Pyoderma gangrenosum

Product Points

During a routine physician visit, Mrs T, 67, reports trouble with her colostomy pouch, which slides off and will not adhere to her peristomal skin. She also complains of pain around the stoma. Mrs T is being cared for at home by her husband.

An Unusual Wound

Mrs T's right-sided colostomy was created 3 years ago because of complications from ulcerative colitis. About 18 months ago, a wound started to develop around the stoma and gradually increased in diameter. At first, Mrs T was able to get the pouch to adhere with various pastes and powders. But lately, the pouch has started leaking the day after it is applied.

The 2-piece, drainable pouching system is removed, revealing a bright red stoma; the mucocutaneous junction is intact (Figure 1). However, the peristomal skin is severely compromised, with a well-defined, circular, full-thickness wound. The borders of the wound are irregular and the wound bed is 90% red and 10% yellow. No satellite lesions can be seen on the periwound skin, which would indicate a fungal infection.

This well-defined wound around the stoma is unusual, but Mrs T has a history of ulcerative colitis. Because of this, peristomal pyoderma gangrenosum (PPG) is suspected. PPG is an unusual deviation of pyoderma gangrenosum that occurs almost exclusively in patients with inflammatory bowel disease. Pyoderma gangrenosum is an autoimmune disease characterized by painful ulcers that may communicate with the bowel. Because it can also occur on the abdomen, buttocks, face, and legs, careful assessment of all other lesions is essential. Once active lesions are present, superficial trauma may trigger new lesions. This wound is diagnosed by exclusion: A skin biopsy, for example, cannot diagnose pyoderma gangrenosum, but it can rule out other problems.

First Steps

Managing the peristomal wound and the pouching system can be a challenge when a patient has PPG. Systemic steroid therapy is commonly the first line of defense. Mrs T is given systemic steroids and stoma relocation is discussed. However, because new lesions often develop at the new stoma site, the clinicians and family decide against stoma relocation.

Manage the pouching system as shown in Figures 2 through 5. Give the family complete directions and extra supplies and teach them how to use the new pouching system. Also teach Mrs T to report any signs of PPG promptly if they recur.

Cathy Thomas Hess, BSN, RN, CWOCN

Cathy Thomas Hess, BSN, RN, CWC)CN, is President, Wound Care Strategies, Inc, Harrisburg, PA. She is the Clinical Consultant for Advances in Skin & Wound Care and the author of Clinical Guide: Wound Care, 3rd edition, published by Springhouse. This article is adapted from Hess CF. Per stoma[ pyoderma gangrenosum. Nursing2001 2001;31(7)68.

Copyright Springhouse Corporation Nov/Dec 2001
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