and
Sinclair, 2010). Sore skin and leakage of the stoma appliance
are highlighted as the main concerns for ostomists in Prieto
et als (2005) quality of life study.
Peristomal skin complications can be caused by a number
of factors, including chemical injury, mechanical destruction,
infection, immunological reactions or disease-related
conditions (Black, 2007; Thompson et al, 2011). Chemical
irritants can be from the pouch, from accessories used,
medication applied on the peristomal skin or further
treatments such as chemotherapy. However, the main reason
for skin disorders has been identified as chemical irritation
as a result of effluent from the stoma (Herlufsen, 2006;
Thompson et al, 2011; Rolstad et al, 2012). This may be
owing to the highly alkaline levels and proteolytic enzymes
of the stool from an ileostomy output and the bacterial
content in the stool from a colostomy output (Redmond
et al, 2009; Rolstad et al, 2012). Because of its liquidity,
urine has the ability to undermine the strongest adhesive
or hydrocolloid, especially where skin creases are present
resulting in skin irritation (Fillingham, 2005). Ideally, urinary

S41

pH should be slightly acidic and range between 6 and 7.5.

An alkaline urinary pH of 78 can lead to complications
with the peristomal skin and stoma such as stomal bleeding,
ulceration, urinary tract infections and urinary calculi
(Vujnovich, 2006). Effluent comes into contact with the
peristomal skin in a number of ways including via a poorly
spouted stoma, dips and creases around the stoma, silent
leakage beneath the barrier when trying to extend wear
time of the pouch, incorrect-shaped/sized template or
the adhesive on the skin barrier not bonding to the skin
successfully (Breckman, 2005).
Alginates are quite abundant in nature although all
commercial alginates are produced from marine brown
algae (seaweed) (Timmons, 2006). They have been used
for decades as helping agents in various human health
applications. Some examples include use in traditional
wound dressings, dental impression material and some
formulations preventing gastric reflux. Alginate products
?????????????????
have been used in wound care for a long time (Heenan,
2007). Originally discovered in the 1800s, it was observed
that seaweed was very effective in the treatment of wounds
in sailors (Williams, 1998). Alginates made their first
big impression in wound care in the 1980s as dressings
for split-skin donor sites. A study comparing the use of
alginates and paraffin gauze on the donor sites had to be
abandoned by Attwood (1989) as there was consistently
better healing under the alginates (Heenan, 2007), as there
was for ODonoghues study in 2000 (Arklie et al, 2005).
Other studies have also shown significant results. The use
of an alginate showed that healing time was significantly
faster compared with a hydrocolloid in Stage III or IV
pressure ulcers (Arklie et al, 2005). A randomised controlled
trial comparing an alginate with a hydrofibre dressing in
the management of various wound types demonstrated
that the alginate had statistically significant faster healing
time (Kammerlander and Andriessen, 2000). It is not fully
understood why alginate actively promotes healing.
Alginates are biocompatible, hydrophilic (water loving)
and biodegradable (Woo-Ram et al, 2009). Once a gel has
been formed via ion exchange between the alginate and
the wound, the secretions and bacterial contamination are
minimised, promoting wound healing (Timmons, 2009).
Alginate dressings can also exert bioactivity, which may
modulate cell function and so influence the healing process
(Thomas et al, 2000). Thomas et al (2000) concluded:
some alginate containing dressings have
the potential to activate macrophages within
the chronic wound bed and generate a pro
inflammatory signal which may initiate a resolving inflammation characteristic of healing
wounds.

Alginate wafer
The alginate wafer (Oakmed Ltd, UK) incorporates alginate
in the ostomy pouch wafer so it can actively aid the healing
of any sensitive, sore, excoriated peristomal skin. This paper
will now report on the outcome of four case studies using
the alginate ostomy pouch.

S42

Figure 1. Patient 1: Adhesive-shaped erythema

Figure 2. Patient 1: The stoma 2 weeks after the alginate was introduced

Patient 1: Sub-total colectomy and ileostomy

Authors: Gillian Powell and Lesley Verill, Clinial Nurse
Specialists, Stoma Care
The patient had already undergone a sub-total colectomy
and formation of ileostomy for ulcerative colitis. He was
then admitted for ileo-anal pouch surgery. On admission,
there was a bright red adhesive-shaped erythema and areas of
excoriation noted.This was showing sensitivity to his current
adhesive (see Figure 1). The patient said it had been like this
for a while and he had begun to have problems with pouch
patency, which was leading to an increased number of pouch
changes. The patient described the area as uncomfortable. He
was assessed for other causes for the leakage such as dips and
creases or change in stoma size but none was found. He was
on no medication that would affect skin healing and was not
known to have any allergies.
The Oakmed alginate drainable flat pouch was selected

British Journal of Nursing, 2012 (Stoma Care Supplement), Vol 21, No 16

because of the skin-healing properties of the alginate within

the adhesive. The pouch was applied immediately after
surgery and initially left in situ. At a later post-operative stage,
it was changed every other day. No accessories were required.
After 2 weeks, there was no residual inflammation. There
were some patchy red areas in the previously excoriated area
that were returning to normal (Figure 2). The patients skin
was healed successfully within 2 weeks and there was no
need for accessories. The patient continues to use the alginate
successfully rather than his previous appliance, changing the
pouch on alternate days. He remains happy with his pouch.

Patient 2: Colectomy and ileostomy

Author: Julie Hemmingway, Clinial Nurse Specialist, Stoma Care
Patient 2 underwent emergency surgery involving a
colectomy and formation of an ileostomy. The acute nature
of the surgery meant the patient was not sited pre-operatively
for his stoma formation; the stoma was inappropriately placed
Figure 3. Patient 2: Sore peristomal skin as a result of appliance leakage

and became very flat and recessed. This caused frequent

appliance leakage resulting in sore peristomal skin (Figure 3).
Assessment showed that the peristomal excoriation was
caused by chemical damage of liquid faecal matter. The
ward staff had started treatment with skin-barrier protection,
hydrocolloid seals and flange-retention strips. The appliances
continued to leak and a referral was made to the stoma care
nurse (SCN). The Oakmed Soft Convex alginate pouch was
chosen as the healing agent is integral to the pouch wafer.
The loss of peristomal skin integrity affected Patient 2s
wellbeing, confidence and quality of life. The sore skin was
leading to leaks, pain and embarrassment. Four days after
application of the Oakmed alginate pouch, dermatological
healing of the peristomal surface was significant; complete
resolution of pain, discomfort and leakages was apparent. Ten
days after application, the peristomal area was completely
healed (Figure 4).
The patient expressed relief of no further episodes of
discomfort, pain, soreness or embarrassment. A noticeable
increase was observed in his general wellbeing, confidence
and morale.
The additional benefits of cost reduction were also evident
as the SCN no longer needed to use ostomy belts, skin
protection barrier films or flange-retention strips. The wear
time of the appliance increased from five times a day to every
3days.

Patient 3: Loop colostomy

Figure 4. Patient 2: Tendays after application of the alginate pouch

S44

Author: Sarah Taylor, Clinial Nurse Specialist, Stoma Care

Patient 3 was 68 years old. She had had surgery on her
back in 1980 that affected her nervous system and left her
incontinent; she was given a loop colostomy as a result. She
was not taking any medication that may have affected skin
healing in any way and there was no other medical history.
Patient 3 had experienced sore skin for approximately
1year. This was owing to problems with leakage that made
the skin ulcerate, macerated and wet.
She had tried many different products, including various
convex pouches and different accessories in an effort to solve
her sore skin, none of which worked. She did have some
success with an alginate-based wound dressing, which led
us to think of the Oakmed alginate pouches for the skinhealing and moisture-absorption qualities.
On examination, Patient 3s skin was raw and excoriated.
The area of raw skin measured 4cm x 2 cm with a dip in
the 9 oclock position (Figure 5). She complained of being
sore and uncomfortable in the peristomal area most of the
time. She also suffers with pancaking (when the faeces sits at
the top of the stoma appliance) and is fearful of leaks, which
affects her mood.
Patient 3 was changing her pouch 45 times a day because
the pouches would not stick onto her macerated skin and
this resulted in leakage. However, she was still managing to
go out and was really trying not to let it stop her living her
life. She attended the stoma clinic regularly for her sore skin
and leakage problems.
The Oakmed Alginate Connect two-piece pouch was
chosen, without any accessories. After 1 week, the area of
macerated skin had decreased by 20-25%. After a further

British Journal of Nursing, 2012 (Stoma Care Supplement), Vol 21, No 16

PRODUCT FOCUS

Figure 5. Patient 3: Ulcerated and macerated skin around the stoma

Figure 6. Patient 3: Decrease of macerated skin by 85% after 2weeks

2 weeks, the area of macerated skin had decreased by 85%

(Figure 6).
There was formation of granulation tissue, epithelialisation
and contraction of the surface area of raw excoriated skin.
The skin healing process was virtually complete after
3weeks.
Author: Jane Gascoigne Clinical Nurse Specialist, Stoma Care
Patient 4 is a 24-year-old male who had a panproctocolectomy
in 2009 for Crohns disease. During the case study, he
was not taking any medication and was using a one-piece
hydrocolloid. He felt he had tried everything to resolve his
sore peristomal skin. He had in fact tried five different types
of pouches but his skin had remained sore for months. He
had also had a dermatological referral and been re-educated
to correct the method of his stoma management as he had
flitted from one product to another along with many types
of accessories.
The patient self-referred to the SCN for advice. On
inspection, the ileostomy appeared slightly proud of the
skin, sloughy and with slight ulceration around the aperture.
The peristomal skin appeared excoriated and red with some
bleeding points (Figure 7).

His stoma had been situated high at his own request

and he reported constant leakage, which was causing skin
excoriation. His skin was incredibly itchy and, as a result, he
had been suffering from a lack of sleep. His pain score, on a
scale of 110 (with 10 being the worst), was 10 on occasions
and 7 at other times. He was seen very frequently in the
stoma clinic because of his problems: at least once a week for
20minutes.
He was advised by the CNS to use a pouch from the
Oakmed Alginate range of products because of their skinhealing and moisture-absorption properties. He chose a flat
drainable bag. No skin creams or barrier films were used as
this was not necessary with the alginate products. He was
also educated not to use inappropriate wipes on his skin.
Patient 4 was seen on day 5 of using the alginate bag
and photographs were taken (Figure 8). The peristomal skin
appeared less excoriated and not as red. He reported less
itching and no leakage. Evidence is seen in Figure 8 of a
marked reduction in surface area of sore peristomal skin
and moisture.
The patient reported how pleased he was with the new
product. He also reports that his quality of life is much
improved and his pain score is reduced to 4 (out of 10).
His sleep pattern is much improved so he is less tired and

Figure 7. Patient 4: Excoriated peristomal skin

Figure 8. Patient 4: The stoma 5 days after introducing the alginate bag

Patient 4: Panproctocolectomy

British Journal of Nursing, 2012 (Stoma Care Supplement), Vol 21, No 16

S45

he now attends the clinic less regularly for 10-minute

appointments. He has now the confidence and energy to
book a holiday.
The patients skin had visibly improved after 5 days and
was well on its way to being completely healed just with the
use of the alginate pouch.

Conclusion
Skin problems are common among ostomates and are
caused by a variety of factors, many of which are beyond
their control, resulting in reduced quality of life.
The main outcomes assessed in these case studies were
resolution of sore peristomal skin, quality of life, amount of
product and accessories required and time required with the
SCN.
In this cohort, the patients all found their quality of life
had improved as the leaks were resolved and sore peristomal
skin was healed. There was no need for any accessories while
using the alginate products whereas a number had been used
previously. The number of bag changes also dramatically
reduced.
The sore peristomal skin, which had been a problem for
many months for a couple of patients, was showing signs of
healing within a few days, and was healed for Patients 1, 2 and
4 by day 10. Patient 3 had seen 85% healing in her wound.
The Oakmed alginate product was successful in improving
quality of life, reducing the need for extra products and
accessories, initiating wound healing and reducing the SCN
time required.
Further in-depth study would be required to test
conclusively how effective the alginate product is compared
with others in the arena of wound healing, however, the
Oakmed alginate products may represent a significant costBJN
effective treatment for sore peristomal skin. 


Conflict of interest: This article was supported by Oakmed Limited.

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