J Wound Ostomy Continence Nurs. 2014;41(5):484-486. Published by Lippincott Williams & Wilkins
CHALLENGES IN PRACTICE
Intradermal Botulinum Toxin A for Peristomal Hyperhidrosis A Case Study Kristen Kalkbrenner Kyle Sanniec Lyndsey Bryant Heather McEntarffer Alanna Rebecca
Jacques Heppell
■ ABSTRACT
■ Case
BACKGROUND: Peristomal hyperhidrosis can interfere with pouch adherence, resulting in pouch leakage and peristomal skin damage. CASE: A patient with autonomic dysregulation resulting in excessive sweating (hyperhidrosis) experienced difficulty with adherence of her ileostomy appliance. Two hundred units of botulinum toxin A (BTX-A) were injected in the dermis of the surrounding skin in order to improve adherence of her pouching system and alleviate moisture of her peristomal skin. RESULTS: Following BTX-A injection, the typical wear time of her pouching system improved from less than 24 hours to 120 hours. Peristomal moisture-associated skin damage resolved almost completely. These effects lasted 3 months. A repeat intradermal BTX-A injection had a similar positive effect. CONCLUSION: Peristomal hyperhidrosis can be controlled with BTX-A intradermal injections, improving patient pouch adherence and alleviating moisture-associated skin damage. KEY WORDS: appliance, appliance adherence, botulinum toxin A, dermatitis, hyperhidrosis, ileostomy, moistureassociated skin damage peristomal dermatitis, peristomal hyperhidrosis.
Ms A is a 27-year-old white woman with a history of ulcerative colitis diagnosed at the age of 13 years. She underwent total colectomy with ileal pouch anal anastomosis and diverting loop ileostomy at the age of 16 years. Approximately 3 months later she underwent takedown of her ileostomy. Ms A did well postoperatively until 1 year later when she experienced a severe lower gastrointestinal bleed that required blood transfusion. Following this event, she had numerous episodes of pouchitis requiring long-term antibiotic therapy. Ms A consulted the Department of Colorectal Surgery and Department of Gastroenterology at Mayo Clinic for a second opinion concerning the possible salvage of her ileal pouch and treatment options for her chronic pouchitis. She reported consulting with multiple providers who recommended removal of her pouch, but she wanted to salvage her ileal pouch if possible to avoid living permanently with a stoma. Unfortunately, after multiple failed treatments, the decision was made to remove the ileal pouch and create an end ileostomy. Postoperatively, Ms A had multiple issues with her ileostomy pouching system including peristomal
■ Introduction Hyperhidrosis is a disorder of excessive sweating that may negatively affect the peristomal skin of ostomy patients. Multiple treatments have been suggested including topical therapy using aluminum chloride or glycopyrrolate, iontophoresis; systemic therapies such as glycopyrrolate or clonidine, and surgical treatments such as a sympathectomy.1 Another modality discussed in the literature is treatment with botulinum toxin A (BTX-A).1 Botulinum toxin A has been used to manage hyperhidrosis in the axillary area, anal fold, palmar surface of the hand, and face in persons with Frey syndrome.2-5 Efficacy for this treatment is high and the associated risk has been low.1
484 J WOCN ■ September/October 2014
Kristen Kalkbrenner, PA-C, Department of Surgery, Mayo Clinic Arizona, Phoenix. Kyle Sanniec, MHA, MA, Department of Surgery, Mayo Clinic Arizona, Phoenix. Lyndsey Bryant, PA-C, Department of Surgery, Mayo Clinic Arizona, Phoenix. Jacques Heppell, MD, Department of Surgery, Mayo Clinic Arizona, Phoenix. Heather McEntarffer, RN, WOCN, Department of Nursing, Mayo Clinic Arizona, Phoenix. Alanna Rebecca, MD, Department of Surgery, Mayo Clinic Arizona, Phoenix. The authors declare no conflict of interest. Correspondence: Kristen Kalkbrenner, PA-C, Department of Surgery, Mayo Clinic Arizona, 5777 East Mayo Blvd, Phoenix, AZ 85054 ([email protected]). DOI: 10.1097/WON.0000000000000061
Copyright © 2014 by the Wound, Ostomy and Continence Nurses Society™
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-13-00012_LR 484
26/08/14 7:40 PM
J WOCN
■ Volume 41/Number 5
moisture-associated skin damage, hyperhidrosis of the peristomal skin, and difficulty securing her appliance. Of greatest concern was severe skin irritation characterized by erythema and pruritus. Persistent peristomal skin irritation led to trials of numerous appliances in the hopes that one would prove less irritating. The stoma was evaluated several times and was found to be properly budded with a centered os, and it was determined that the leakage was caused by the hyperhidrosis. Ms A continued to work with WOC nurses near her home. She seemed to have the least peristomal skin irritation with one pouch (SenSura Coloplast, Holtendam, Denmark), in combination with a steroid cream. The steroid cream was used in conjunction with a crusting technique to enhance adherence of the wafer. Because she lived out of state, the WOC nurse used telephone triage to evaluate the effect of the pouching system and steroid cream on Ms A’s peristomal skin and pouch adherence. When Ms A was seen at our clinic, patch testing was performed with other commercial products, none of which caused a skin reaction. Along with the peristomal dermatitis, we observed peristomal hyperhidrosis that was causing her appliance to slip off, allowing a maximum wear time of no more than 1 to 2 days. Ms A would frequently reinforce the area with tape and/or completely repouch the stoma several times daily. Frequent pouch changes increased the severity of her peristomal dermatitis. The dermatitis was attributed to epithelial stripping and exposure of the peristomal skin to effluent from the stoma. Physical examination of the skin did not reveal any evidence of a candidal infection. Ms A was seen by an outside provider for the hyperhidrosis and was started on oral glycopyrrolate. Treatment improved her overall diaphoresis but did not significantly impact sweating of the peristomal skin. At this point Ms A was referred to the Department of Plastic and Reconstructive Surgery for their input on possibly injecting the peristomal skin with BTX-A to treat the hyperhidrosis. After obtaining informed consent, the peristomal skin was prepped and injected circumferentially with 200 units of BTX-A while temporarily obstructing the stoma output to avoid bacterial contamination during injection. Within several days of the injection, Ms A reported a significant decrease in peristomal perspiration allowing up to 5 days wear time before changing her pouching system. She also noted improvement in her peristomal dermatitis. She continued to use the same appliance during this time frame. Ms A noticed a gradual decline in wear time of her appliance between 3 and 4 months following her initial injection and returned for repeat injection of BTX-A. It was recommended that repeat injections be performed every 3 months for continued maintenance.
■ Discussion Botulinum toxin A inhibits perspiration by blocking the release of acetylcholine from the presynaptic membrane
Kalkbrenner et al
485
of nerves within the sweat glands.6 Clinical studies have demonstrated that BTX-A is safe and effective for hyperhidrosis of the axillary fold, anal fold, palms, and plantar surfaces of the feet,2-6,7 and we postulated that BTX-A would exert a similar effect on the peristomal skin. Results of our case study support the use of intradermal injection of BTX-A to minimize peristomal perspiration and facilitate ileostomy care. A literature review did not reveal any articles focusing on the use of BTX-A for peristomal hyperhidrosis. Peristomal complications have been discussed extensively in the literature; the most prevalent of these complications involve the peristomal skin.8-13 Peristomal skin complications are associated with multiple factors such as infections (Candida, tinea, or folliculitis), inflammatory issues (chemical, abnormal local pH, or skin stripping), and immunological conditions (allergic contact dermatitis, psoriasis, or Pyoderma gangrenosum).14,15 Peristomal moistureassociated dermatitis is attributed to excessive exposure to effluent from the ostomy (stool or urine) that can break down the appliance over time.15 Moisture-associated dermatitis can also be caused by exposure to other moisture sources such as perspiration. Most ostomy appliances are made with hydrocolloids that are designed to absorb moisture from the skin and stomal effluent. However, when challenged by excessive moisture, the absorptive qualities of the appliance are overwhelmed, resulting in a breakdown of the seal between faceplate and skin. This in turn creates an overly moist environment of the peristomal skin leading to dermatitis.15 Pectin-based stomal powders with skin sealants, deodorant, and/or changes in the ostomy appliance are some of the options that are available when dealing with this issue. It is also important to consider the financial impact of peristomal moisture-associated dermatitis exerts on the patient. Changing the pouching system daily or multiple times per day may result in a significant financial burden. When combining the costs of multiple appliances each day as well as pharmaceutical adjuvant treatment, injection of BTX-A every 3 to 4 months becomes cost-effective. The social implications of her peristomal complications are also relevant to this case study. Peristomal hyperhidrosis significantly impaired Ms A’s quality of life and interfered with social interactions. She stated that she constantly worried about failure of her pouching system, and did not feel comfortable leaving her home owing to fear of pouch leakage or loss of the appliance. The improvement in pouch wear time and peristomal skin health experienced after BTX-A treatment allowed Ms A to increase her physical activity and spend more time away from home. Ms A further noted that she is happy with the results and will continue to return for the peristomal BTX-A injections. Other treatment options for hyperhidrosis exist, but they are often more invasive than BTX-A.1 For example, studies have evaluated surgical sympathectomy or surgical
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-13-00012_LR 485
26/08/14 7:40 PM
486
J WOCN
Kalkbrenner et al
excision of the sweat glands in treating hyperhidrosis with promising results, but additional surgeries are not always a viable option in a patient who already has a stoma.
■ Conclusion Based on findings from this case, we conclude that BTX-A is a viable noninvasive option for treatment of hyperhidrosis of the peristomal skin. Hyperhidrosis is a challenging issue for patients as well as the WOC nurse and surgical team caring for the patient. In the case of Ms A, hyperhidrosis reduced pouch wear time and led to moisture-associated dermatitis of the peristomal skin. We, therefore, evaluated treatment options for alleviating the underlying perspiration that was interfering with successful adaptation to life with an ostomy. Botulinum toxin A injections should be considered for patients with hyperhidrosis of the peristomal skin who fail to respond to more conservative modalities.
■ References 1. Walling HW, Swick BL. Treatment options for hyperhidrosis. Am J Clin Dermatol. 2011;12:285-295. 2. Bechara FG, Sand M, Achenbach RK, et al. Focal hyperhidrosis of the anal fold: successful treatment with botulinum toxin A. Dermatol Surg. 2007;33:924-927. 3. Steffen A, Rotter N, Konig IR, et al. Botulinum toxin for Frey’s syndrome: a closer look at different treatment responses. J Laryngol Otol. 2012;126:185-189. 4. Swartling C, Naver H, Lindberg M. Botulinum A toxin improves life quality in severe primary focal hyperhidrosis. Eur J Neurol. 2001;8:247-252.
■ September/October 2014
5. Yamashita N , Shimizu H , Kawada M , et al. Local injection of botulinum toxin A for palmar hyperhidrosis: usefulness and efficacy in relation to severity. J Dermatol. 2008 ; 35 :325-329. 6. Lakraj A, Moghimi N, Jabbari B. Hyperhidrosis: anatomy, pathophysiology and treatment with emphasis on the role of botulinum toxins. Toxins. 2013;5(4):821. 7. Meisner S, Lehur PA, Moran B, Martins L, Jemec GB. Peristomal skin complications are common, expensive, and difficult to manage: a population based cost modeling study. PLoS One. 2012;7(5):e37813. 8. Colwell J. Stomal and peristomal complications. In: Colwell J, Goldberg M, Carmel J, eds. Fecal & Urinary Diversions: Management Principles. St Louis, MO: Mosby; 2004:308-325. 9. Ratliff C, Donovan A. Frequency of peristomal complications. Ostomy/Wound Manage. 2001;47(8):26-29. 10. Park J, Del Pino A, Orsay C, et al. Stoma complications: The Cook County Hospital experience. Dis Colon Rectum. 1999;42:1575-1580. 11. Londono-Schimmer EE, Leong AP, Phillips RK. Life table analysis of stomal complications following colostomy. Dis Colon Rectum. 1994;37:916-920. 12. Ratliff CR, Scarano KA, Donovan AM, Colwell JC. Descriptive study of peristomal complications. J Wound Ostomy Continence Nurs. 2005;32(1):33-37. 13. Woo KY, Sibbald RG, Ayello EA, et al. Peristomal skin complications and management. Adv Skin Wound Care. 2009;22: 522-532. 14. 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;38:541-553; quiz 554-545. 15. Naumann M, Lowe NJ, Kumar CR, Hamm H. Botulinum toxin type A is a safe and effective treatment for axillary hyperhidrosis over 16 months a prospective study. Arch Dermatol. 2003;139(6):731-736.
Call for Authors: Challenges in Practice Our Challenges in Practice Section Editor invites case studies or multiple cases series that illustrate the importance of critical thinking or provide alternative or novel approaches to WOC management. This section is ideal for the novice author who has not published platform articles in JWOCN or other journals. Potential cases discussed on the WOC Web Forum that would translate into excellent Challenges in Practice articles include: • Perineal erythema in a frail elderly patient nonresponsive to urinary stream diversion with an indwelling catheter • Rationale for selecting a particular debriding technique based on wound type, care setting, and expertise within the facility • Case studies or case series focusing on initial experiences with novel mattresses, wound care dressings, wound care devices, or other topical wound care therapies • Case studies or case series focusing on unusual stomal or peristomal complications
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-13-00012_LR 486
26/08/14 7:40 PM
CHALLENGES IN PRACTICE
Intradermal Botulinum Toxin A for Peristomal Hyperhidrosis A Case Study Kristen Kalkbrenner Kyle Sanniec Lyndsey Bryant Heather McEntarffer Alanna Rebecca
Jacques Heppell
■ ABSTRACT
■ Case
BACKGROUND: Peristomal hyperhidrosis can interfere with pouch adherence, resulting in pouch leakage and peristomal skin damage. CASE: A patient with autonomic dysregulation resulting in excessive sweating (hyperhidrosis) experienced difficulty with adherence of her ileostomy appliance. Two hundred units of botulinum toxin A (BTX-A) were injected in the dermis of the surrounding skin in order to improve adherence of her pouching system and alleviate moisture of her peristomal skin. RESULTS: Following BTX-A injection, the typical wear time of her pouching system improved from less than 24 hours to 120 hours. Peristomal moisture-associated skin damage resolved almost completely. These effects lasted 3 months. A repeat intradermal BTX-A injection had a similar positive effect. CONCLUSION: Peristomal hyperhidrosis can be controlled with BTX-A intradermal injections, improving patient pouch adherence and alleviating moisture-associated skin damage. KEY WORDS: appliance, appliance adherence, botulinum toxin A, dermatitis, hyperhidrosis, ileostomy, moistureassociated skin damage peristomal dermatitis, peristomal hyperhidrosis.
Ms A is a 27-year-old white woman with a history of ulcerative colitis diagnosed at the age of 13 years. She underwent total colectomy with ileal pouch anal anastomosis and diverting loop ileostomy at the age of 16 years. Approximately 3 months later she underwent takedown of her ileostomy. Ms A did well postoperatively until 1 year later when she experienced a severe lower gastrointestinal bleed that required blood transfusion. Following this event, she had numerous episodes of pouchitis requiring long-term antibiotic therapy. Ms A consulted the Department of Colorectal Surgery and Department of Gastroenterology at Mayo Clinic for a second opinion concerning the possible salvage of her ileal pouch and treatment options for her chronic pouchitis. She reported consulting with multiple providers who recommended removal of her pouch, but she wanted to salvage her ileal pouch if possible to avoid living permanently with a stoma. Unfortunately, after multiple failed treatments, the decision was made to remove the ileal pouch and create an end ileostomy. Postoperatively, Ms A had multiple issues with her ileostomy pouching system including peristomal
■ Introduction Hyperhidrosis is a disorder of excessive sweating that may negatively affect the peristomal skin of ostomy patients. Multiple treatments have been suggested including topical therapy using aluminum chloride or glycopyrrolate, iontophoresis; systemic therapies such as glycopyrrolate or clonidine, and surgical treatments such as a sympathectomy.1 Another modality discussed in the literature is treatment with botulinum toxin A (BTX-A).1 Botulinum toxin A has been used to manage hyperhidrosis in the axillary area, anal fold, palmar surface of the hand, and face in persons with Frey syndrome.2-5 Efficacy for this treatment is high and the associated risk has been low.1
484 J WOCN ■ September/October 2014
Kristen Kalkbrenner, PA-C, Department of Surgery, Mayo Clinic Arizona, Phoenix. Kyle Sanniec, MHA, MA, Department of Surgery, Mayo Clinic Arizona, Phoenix. Lyndsey Bryant, PA-C, Department of Surgery, Mayo Clinic Arizona, Phoenix. Jacques Heppell, MD, Department of Surgery, Mayo Clinic Arizona, Phoenix. Heather McEntarffer, RN, WOCN, Department of Nursing, Mayo Clinic Arizona, Phoenix. Alanna Rebecca, MD, Department of Surgery, Mayo Clinic Arizona, Phoenix. The authors declare no conflict of interest. Correspondence: Kristen Kalkbrenner, PA-C, Department of Surgery, Mayo Clinic Arizona, 5777 East Mayo Blvd, Phoenix, AZ 85054 ([email protected]). DOI: 10.1097/WON.0000000000000061
Copyright © 2014 by the Wound, Ostomy and Continence Nurses Society™
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-13-00012_LR 484
26/08/14 7:40 PM
J WOCN
■ Volume 41/Number 5
moisture-associated skin damage, hyperhidrosis of the peristomal skin, and difficulty securing her appliance. Of greatest concern was severe skin irritation characterized by erythema and pruritus. Persistent peristomal skin irritation led to trials of numerous appliances in the hopes that one would prove less irritating. The stoma was evaluated several times and was found to be properly budded with a centered os, and it was determined that the leakage was caused by the hyperhidrosis. Ms A continued to work with WOC nurses near her home. She seemed to have the least peristomal skin irritation with one pouch (SenSura Coloplast, Holtendam, Denmark), in combination with a steroid cream. The steroid cream was used in conjunction with a crusting technique to enhance adherence of the wafer. Because she lived out of state, the WOC nurse used telephone triage to evaluate the effect of the pouching system and steroid cream on Ms A’s peristomal skin and pouch adherence. When Ms A was seen at our clinic, patch testing was performed with other commercial products, none of which caused a skin reaction. Along with the peristomal dermatitis, we observed peristomal hyperhidrosis that was causing her appliance to slip off, allowing a maximum wear time of no more than 1 to 2 days. Ms A would frequently reinforce the area with tape and/or completely repouch the stoma several times daily. Frequent pouch changes increased the severity of her peristomal dermatitis. The dermatitis was attributed to epithelial stripping and exposure of the peristomal skin to effluent from the stoma. Physical examination of the skin did not reveal any evidence of a candidal infection. Ms A was seen by an outside provider for the hyperhidrosis and was started on oral glycopyrrolate. Treatment improved her overall diaphoresis but did not significantly impact sweating of the peristomal skin. At this point Ms A was referred to the Department of Plastic and Reconstructive Surgery for their input on possibly injecting the peristomal skin with BTX-A to treat the hyperhidrosis. After obtaining informed consent, the peristomal skin was prepped and injected circumferentially with 200 units of BTX-A while temporarily obstructing the stoma output to avoid bacterial contamination during injection. Within several days of the injection, Ms A reported a significant decrease in peristomal perspiration allowing up to 5 days wear time before changing her pouching system. She also noted improvement in her peristomal dermatitis. She continued to use the same appliance during this time frame. Ms A noticed a gradual decline in wear time of her appliance between 3 and 4 months following her initial injection and returned for repeat injection of BTX-A. It was recommended that repeat injections be performed every 3 months for continued maintenance.
■ Discussion Botulinum toxin A inhibits perspiration by blocking the release of acetylcholine from the presynaptic membrane
Kalkbrenner et al
485
of nerves within the sweat glands.6 Clinical studies have demonstrated that BTX-A is safe and effective for hyperhidrosis of the axillary fold, anal fold, palms, and plantar surfaces of the feet,2-6,7 and we postulated that BTX-A would exert a similar effect on the peristomal skin. Results of our case study support the use of intradermal injection of BTX-A to minimize peristomal perspiration and facilitate ileostomy care. A literature review did not reveal any articles focusing on the use of BTX-A for peristomal hyperhidrosis. Peristomal complications have been discussed extensively in the literature; the most prevalent of these complications involve the peristomal skin.8-13 Peristomal skin complications are associated with multiple factors such as infections (Candida, tinea, or folliculitis), inflammatory issues (chemical, abnormal local pH, or skin stripping), and immunological conditions (allergic contact dermatitis, psoriasis, or Pyoderma gangrenosum).14,15 Peristomal moistureassociated dermatitis is attributed to excessive exposure to effluent from the ostomy (stool or urine) that can break down the appliance over time.15 Moisture-associated dermatitis can also be caused by exposure to other moisture sources such as perspiration. Most ostomy appliances are made with hydrocolloids that are designed to absorb moisture from the skin and stomal effluent. However, when challenged by excessive moisture, the absorptive qualities of the appliance are overwhelmed, resulting in a breakdown of the seal between faceplate and skin. This in turn creates an overly moist environment of the peristomal skin leading to dermatitis.15 Pectin-based stomal powders with skin sealants, deodorant, and/or changes in the ostomy appliance are some of the options that are available when dealing with this issue. It is also important to consider the financial impact of peristomal moisture-associated dermatitis exerts on the patient. Changing the pouching system daily or multiple times per day may result in a significant financial burden. When combining the costs of multiple appliances each day as well as pharmaceutical adjuvant treatment, injection of BTX-A every 3 to 4 months becomes cost-effective. The social implications of her peristomal complications are also relevant to this case study. Peristomal hyperhidrosis significantly impaired Ms A’s quality of life and interfered with social interactions. She stated that she constantly worried about failure of her pouching system, and did not feel comfortable leaving her home owing to fear of pouch leakage or loss of the appliance. The improvement in pouch wear time and peristomal skin health experienced after BTX-A treatment allowed Ms A to increase her physical activity and spend more time away from home. Ms A further noted that she is happy with the results and will continue to return for the peristomal BTX-A injections. Other treatment options for hyperhidrosis exist, but they are often more invasive than BTX-A.1 For example, studies have evaluated surgical sympathectomy or surgical
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-13-00012_LR 485
26/08/14 7:40 PM
486
J WOCN
Kalkbrenner et al
excision of the sweat glands in treating hyperhidrosis with promising results, but additional surgeries are not always a viable option in a patient who already has a stoma.
■ Conclusion Based on findings from this case, we conclude that BTX-A is a viable noninvasive option for treatment of hyperhidrosis of the peristomal skin. Hyperhidrosis is a challenging issue for patients as well as the WOC nurse and surgical team caring for the patient. In the case of Ms A, hyperhidrosis reduced pouch wear time and led to moisture-associated dermatitis of the peristomal skin. We, therefore, evaluated treatment options for alleviating the underlying perspiration that was interfering with successful adaptation to life with an ostomy. Botulinum toxin A injections should be considered for patients with hyperhidrosis of the peristomal skin who fail to respond to more conservative modalities.
■ References 1. Walling HW, Swick BL. Treatment options for hyperhidrosis. Am J Clin Dermatol. 2011;12:285-295. 2. Bechara FG, Sand M, Achenbach RK, et al. Focal hyperhidrosis of the anal fold: successful treatment with botulinum toxin A. Dermatol Surg. 2007;33:924-927. 3. Steffen A, Rotter N, Konig IR, et al. Botulinum toxin for Frey’s syndrome: a closer look at different treatment responses. J Laryngol Otol. 2012;126:185-189. 4. Swartling C, Naver H, Lindberg M. Botulinum A toxin improves life quality in severe primary focal hyperhidrosis. Eur J Neurol. 2001;8:247-252.
■ September/October 2014
5. Yamashita N , Shimizu H , Kawada M , et al. Local injection of botulinum toxin A for palmar hyperhidrosis: usefulness and efficacy in relation to severity. J Dermatol. 2008 ; 35 :325-329. 6. Lakraj A, Moghimi N, Jabbari B. Hyperhidrosis: anatomy, pathophysiology and treatment with emphasis on the role of botulinum toxins. Toxins. 2013;5(4):821. 7. Meisner S, Lehur PA, Moran B, Martins L, Jemec GB. Peristomal skin complications are common, expensive, and difficult to manage: a population based cost modeling study. PLoS One. 2012;7(5):e37813. 8. Colwell J. Stomal and peristomal complications. In: Colwell J, Goldberg M, Carmel J, eds. Fecal & Urinary Diversions: Management Principles. St Louis, MO: Mosby; 2004:308-325. 9. Ratliff C, Donovan A. Frequency of peristomal complications. Ostomy/Wound Manage. 2001;47(8):26-29. 10. Park J, Del Pino A, Orsay C, et al. Stoma complications: The Cook County Hospital experience. Dis Colon Rectum. 1999;42:1575-1580. 11. Londono-Schimmer EE, Leong AP, Phillips RK. Life table analysis of stomal complications following colostomy. Dis Colon Rectum. 1994;37:916-920. 12. Ratliff CR, Scarano KA, Donovan AM, Colwell JC. Descriptive study of peristomal complications. J Wound Ostomy Continence Nurs. 2005;32(1):33-37. 13. Woo KY, Sibbald RG, Ayello EA, et al. Peristomal skin complications and management. Adv Skin Wound Care. 2009;22: 522-532. 14. 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;38:541-553; quiz 554-545. 15. Naumann M, Lowe NJ, Kumar CR, Hamm H. Botulinum toxin type A is a safe and effective treatment for axillary hyperhidrosis over 16 months a prospective study. Arch Dermatol. 2003;139(6):731-736.
Call for Authors: Challenges in Practice Our Challenges in Practice Section Editor invites case studies or multiple cases series that illustrate the importance of critical thinking or provide alternative or novel approaches to WOC management. This section is ideal for the novice author who has not published platform articles in JWOCN or other journals. Potential cases discussed on the WOC Web Forum that would translate into excellent Challenges in Practice articles include: • Perineal erythema in a frail elderly patient nonresponsive to urinary stream diversion with an indwelling catheter • Rationale for selecting a particular debriding technique based on wound type, care setting, and expertise within the facility • Case studies or case series focusing on initial experiences with novel mattresses, wound care dressings, wound care devices, or other topical wound care therapies • Case studies or case series focusing on unusual stomal or peristomal complications
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-13-00012_LR 486
26/08/14 7:40 PM
