Most patients are concerned about their peristomal skin status. Poor care in this area leaves stool and urine residues, leading to contamination, skin irritation, increased risk of infection and other stoma complications. Ostomy skin barriers (also known as wafers or flanges) can help minimize such incidences.
“Among the many challenges faced by persons with a stoma is the risk of developing complications relating to the skin around the stoma. Research demonstrates peristomal skin complications are the most commonly experienced physical complication following ostomy surgery, affecting 45% to 68% of long-term ostomates.
The majority of stoma complications are related to leakage, which allows effluent to come into contact with the skin. A skin barrier, which attaches the ostomy pouch to the abdomen, is designed to protect the skin from stoma output, but an ill-fitting barrier can allow effluent to come into contact with the skin, causing peristomal skin breakdown. A person with a stoma who develops compromised peristomal skin can experience a vicious cycle of suboptimal barrier adhesion, continual leakage, and further peristomal skin breakdown. Accordingly, healthy peristomal skin is essential to achieving a secure seal between the barrier and the peristomal skin; conversely, a secure seal is essential to preventing leakage and maintaining healthy peristomal skin.”1
How to Avoid Peristomal Skin Irritation
- “The best skin protection is a well-fitted and comfortable pouching system. Your WOC (Wound, Ostomy and continence) nurse or health care provider will help you choose the system that works best for you.
- The opening of the barrier on your pouching system should be the size of the stoma unless otherwise instructed by your WOC nurse or health care provider.
- Measure your stoma each time you change your pouching system for the first 6 to 8 weeks after your ostomy surgery.
- Re-measure your stoma occasionally if you notice that your stoma has changed shape or size.
- Your stoma may change and you will need to change the size of the opening in the pouching system when your stoma size changes.
- Hold your skin smooth as you put your pouching system on to avoid wrinkles in the skin that may lead to leakage.
- Each time you remove your pouching system, check your skin for signs of irritation. Check the sticky backing of your pouching system for signs of moisture leakage.
- Use a mirror to check your skin around the stoma. Look for any places where stool or urine may have leaked under the pouching system and onto your skin. When you apply your next pouching system, these areas may need extra reinforcement with skin barrier strips, rings or paste. There are a variety of these barrier products available. Your WOC nurse or health care provider will advise you when this is needed.”2
How Ostomy Skin Barriers Prevent Skin Irritation?
They form a seal around the stoma. Once the user attaches the pouch, discharge is unable to touch the skin. A skin barrier can be part of the pouch, as in a one-piece ostomy bag, or separate, as in a two-piece system.
Properties of an Ostomy Skin Barrier
- Protects the skin around the stoma from contamination with urine or stool.
- Adhesiveness is not affected by wetness or body moisture, an important feature for patients who perspire a lot.
- Protects against discharge odors.
- Causes no friction to the skin around the stoma.
- Continues to be effective even when the stoma shape changes. The size of the stoma usually gets smaller once post-surgery swelling diminishes (patients must size down accordingly).
- Peels off painlessly causing no injury to the skin during removal.
- It is custom cutting. “Custom cutting is die-cutting the center opening of a wafer to fit the exact shape and size of your stoma. Provides accurate sizing and proper fit so less time is spent changing the appliance. A better fit translates into longer wear time. Decrease leakage issues and skin irritation. Less skin breakdown translates to fewer physician visits. […] Custom cutting is most beneficial six to eight weeks after surgery, once your stoma has shrunk and stabilized in size.”3
The type of barrier the patient uses is a matter of personal preference and the contours of the stoma. Common types include:
- Cut-to-fit skin barriers, used for irregularly shaped stomas or for those reducing in size.
- Pre-cut skin barriers, ideal for well-marked and round stomas.
- Convex skin barriers protrude towards the skin around the stoma so as to fit flat or retracted stomas.
- Moldable wafers are molded (manipulated) to the patient’s body contours.
- Flexible skin barriers adapt to skin folds and curves.
Standard and Extended Wear
In situations where the skin is irritated or inflamed, use a standard wear skin barrier. Standard barriers absorb moisture from the peristomal skin and maintain low adhesiveness to diminish skin trauma during removal. Extended wear skin barriers are ideal for longer periods. If the stoma drains urine or liquid stool, extended wear barriers are better absorbing moisture while retaining adhesive strength.
- “Standard wear barriers are designed for more solid stool and are commonly used with colostomies. They absorb moisture quickly, so they are able to handle perspiration and still stay bonded to the skin. If they are exposed to moisture for long periods of time, however, these barriers may begin to erode or break down. Keep this in mind if you have a bout of diarrhea. In that case you may need to change the barrier more often.
- Extended wear barriers are designed to manage loose stools or liquid drainage from the stoma. They are commonly used with either an ileostomy or a urostomy. They resist absorbing moisture and maintain their shape longer than the standard wear barrier. If you have an ileostomy or urostomy, the extended wear barrier isn’t likely to erode, so you should be able to wear it longer than a standard wear barrier.
There are also different barrier shapes: A skin barrier will either have a flat shape or a convex (curved) shape. Most people will use a flat barrier right after surgery. As the swelling from surgery decreases you may find you need a convex barrier. Convex barriers are designed to gently push against the skin around your stoma. This helps prevent leakage by creating a secure seal.
Your WOC Nurse may suggest that you wear a convex barrier if any of the following apply to you:
- Your stoma is flush with the skin or below skin level
- The skin around your stoma is not flat
- Your abdomen is very soft around your stoma
- If you often have leakage – even if your stoma protrudes (sticks out) from your skin
Make sure you discuss convex barriers with your WOC Nurse before trying them on your own.”4
Standard and Moldable Skin Barriers
“Standard ostomy barriers (cut-to-fit and precut) are used to help maintain the ostomy appliance/skin seal and prevent leakage require the patient to master complex skills. The barriers may not fit precisely, leaving exposed skin subject to the risk of breakdown, and the rough edges on cut-to-fit barriers may cause mechanical trauma to the stoma.
Moldable Technology Skin Barriers were developed to provide easy application and a customized fit around the stoma for a more secure seal. The barrier is fitted to an individual stoma by rolling the moldable barrier to the approximate stoma size, applying the barrier to the body, and rolling back the moldable barrier so it securely hugs the base of the stoma. The moldable barrier allows a personalized fit, with improved adhesion onto irregular skin surfaces and around irregularly shaped stomas; two types of moldable barriers accommodate a flat or convex wafer support system.
The most frequently reported reasons for switching from the traditional barrier to the moldable barrier were to improve fit around the stoma and to avoid cutting the wafer.”5
Skin Barrier Rings – How To UseThem
“People with chronic leakage and fitting problems, or very sensitive skin may find using skin barrier rings beneficial. The rings, or seals, as they are sometimes called, are similar to a flange, but made out of different material that is hypoallergenic and soothing to the skin. Rings come in two sizes and can be molded or stretched by hand to custom fit around the stoma, and increase the adhesion of the flange, which is applied over top. Sometimes pieces of the ring material are all that’s required to address a small problem area.”6
Do I need to use a skin barrier product (tube paste, strip paste, powder or rings)?
- Skin barrier rings or strips can be used to fill in creases around your stoma to prevent drainage from leaking through these areas. Rings or strips can be applied as a whole or in small pieces that can be molded and placed where they are needed.
- Skin barrier rings or strips can be applied directly to the skin or on the back of the pouching system. They are available in various sizes and thicknesses.
- Ostomy skin barrier tube paste can be used as a filler for small uneven areas and creases around the stoma. Skin barrier paste is not to be used as glue and should only be used in small amounts. A small amount of paste may improve the seal and prevent leakage.
- Skin barrier strip paste is a different form of paste that can be molded to fit around the stoma to fill in uneven areas.
- You do not need to use paste if the skin around your stoma is smooth, you are getting a good fit with your pouching system, or you are not having any problems with leakage. Paste is not recommended for persons with a urostomy.
- Some pastes contain alcohol and will cause a burning sensation if used on open skin.
- Apply paste around the opening that is cut in the pouching system, unless instructed otherwise. Use only a small bead of paste. Let the paste sit for one minute (this gives the alcohol in the paste the chance to evaporate). Do not spread the paste or use too much.
When trying to remove paste from the skin let it dry first. Do not worry if a little bit of paste is left on your skin.
Skin barrier film: Contains a polymer and plasticizer that form a breathable, clear coating on the skin; protects the skin from body fluids, adhesives, and friction; is alcohol free (no-sting product), noncytotoxic and hypoallergenic; can be used on intact or damaged skin
How can I get the pouching system to stick better if I sweat?
- To help absorb perspiration and allow the pouching system to stick better, dust the skin with an ostomy skin barrier powder then dab skin sealant on top of the powder before applying the pouching system.
When do I need to use an ostomy skin barrier powder?
- Ostomy skin barrier powder is used to heal an irritated weepy area on the skin. You only need to use powder if you are having problems with skin irritation.
- Ostomy skin barrier powder should be dusted lightly over the area of skin irritation and the excess powder should be brushed off to avoid caking. To form a crust, dab or spray a no-sting skin sealant over the powder and allow it to dry before putting on your pouching system.7
How to Measure a Stoma Before Skin Barrier Placement
- For oval stomas, the nurse/ostomate must provide the horizontal measurement.
- The nurse/ostomate must also provide the vertical measurement.
- The size now becomes, for example: f “v x 14″ h
Prepare and clean the peristomal skin with wipes, sprays or creams. Ideally, placing the skin barrier on a clean surface reduces risks of skin injury during wafer removal. Some patients have sensitive skins and react to skin preparation substances or skin barrier material. Report any history of skin sensitivity to the ostomy nurse for evaluation, including allergy or other pertinent tests. For more information on the correct use of an ostomy skin barrier, seek an ostomy specialist or an experienced user.
(1, 5) The Effects of Using a Moldable Skin Barrier. https://www.o-wm.com/article/effects-using-moldable-skin-barrier-peristomal-skin-condition-persons-ostomy-results
(2, 7) Ostomy Catalog. https://www.ostomy.org/wp-content/uploads/2018/11/wocn_basic_ostomy_skin_care_2018.pdf
(3) MOLDABLE ADHESIVE WAFER. https://patentimages.storage.googleapis.com/16/c2/f7/d4ff429c3fcfab/US8460259.pdf
(4) Living Well Urostomy M6079N.pdf https://www.coloplast.us/Global/US/Ostomy/Documents/Living%20Well_Urostomy_M6079N.pdf
(5) Ostomy Handbook. http://www.ostomytoronto.ca/pdf/handbook.pdf
(6) Basic Ostomy Skin Care https://www.ostomy.org/wp-content/uploads/2018/11/wocn_basic_ostomy_skin_care_2018.pdf