The patient is a 44 year old man with parastomal ulceration over the last 12 months.
He had a stable stoma for 12 years, following colostomy to remove rectal tumour (carcinoid) and is healthy otherwise with no bowel problems and no skin disease elsewhere.
Last year he received IV antibiotics for peristomal cellulitis, with complete recovery. A month or so later the peristomal skin began ulcerating. Partial healing is followed by skin lifting off at bag changes alternate days, leaving painful ulceration. Meticulous hygiene resulted in no improvement with different devices or topical steroid for one month, applied as beclomethasone nasal spray. Now trying clobetasol solution on appliance, allowed to dry before fitting to skin. He is on no medications.
Swab: group G streptococcus on two swabs - no deep fungi or mycobacteria.
Blood screen: all normal - no sign carcinoid or other disease
Clinical Photos (July '09 (top) and February '09 bottom):
Histology: paucicellular; subepidermal clefting. Not diagnostic.
Dr. Oakley's Comments: Most stomal rashes are dealt with by stoma nurses and a dermatologist's opinion is rarely sought; so we don't see many of them. I see irritant dermatitis from time to time and it responds to topical steroids. He has no risk factors for pyoderma gangrenosum, and the histology is not typical of that.
Questions: Could group G streptococcus do this? There is no cellulitis or abscess formation and I have prescribed antibiotics without improvement.
Any suggestions re: diagnosis and treatment will be gratefully received! I am hoping some dermatologists have greater exposure to stomal disease and I can benefit from their experience.
Reference:
Yeo H, Abir F, Longo WE. Management of parastomal ulcers.
World J Gastroenterol. 2006 28;12(20):3133-7.
Management of surgically placed ostomies is an important aspect of any general surgical or colon and rectal surgery practice. Complications with surgically placed ostomies are common and their causes are multifactorial. Parastomal ulceration, although rare, is a particularly difficult management problem. We conducted a literature search using MD Consult, Science Direct, OVID, Medline, and Cochrane Databases to review the causes and management options of parastomal ulceration. Both the etiology and treatments are varied. Different physicians and ostomy specialists have used a large array of methods to manage parastomal ulcers; these including local wound care; steroid creams; systemic steroids; and, when conservative measures fail, surgery. Most patients with parastomal ulcers who do not have associated IBD or peristomal pyoderma gangrenosum (PPG) often respond quickly to local wound care and conservative management. Patients with PPG, IBD, or other systemic causes of their ulceration need both systemic and local care and are more likely to need long term treatment and possibly surgical revision of the ostomy. The treatment is complicated, but improved with the help of ostomy specialists. Note: This reference is available as free full text from the publisher.
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