BJON 2014-23-22 Using Silicone Technology Stoma Care 1.12.14

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1/516 Brit ish Journal of Nursing, 2014, Vol 23, No 22

Using silicone technology tomaintain healthy skin in stoma care

T he Association of Stoma Care Nurses (ASCN, 2013)

stipulates that choosing an appropriate appliance to suit

the patient’s needs is a standard of care expected from

the stoma care nurse (SCN). Protecting peristomal

skin, preventing skin stripping, and treating areas of soreness

are all scenarios in which the SCN has to make a formal

assessment and judgement regarding a product choice. It seemslogical, therefore, that an extensive knowledge of the range

and availability of products is required, but understanding the

rationale for choosing a product for its technical qualities and

potential is vital. Some of this knowledge comes from practical

experience and anecdotal evidence, but understanding the

science behind the end product is also helpful.

As discussed in a previous article (White, 2014), silicone is

a generic term relating to materials that contain the element

silicon, along with carbon, hydrogen and oxygen. Silicon

is the second most abundant element in our planet’s crust.

Oxygen (47.3%) and silicon (27.7%) together make up 75%

of the weight of Earth’s crust. Most of the crust’s silicon exists

as silicon dioxide; we are familiar with this as sand or quartz

(Chemicool, 2014).

Maddie White

Silicon exists in its unrefined state—in sand, for example—

but when refined, it is used in products in industry, electronics,

building, kitchen appliances and personal materials. Examples

include kitchen utensils, silicone chips in computers, and in

the cosmetic industry such as in breast implants.

SkinIt is essential to understand the anatomy and physiology of

skin. Skin is the largest organ of the body and provides a

waterproof, protective layer as well as being a thermoregulatorIt comprises several layers—the dermis, the epidermis and

the hypodermis—which differ in thickness, structure and

function (Stephen-Haynes, 2014).

Skin has several functions, which include absorption,

excretion, protection and immunity as well as permitting the

sensations of touch, heat and cold and the synthesis of vitamin

D (Denyer, 2011). Its protection is paramount to prevent

infection and systemic illnesses.

Skin types vary from one individual to another and can

be oily, normal, sensitive or fragile or dry (Thompson et al,

2011), which implies the need for assessment before choosing

a suitable appliance.

For stoma patients, the skin surrounding the stoma is

vulnerable to faecal material or urine, both of which canbe harmful and cause breakdown of skin very easily. The

resulting physical and psychological distress can have a huge

impact upon a patient’s quality of life (Nichols and Riemer

2011). Care of the peristomal skin area is therefore essential to

maintain its integrity and prevent problems with adherence

of products, as well as maintaining the patient’s comfort.

Peristomal skin integrityThe skin around the stoma should be clean, intact and dry

and not differ in any way to the remainder of the abdominal

skin (Stephen-Haynes, 2014). Assessment of the peristomal

skin should be undertaken to assess this as well as the effects

of the adhesive and the potential effects of the effluent on the

skin. Tools do exist to assist the nurse in assessing skin integr ity

and can be useful for newly qualified health professionals who

do not have the experience to assess independently. The

Ostomy Skin Tool (Martins et al, 2008), for example, provides

the clinician with a formula to measure the discolouration,

excoriation and tissue overgrowth of peristomal skin and use

a scoring system to evaluate progress. Peristomal excoriation

can, understandably, be a huge challenge to patients and

nurses alike (Lowther and Osborne, 2013).

Excoriation of the skin is the destruction and removal of

the surface of the skin and is common in ileostomates and

Maddie White, Colorectal Nursing Team Leader, University Hospital

Birmingham NHS Foundation Trust

Case studies 1 and 2 were undertaken by Claire Gough, Clinical Nurse

Specialist, Stoma Care, St George’s Healthcare

The patient perspective was provided by Anne Howie

Accepted for publication: November 2014

AbstractThe use of silicone in stoma care has grown in recent years and

may be considered the next step in the revolutionary development

of stoma care products. Clinical nurse specialists aim to provide

evidence-based care at all times, and the same is true for stoma

care nurses. Preventing harm by choosing products which have a

sound research base provides the patients with up-to-date, quality

care which enables them to adapt to life with a stoma and return to‘normal’ functioning. This article explores the issue of peristomal skin

problems and the development of silicone products, and highlights

scenarios where it could be an advantage to choose a silicone product.

Key words: Silicones ■ Quality of life ■ Surgical stomas ■ Adhesives


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urostomates because of the nature of the effluent produced

(Burch, 2008). Ileostomy effluent contains digestive enzymes

which can cause skin breakdown (Richards, 2005). Urine can

dissolve or erode the stomal skin barrier and macerate the

epidermis (Rolstad et al, 2012).

It is important to document findings and include details

such as the size of the excoriated area, the depth of excoriation

and the extent to which this affects adhesion of the appliance.Assessment using a recognised skin tool gives the nurse the

opportunity to record the exact details of the excoriation

and use as a comparison each time the appliance is changed

in order to measure progress. Photographic evidence can also

be used in order to record episodes of skin damage. Local

trust guidelines will determine how these measurements

are recorded, such as on a care plan or wound management

document. Other factors to consider are the size and type of

stoma, its position, whether spouted or not and the patient’s

management of the stoma. Poor-fitting appliances can, for

example, lead to leakage, which in turn leads to excoriation.

Frequent appliance changes can also cause the peristomal

skin to become broken and sore with psychological factorsaffecting the patient’s perception of ‘normal management’. In

a study by Nichols and Riemer (2011), it was demonstrated

that a negative body image occurs more frequently when the

ostomy patient has non-normal peristomal skin.

‘Skin stripping’ is mentioned frequently throughout the

literature and refers to skin damage caused when appliances

are removed, frequently resulting in damage to the peristomal

skin. Removing the skin barrier will pull off a layer of cells

each time (Thompson et al, 2011) so the choice of appliance

is of paramount importance.

Some patients will have existing skin problems such as

psoriasis or eczema which need to be taken into consideration

when selecting appropriate management systems and adhesives.

Treatment for the skin condition may affect the range ofchoice of appliances being considered. Oil-based creams will

undermine adhesion of the pouch and a multidisciplinary

approach may be needed with input from dermatology and

the SCN, particularly for severe problems such as pyoderma

granulosum Pyoderma is a rare inflammatory skin disorder

which can be associated with inflammatory bowel disease.

Peristomal skin appears to be uniquely predisposed, it begins as

an extremely painful nodule which rapidly ulcerates appearing

bluish in colour and ragged (Williams and Lyon, 2010).

Any infection, such as fungal or bacterial infections, should

be adequately treated. These are more frequent in patients who

are immunocompromised such as transplant patients or those

undergoing chemotherapy or radiotherapy (Rudoni, 2011).

Causes of peristomal skin damageLeakageThe most common cause of peristomal skin damage is

leakage (Herlufsen et al, 2006). Leakage from an appliance will

inevitably cause a breakdown of the peristomal skin, owing

to the corrosive nature of the effluent, particularly if this is

a repeated occurrence. The aim is to correct the underlying

cause for the leak and not just treat the sore skin. Figure 1 gives

some suggestions for frequent causes of leakage leading to sore

peristomal skin.

Problem Evidence Solution

Poor-

fitting

appliance

or flush

stoma

Exposed sore skin or trauma to stoma

from ill-fitting appliance

■ Re-measure and ensure

correct hole to fit stoma

■ Protective barrier wipe

■ Add seal under

appliance for added

protection

Stomal

retraction

or ‘moat’

around

stoma

Sore skin from contact with effluent ■ Consider and assess for

convexity to fill moat or

allow spout to protrude

■ Convex seal underneath

existing appliance

Skin

creases

Assess depth of crease with patient

sitting; does effluent leak along channelcreated?

■ Fill crease with filler,

paste or seal to improvepouch adherence

■ Soft or firm convex

pouch with or without

belt

Pancaking Faeces ‘sit’ on stoma and cause sore skin

and leaks

■ Advise re-measures to

prevent pancaking such

as Vaseline/oil in bag,

filter cover etc

Altered

stool i.e.

diarrhoea

Liquid/watery stool on base of flange ■ Treat diarrhoea and

return function to norma

i.e. stool thickeners

■ Add solidifying agent to

the inside of pouch

Hernia Reduced area of adhesive after cutting

flange

■ Alternative appliance

with flexible, large area

of adhesive. Re-measure

the expanding stoma

■ Consider support belt

Figure 1. Table identifying causes of leakage



Dermatitis and allergyPeristomal skin provides an ideal situation for developing

either allergy or irritation (Williams and Lyon, 2010).

Irritation is caused by removing appliances frequently andthis, coupled with exposure to effluent and a warm, moist

environment, fuels the risk of sensitisation. Protection of the

skin becomes paramount; therefore removing the irritant

or an adjustment to stoma management should correct

the problem. If, however, the problem persists, referral to a

dermatologist may become necessary to rule out allergic

causes, although, in the author’s exper ience, true allergies are

rare.

Silicone in stoma productsSo why is silicone used in stoma care? Voegeli (2008) states

that silicone is ideal for use in skin care products because it

is non-toxic, able to repel water and chemical attack and is

non-alcohol based and therefore non-irritant. These propertiesmake it particularly suitable for use in peristomal skin care.

Black (2007) advocates routine use of silicone in the form of

an adhesive remover as it penetrates the adhesive skin bond

by spreading effectively and rapidly on the peristomal-skin

surface. This aids removal of the adhesive flange as opposed

to skin stripping occurring if a silicone-based remover is not

used. Skin stripping alters the barrier property of the skin and

exposes deeper skin cells susceptible to attack from effluent and

bacteria. This may be more evident in patients who are elderly,

as their skin can be thin and friable (Burch, 2014). Once the

barrier function is compromised, desquamation occurs owing

to an increased transdermal water loss (Rudoni, 2011).

Other silicone stoma accessory products such as barrier

wipes, seals and flange extenders have been developed to

help patients better manage their stomal complications and

skin care (Rudoni, 2011) but these are not necessarily used

routinely. Stomas are not always in an ideal position or have

a perfect spout and it may be necessary to use an accessory

to achieve a good seal and prevent leakage, which in turn

leads to peristomal skin damage. Cottam (2005) describes her

audit findings in which it was revealed that 34% of patients

developed an early post-operative complication resulting in a

problematic stoma. A follow-up to this study in 2011 revealed

little had changed (Cottam and Richards, 2011).

Many studies have been undertaken to show the increased

benefit of silicone products (Cutting, 2006; Rudoni, 2011).

There is certainly more emphasis and awareness now

around the increasing costs to the NHS of stoma products

and accessories (Martins et al, 2012) and a cost-effective

solution such as a silicone product will help to promote

an economically effective approach to care. This is evident

from using silicone remover sprays because they prevent skinstripping, thereby reducing the need for further product use.

Other silicone products need to be formally assessed for cost

effectiveness as their use increases. Factors such as increased

wear time compared to other products such as hydrocolloids

which breakdown more readily are appealing to GPs who

may question the use of an accessory product when added

to a prescription. For example, it would appear that in some

situations these silicone-based products have an advantage over

more conventional products, by offering greater protection

against repeated moisture exposure, thereby prolonging wear

time (Voegeli, 2013). The SCN should be able to explain the

rationale of choice of product to justify its use.

The advantages of silicone productsSilicone products offer an alternative to other accessories.

They can be beneficial because they:

■ Are hydrophobic as opposed to hydrophilic traditional

hydrocolloid products—silicone does not absorb faeces or

urine, therefore it does not break down (Voegeli, 2008)

■ Allow the skin to breathe (Gabe and Slater, 2013)

■ Reduce the risk of leakage—silicone can extend the

wear time of the stoma appliance because of an improved

adherence and less breakdown from effluent (Voegeli, 2008)

■ Are easily removable and leave no residue on the skin

(Cutting, 2006).

■ Allow for atraumatic removal—there is less skin irritation

and therefore this provides more comfortable stoma care(Grove et al, 1993, cited in Rudoni, 2011)

■ Non-sting compared to alcohol-based ingredients (Grove

et al, 1993, cited in Rudoni, 2011).

Trio Siltac® and Silvex® Silicone Ostomy SealsThese silicone rings conform to the shape of the stoma,

forming a secure seal around the base. Usually pre-cut or cut-

to-fit skin barriers are measured 2-3 mm (minimum) larger

than the stoma to allow peristalsis. As a result, there is always

skin that is exposed, which is prone to irritation. With both

of these seals, the exposed skin is protected by the silicone.

Additional benefits are that they remove clean and in one

piece, they reduce wastage due to the nature of the silicone,

which returns to its natural size and shape. They do not

absorb effluent and therefore do not break down. Ostomates

find them easy to handle and they are quite ‘forgiving’, which

gives the ostomates more control.

Silvex can also be a support for a convex flange as well as a

flat; it can fill difficult contours on the skin around the stoma

while protecting from the convexity itself. This seal can be

used both ways making it versatile.

The sizes are generous and often it is worth trying the

smaller seal for a firmer fit. Both seals can be used alone or in

conjunction with Silken® stoma gel.

Figure 2. Excoriation from allergy to stoma product


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Silken® Silicone Stoma GelSilken silicone stoma gel can be used to fill difficult contours,

creases and channels that allow liquid to escape. The gel

can be applied directly from the tube to the area and an

appliance added without the need to spread it. The catalyst

for silicone to cure is moisture or humidity. This process is

known as ‘room temperature vulcanisation’ (RTV). When

occluded, the gel will cure over a longer period, if at all. Asa result, it will not harden in the tube but will start to skin

over within 20 minutes on the body under a flange.

Silex® Silicone Flange Extender This ultra-thin flange extender enables longer wear times for

ostomates. It is flexible and removes easily without stripping

the skin and without the need for adhesive removers. It is

especially beneficial for abdomens with challenging contours

such as hernias.

Trio has developed a new customer silicone formulation

designed to specifically overcome problems associated with

hydrocolloids. This is specific to these products and makes

them breathable and avoids maceration of the skin byallowing good rates of moisture vapour transfer (MVTR). A

commonly asked question is whether they will stick to wet

skin? Skin should be prepared as per usual practice then the

seal or gel can be applied as normal.

As SCNs, it is a benefit when ostomates can be kept on

the stoma management system they are accustomed to by

providing them with a solution that is compatible with all

current systems available. This can avoid adoption of a new

system and minimise anxiety for the ostomates, and reduce

clinic time too.

Case studies

The following case studies and patient perspective (Box 1)describe incidents where silicone products have been used

successfully.

Patient 1 (VB)VB was born in 2011 at 24+4 weeks gestation, weighing just

675 grams. He developed neonatal necrotising enterocolitis

and had formation of an end ileostomy and mucous fistula.

He underwent closure of his stoma, but subsequently

developed an enterocutaneous fistula. Repair of the fistula

was unsuccessful and he developed multiple enterocutaneous

fistulae with repeated failed attempts at repairing the fistulae.

He was left with a well-established gastrocutaneous fistula

which produced copious amounts of acidic gastric fluids.

VB had complex needs and multiple comorbidites. It was no

longer possible to apply a stoma bag over the fistula owing to

a severe abdominal defect, excoriated skin and the restriction

of movement that resulted from the presence of a stoma

bag and the application of multiple accessories. In addition,

the bag had a tendency to lift off when VB was in a sitting

position, but he was happiest when sitting and interacting

with others. It was necessary to find a solution which allowed

management of the corrosive output and enabled VB to

develop and reach the milestones for his age and socialise

with others.

VB received enteral nutrition via a gastroduodenal feeding

tube and long-term parenteral nutrition via a Hickmann line.

Unfortunately, both tubes had been sited very close to thegastrocutaneous fistula and there was a risk of contamination

and infection developing at both tube sites. It was not possible

to apply a stoma bag, so Trio Silken silicone stoma gel was

applied in the creases around the fistula to even out VB’s skin

contours and to create a barrier to prevent contamination

of the tube sites. Skin protection products were applied

to the surrounding skin and absorbent gauze was applied

with bandages to secure the gauze. The combination of

skin protection, Trio Silken silicone stoma gel applied in the

creases and absorbent gauze provided a satisfactory fistula

management system. VB’S mother was delighted with the

Trio Silken silicone stoma gel and described it as being ‘very

good, easy to apply, easy to remove and it stops the spread of

the fistula output’.

Patient 2 (PN)PN has Crohn’s disease and had an emergency defunctioning

loop ileostomy and small bowel resection for a perforation.

He was initially managing his stoma care without any

problems, but he had recently lost a large amount of weight

owing to ongoing problems with his Crohn’s disease and a

high-stoma output, despite employing strategies to reduce

the output, including high doses of Loperamide. His stoma

is situated in several deep creases, which had become more

prominent and problematic since his increased weight loss.

PN enjoys an active lifestyle, so needed an appliance that was

secure. Unfortunately, because of the prominent creases and

skin folds, PN’s stoma was completely obscured. In addition, a

high stoma output was causing distressing leaks and increasing

peristomal excoriation. PN had tried a variety of bags and

accessories to try to overcome the frequent leaks, but we were

running out of solutions as his weight loss continued and his

output increased. We offered PN Trio silken silicone stoma gel

to try, as hydrocolloid paste had been unsuccessful in filling

the multiple creases around his stoma and we wondered if an

alternative product would improve the situation. After a trial

period, PN contacted us to say he was delighted with the

outcome. He was pleased to report that the wear time for his

Figure 3. Products available from Trio using advanced silicone technology



stoma bags had increased to 48 hours and his peristomal skin

was improving. He found the gel ‘easy to apply, like a cream,

it doesn’t stick all over the fingers, easy to remove—just have

to peel it off.’

ConclusionThe literature, case studies and patient perspective suggest

that silicone products are of benefit to patients. Therefore,

SCNs should have an increased awareness of the properties

within silicone to understand the advantages of silicone

products in order to make an appropriate appliance or

accessory choice. Making the correct choice for and with

the patient affects the patient’s physical and emotional well-

being, as well as having an economic benefit. It is the SCN’s

responsibility to give evidencd-based advice in order to

ensure that quality care is delivered within an appropriate,

individualised care plan. BJN

Conflict of interest:

Association of Stoma Care Nurses (2013) Stoma Care Nursing Standards and Audit Tool . http://tinyurl.com/nrohu49 (accessed 25 November 2014)

Black P (2007) Peristomal skin care: an overview of available products.Br J Nurs16(17): 1048–54 passim. doi: 10.12968/bjon.2007.16.17.27249

Burch J (2008) Stoma Care .Wiley-Blackwell, Chichester Burch J (2014) Looking after the stoma and the surrounding skin. Nursing and

Residential Care 16(4): 190-5Chemicool (2014) Silicon Element Facts. http://www.chemicool.com/

elements/silicon.html (accessed 27 November 2014)Cottam J (2005) Audit of Stoma complications within 3 weeks of surgery.

Gastrointestinal Nursing 3(1): 19-23Cottam J, Richard K (2011) Closing the audit loop—stoma complications

within 3 weeks of surgery. Gastrointestinal Nursing 9(9): 18-22Cutting K (2006) Silicone and skin adhesive Journal of Community Nursing

20(1): 36-7Denyer J (2011) Reducing pain during the removal of adhesive and adherent

products. Br J Nurs 20(15): S28–35Gabe S, Slater R (2013) Managing high-output stomas: module 1 of 3. Br J

Nurs 22(5): S26–30Herlufsen P, Olsen AG, Carlsen B, Nybaek H, Karlsmark T, Laursen TN et al

(2006) Study of peristomal skin disorders in patients with permanent stomasBr J Nurs 15(16): 854–62

Lowther C, Osborne W (2013) Peristomal Skin Assessment. GastrointestinalNursing 11(7):11-2

Martins L, Tavernelli K, Serrano JLC (2008) Introducing a Peristomal SkinAssessment Tool: The Ostomy Skin Tool. World Council Enterostomal Therapy

J 28(2Suppl): S3-13Martins L, Tavernelli K, Sansom W, Dahl K, Claessens I, Porrett T et al (2012)

Strategies to reduce treatment costs of peristomal skin complications. Br JNurs 21(22): 1312–5

Nichols TR, Riemer M (2011) Body image perception, the stoma peristomal

skin perception. Gastrointestinal Nursing 9(1): 22-6Richards A (2005) Intestinal physiology and its implications for patients with

bowel stomas. In: Breckman B (ed) Stoma Care and Rehabilitation. Elsevier,London: 17–26

Rolstad BS, Ermer-Seltun J, Bryant RA (2012) Relating knowledge of anatomyand physiology of the skin to peristomal skin care.World Council EnterostomalTherapy J 32(1): 4-10

Rudoni C (2011) Peristomal skin irritation and the use of a silicone-based barrier film. Br J Nurs 20(16): S12–16 passim. doi: 10.12968/bjon.2011.20.16.S12

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10.12968/bjon.2014.23.Sup17.S14Williams JD, Lyon C (2010), Dermatitis: contact irritation and contact allergy.In: Lyon CC, Smith A (eds) Abdominal Stomas and Their Skin Disorders (2 edn).Informa Healthcare, London

KEY POINTS

n Peristomal skin is vulnerable to excoriation and must be protected

n Silicone technology has led to the development of new products for use in

stoma care

n Silicone is flexible, easily applied and does not leave a residue on peristomal

skin

n Silicone products provide an alternative for the stoma care nurse

n The cost-effectiveness of silicone accessories needs to be formally evaluated

Box 1. Patient perspective

My name is Anne Howie and on 2 July 2014 I had my bladder removed owing to a

vaginal melanoma and because of this had a urostomy. As a result of complications

I also had a colostomy so I have two stomas to deal with, but it is my urostomy that

I have had most difficulties with.

Like most people who have stomas I had a few problems at first until I got

a bag that suited my urostomy. I was quite happy until my wound healed andcaused a dip in my skin right up to the stoma. This caused me lots of leaks and,

because of the leaks and the fact I needed to change clothes and bag so regularly,

I didn’t want to go out. My stoma nurse was great, visiting me regularly and

giving me things to try as a solution. I tried paste, rings and lots of different bags

without a solution. I was having to change clothes and bag up to six times a day,

which was not only inconvenient but made me down and depressed and not

wanting to go out or see people.

Then on my stoma nurse’s next visit she brought a sample of a new product

she had seen at a conference; it was Silken silicone stoma gel. She had seen the

demonstration and thought of me straight away. It’s not like any other product as

urine does not affect it so it stays where it needs to be. Suddenly my bag was back

to lasting 24–48 hours, I didn’t need to change clothes as often and was able to go

out without fear of it leaking. There is nothing worse than the constant worry of a

leak or the sudden feeling you are wet while away from home.

Silken silicone stoma gel has changed my life. I no longer worry each time I goout. I no longer have mountains of washing and have to change my clothes several

times each day. It has given me my freedom back and helped me to feel more like

myself again.

BJON 2014-23-22 Using Silicone Technology Stoma Care 1.12.14

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