Differentiating Between Peristomal Contact Dermatitis and Candidiasis
by Beth Hawkins Bradley RN, MN, CWOCN
I recently did an “internet consult.” A friend of a friend had a new ostomy, lived a thousand miles away, had asked his home health nurse to help him with his problem, and was told apologetically that she “did not do ostomies.” By evaluating the photo he sent me and having him answer a few questions, I was able to guide him to a quick solution. It is unfortunate that so many clinicians feel unqualified when it comes to ostomies. In my effort to demystify common problems relating to ostomies, we will discuss practical differentiation between contact dermatitis (allergy) and candidiasis (yeast) in the peristomal skin.
In my experience, many people think that they are allergic to certain adhesives found in tapes and dressings. Often they are not allergic, but have had aggressive or frequent adhesive removal that has stripped away the epidermis. This results in a red, itchy, often weepy area underneath where the adhesive was. But adhesive injury is different from adhesive allergy. To begin with, adhesive allergy will occur over the entire area of skin that was in contact with the adhesive in question. It will become progressively worse. It begins as erythema with itching, and then progresses to blisters that unroof to expose weepy, dermatitis. If contact with the allergen continues the reaction will worsen in severity.
If a patient relates a history of adhesive allergy, a simple patch test may be performed in any care setting, as long as he does not report previous anaphylaxis. To perform the patch test, take three small pieces (about 2 cm square) of the product in question and place it in an area away from the ostomy appliance. The anterior thigh is a location that he can access and visualize. Instruct him to take one patch off at 24, 48, then 72 hours. If the patient has a true allergy, there will be erythematic and some itching at 24 hours. At 48 hours the itching will be more pronounced and there may be some blisters. He should not continue to 72 hours in this case, and should consider himself allergic to the adhesive. If he has had no reaction, the patch test will serve to reassure him that it is safe to use the product that was tested.
Treatment for contact dermatitis depends of the severity of the reaction. A mild reaction can be treated simply by discontinuing contact with the product. A steroid cream or spray may be indicated for symptom management, and systemic antihistamines may be needed for more severe reactions. Always refer him to his prescribing provider if treatment is needed.
Candidiasis is common in the peristomal area during the post-op period and during hot weather. Recall that most people are given antibiotics during and after surgery. Antibiotics reduce the normal skin flora, allowing opportunistic yeast to flourish. Since yeast does well in warm moist dark places, the skin under an ostomy barrier is a great place for candidiasis to occur. Yeast rashes are different from allergic rashes. Candidiasis begins as a scattered macular-papular rash. This means that there is a combination of small flat red lesions and tiny pustules. As the yeast spreads, the lesions become numerous. Pustules will unroof creating a consolidated reddened area with peeling edges with macules and papules peripheral to the consolidation. Although the rash itches, it is fairly easy to differentiate it from allergy. Candidiasis may eventually extend beyond the margin of the ostomy wafer, or it may not cover but part of the skin under the barrier. Recall that allergies will appear in the same shape as the adhesive in question. Additionally, an allergic reaction will not have macules and papules associated with it.
Treatment of candidiasis must be with an antifungal. The problem can be treated locally while continuing the current skin barrier. If the problem is occurring over large areas of skin, in the perineum and other skin folds for example, a systemic antifungal may be needed. Treating peristomal skin is a bit of a challenge, since creams and ointments will interfere with the skin barrier’s adhesion to the skin. Many clinicians use an antifungal powder, such as miconazole. Apply the powder over the rash and extending past the borders of the rash and rub in a bit. Then seal the powder in with a skin barrier wipe, applied using a patting technique. Then apply the ostomy barrier as usual. It may be helpful to change the barrier more frequently, every 48 hours, until the rash has been clear for at least one pouch change.
Finally, be sure to instruct your patient how to differentiate allergies from candidiasis. Allergy to adhesives may develop after prolonged use of a certain product. Candidiasis may occur more in warm weather, or if a patient is given antibiotics for another condition.
About the Author
Beth Hawkins Bradley, RN, MN, CWOCN has been certified in the specialty of Wound, Ostomy, Continence nursing since 1990. She has been the sole proprietor Care On Call, which provides consultation and education for clinicians and patients. Beth joined Innovative Therapies, Inc. as the Director of Clinical Affairs in 2010 and currently holds the position of Vice President, Clinical.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of OstomySource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.