Care and management of a stoma:
maintaining peristomal skin health
Anna Boyles and Sharon Hunt
ABSTRACT
It is estimated that around one in 500 people in the UK are living with
a stoma, with approximately 21 000 operations that result in stoma
formation being performed each year (Colostomy Association, 2016). These
people face a unique set of challenges in maintaining the integrity of their
peristomal skin. This article explores the normal structure and function of
skin and how the care and management of a stoma presents challenges for
maintaining peristomal skin health. Particular focus is paid to the incidence
of skin problems for those living with a stoma, whether it is temporary
or permanent, and the factors that contribute to skin breakdown in this
population. Wider factors such as the central role of the clinical nurse
specialist and the impact of product usage on positive outcomes and health
economics are also considered.
Key words: Anatomy and physiology  ■ Skin  ■ Stoma care  The skin contains an acid mantle, an invisible covering with
■ MARSI  ■ Skin breakdown  ■ Quality of life  ■ Outcomes
T
he skin is often referred to as the largest organ
of the body and performs a number of functions
vital to the maintenance of homeostasis (Tortora
and Derrickson, 2009). The formation of a stoma
and management of its output with appliances and
accessories can prove to be a challenge to this equilibrium
for a variety of reasons. The Colostomy Association (2016)
estimates that there are currently 120 000 people living with
a stoma in the UK, with around 21 000 operations performed
annually for a wide range of bowel and urinary diseases and
disorders, meaning around 1 in 500 people face this challenge
on a daily basis.
This article explores the normal structure and functions
of the skin, the factors that can influence the preservation of
good skin health, the perspective that stoma care has on the
importance of maintaining good skin integrity and the burden
that the care and management of a stoma place on patients
and those who care for them.
Anna Boyles, Nurse Specialist, Stoma Care, King’s College
Hospital NHS Foundation Trust
Sharon Hunt, Lead Advanced Nurse Practitioner, Wellway Medical
Group, Independent Specialist Wound Care
Accepted for publication: August 2016
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Anatomy and physiology of the skin
The skin is the largest organ in the human body, accounting
for up to approximately 16% of the total body weight of an
average adult, weighing twice as much as the brain (Tortora
and Derrickson, 2009). On average, skin is 1-2 mm in depth,
although it can vary in its thickness depending on its individual
functions and particular area of the body; the eyelids are only
0.5 mm in depth, whereas the plantar region of the foot can
be up to 4 mm (Brooker, 1998). According to Turkington
and Dover (2007), the skin is compiled of thick outer layers,
a complex system of sweat glands sensitive to temperature
alteration and a strong layer of fatty tissue and sensitive cells,
which alert the body to pain, pressure, touch, irritation, heat
and cold triggers, all residing just beneath the skin surface.
a pH range of 4 to 5.5. This provides the closed skin surface
with a protective barrier from outside influences, damage and
injury, particularly excessive moisture, bacteria and frictional
surfaces. The acid mantle aids the skin in the prevention of
excessive fluid and electrolyte loss to maintain homeostasis
(Tortora and Derrickson, 2009). When the acid mantle is
‘interrupted’ through either an increase of acidity or alkalinity,
the skin is vulnerable to epidermal stripping, infection and
wound development (Bateman and Roberts, 2013).
Skin types vary from individual to individual and can be
segregated generally into four types: dry, oily, normal and
sensitive, which can affect how the skin responds to both internal
and external stimuli, nutrients and moisture levels (White, 2014).
Stratum corneum
The skin is comprised of three main layers: the epidermis, the
dermis and subcutaneous tissue (Kanitakis, 2002) whose overall
function is to absorb, excrete, protect, secrete, thermoregulate,
pigment produce, perceive senses and provide a safe environment
through immunological responses (Hampton and Stephen-
Haynes, 2005).
The uppermost layer, the epidermis, consists of 90% stratified
squamous epithelium cells known as keratinocytes, whose
function is to synthesise keratin, a protein with a strong protective
function. It also contains 8% melanocytes, responsible for the
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production of the pigment melanin, and 2% langerhans and
merkel cells, which allow immune responses and touch sensation
respectively (Tortora and Derrickson, 2009). Ceramide is the
main component of the stratum corneum of the epidermis layer,
together with cholesterol and saturated fatty acids. Ceramide
British Journal of Nursing, 2016 (Stoma Supplement), Vol 25, No 17
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 involved in include: forming a ‘bricks and mortar’ model
Sensory nerve ending comprising the corneocytes, as the ‘bricks’ embedded in lipids
for touch Cell loss from
Hair shaft stratum corneum with ceramides, or the ‘mortar (Gray et al, 2011;Voegeli, 2012);
structuring and maintaining water permeability barriers within
Stratum corneum
Sweat pore (horny layer) the skin (Feingold, 2007), and forming waterproofing of the skin.
Stratum lucidum This outer layer is dependent on the next layer, the dermis, for
Stratum granulosum its supply of oxygenation, metabolic delivery and waste removal,
Stratum spinosum
because of its avascular structure. The middle layer, called the
Epidermis Stratum basale
Basement membrane zone dermis, is fundamentally built up of an integrated system of
Sebaceous gland
fibrous, filamentous and amorphous connective tissue inclusive
Blood vessels
of a fibrillary protein, known as collagen. The dermis provides
Dermis the bulk of the skin ensuring its elasticity, pliability and tensile
Papilla of hair strength (Kanitakis, 2002). It is in this layer where lymph vessels,
nerve endings, hair follicles and glands which are responsible
Hair follicle for exchanging nutrients between the dermis and epidermis
are found. There are up to 4 million sweat glands containing
Lymph vessels
hair follicles separated into two types, eccrine and apocrine,
Sweat duct Subcutis which are distinguished by their differing structures, locations and
(hypodermis)
Sweat gland
actual secretion. Eccrine glands allow thermoregulation through
Arrector pili muscle
evaporation to the skin surface ensuring temperature control and
Peter Lamb

Pacinian corpuscle
Nerve fibre skin moisture, whereas apocrine glands, which are activated by
hormones, produce what is commonly known as body odour,
Figure 1. Skin structure
when the secreted sweat metabolises with skin flora (Casey, 2002).
Table 1. Medications: cutaneous side effects and their causes In the final layer, the subcutaneous, fat cells or lipocytes are
separated by fibrous septa made up from large blood vessels and
Medication Cutaneous side effect Cause
collagen. Considered an endocrine organ, subcutaneous fatty
Steroids Bruising Act non-selectively so tissue provides the body with buoyancy, insulation and acts as a
Skin thinning impair healthy anabolic store for energy. It also provides protection and attachment to
processes that build up
Delayed healing underlying bone and muscle tissue (James et al, 2006).
organs and tissues
Fragile skin The skin requires regular maintenance to keep it at its
optimum functioning capacity (cleaning appropriately,
Anti-coagulants Bruising Inhibition of blood clotting
protection from the harmful sun rays, oxygenation through
Prolonged bleeding
physical exercise and a mixed varied healthy diet in rich
Chemotherapy Rash Act non-selectively so nutrients, alongside adequate fluid intake). These key aspects
Dry skin target rapidly dividing cells of skin care become more important as the body ages (National
Delayed healing Institute of Arthritis and Musculoskeletal and Skin Diseases
Increased bleeding from (NIH), 2016).
the stoma surface When skin is damaged owing to injury, infection, friction,
Pruritis excessive moisture, trauma, or dehydration, a system of
biological changes come into action. These are correlated
Nicorandil Ulceration Not understood
into set phases: haemostasis, inflammation, proliferation and
maturation (Collier, 2002).
creates a water-impermeable, protective organ to prevent Haemostasis is the response which starts immediately after
excessive water loss owing to evaporation, as well as a barrier skin injury; it is achieved by a combination of vasoconstriction
against the entry of microorganisms (Hill and Wertz, 2009). to conserve blood loss and the release of clotting factors, with the
Trans epidermal water loss (TEWL) relates to the amount clot acting as a bacterial barrier and a framework for migrating
of water that transfers from within the body to the external cells (Benbow, 2005).The clotting cascade is initiated and a mesh is
environment through the epidermis layer; for example, in formed trapping blood cells to start the next phase of inflammation.
perspiration (Elias, 2005). Gray et al (2011) suggested that Inflammation occurs because of the extensive vasodilation
TEWL increases when skin dysfunction—such as stripping presenting heat, swelling, erythema and often discomfort to the
trauma, infection, eczema and psoriasis—occurs. site of injury, where increased neutrophils appear to cleanse the
The TEWL process is significantly reliant on ceramides, area of bacteria and devitalised tissue, a phase that occurs over
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which play an essential role in minimising water loss, ensuring
the moisture level of the stratum corneum is optimised and
maintaining skin health and protection (Coderch et al, 2003).
Other important aspects related to fluids and management
within the biological system of the body that ceramides are
a 24–48 hour period (Collier, 2002). Wound exudate, which is
produced at this phase, contains substances that are vital for the
tissue to progress to full healing, such as neutrophils, macrophages,
lymphocytes, proteases and essential growth factors. When
contained, wound exudate is vital for wound healing; however,

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 SKIN HEALTH

when in excess and not managed appropriately, tissues may become

macerated, damaged and healing can stall (Timmons, 2006).
Proliferation or granulation, which occurs around day 3 to
14 (Casey, 2002), is where healthy vascular rich tissue is laid
down within the wound bed, allowing wound contraction and
epithelial cells to migrate, to eventually form closure of the wound.
Epithelial cells form within hair follicles, sebaceous and sweat
glands, which are essential to keeping the new tissue protected,
moist and at optimal functioning states (Timmons, 2006).
The onset of maturation varies extensively depending on
the wound size, closing by primary or secondary intention,
comorbidities and overall skin health. During this phase, the
wound is strengthened and the scar will change in colour
significantly. Fully healed and formed scar tissue is relatively
avascular, containing no hair or sweat glands, and can take from
1 to 2 years to achieve (James et al, 2006).

How the stoma and device can contribute to

peristomal skin breakdown
The incidence of peristomal skin problems is widely described in
the literature. Richbourg et al (2007) reported skin breakdown
as the most common complication in their post discharge study
group and put incidence at 74–83%, while other studies point
towards 21–70% of ostomists (those living with a stoma), dealing Figure 1. Mild peristomal excoriation
with complications or a problematic stoma (Leenen and Kuypers,
1989; Bass et al, 1997; Shellito, 1998; Cottam and Richards, 2006).
Other groups have reported that 6-70% of patients experience
peristomal skin irritation or breakdown (Nugent et al, 1999;
Ratliff et al, 2005) and Lyon (2013) postulated that upwards of
10% of peristomal rashes are unable to be attributed to primary
disease, allergy or infection, and are more likely to be secondary to
a low-grade irritant process related to the occlusion of the stoma
appliance. Examples of mild, moderate and severe peristomal
excoriation are illustrated in Figures 1–3.
A study by Herlufsen et al (2006) found that the majority
of problems are experienced by patients with an ileostomy, of
whom 57% have peristomal skin problems. Of those with an
ileal conduit 48% experience issues, while 35% of colostomists
have problems. These findings could well be attributed to the
amount and type of output being contained, but even taking
this into account, it is clear that for every 10 colostomists
who are still using the vast majority of their gut complement
and will therefore have a more conventional stool, at least 3
will still experience issues with their peristomal skin. Woo
et al (2009) offered that of those ostomists diagnosed with a
peristomal skin disorder, 77% could be related to contact with
their stoma output. Figure 2. Moderate peristomal excoriation
All stomas are created by exteriorising part of the bowel
through the abdominal wall to the surface, where it is everted normal length of gut is still in use. The ileocaecal valve is still
and sutured into place. Colostomies sit relatively flush to the in situ acting as a brake between small and large bowel, and the
skin and ideally should spout 10–15 mm (Cottam and Richards, vast majority of absorption has happened during transit.As such,
2005). Ileostomies should protrude slightly more, with a spout the enzymes and salts that aid digestion have been neutralised
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of 2–2.5 cm (Hall et al, 1995), and ileal conduits should be
similar to an ileostomy spouting 1.5–2.5 cm (Fillingham, 2005).
The need for this type of length in a stoma spout is directly
related to the consistency, amount and content of its output.
As a colostomy is formed from part of the colon, most of the
making the stool passed likely to be soft to semi-formed and
less irritant.A colostomy is also likely to have periods of relative
inactivity over the course of the day and tends to function
more in keeping with what patients have been used to as their
usual bowel habit.

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Figure 3. Severe peristomal excoriation
The output from an ileostomy is looser, as stool will not
have passed through the colon where the majority of water
is reabsorbed, giving the stool its form and consistency. The
volume of output passed from an ileostomy increases inversely
to the length of remaining small bowel in continuity, but a
normal output for a terminal ileostomy is considered to be
600–800 ml in 24 hours (Black, 1997). Anecdotally, many
patients manage without problems with an output of around
1000 ml in 24 hours; anything above this can be considered
a high output, putting patients at risk of dehydration and
electrolyte imbalance (Nightingale and Woodward, 2005). Small
bowel content from an ileostomy still contains the acids and salts
secreted higher in the gut to be used for chemical digestion,
which gives it a more corrosive nature when it comes into
contact with peristomal skin.
An ileal conduit will pass urine at a steady rate as the storage
provided by the bladder has been lost. An average volume
may be around 1500 ml per day (Burch, 2006), although this
is variable on the level of hydration and renal function of the
individual. Exposure of the peristomal skin to urine will in itself
increase risk of irritation, but there is an added consideration
of maceration where the appliance holds the moisture next
to the skin for long periods, thus increasing permeability and
the risk of breakdown.
In practice, higher stomal outputs provide a greater
challenge to containment and skin protection. Looser output
in larger volume will find the smallest weakness or gap in
the hydrocolloid barrier, meaning the skin will be exposed
to the stool and make the appliance more likely to leak. A
more corrosive output will also contribute to the corrosion
of the hydrocolloid adhesive, known colloquially as ‘melt’,
which also leads to a loss of the skin barrier next to the stoma
and an increased risk of subsequent skin problems. In the
author’s (A.B.) practice, patients who have a higher output
will often need to change their appliance more regularly or
use accessories, such as seals or skin barrier films, to protect
the peristomal skin and reduce the incidence of irritation
and breakdown.
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The risk of medical adhesive
related skin injury
Adhesives used in stoma appliances and accessories play a part in
maintaining skin integrity. However, there is a potential for the
adhesives themselves to cause skin problems. Medical adhesive
related skin injury (MARSI) is a mechanism of skin injury that
occurs when the skin to adhesive attachment is stronger than the
skin cell to skin cell attachment. This causes a cohesive failure
within the structure of the skin that leads the epidermal layers
to part or separates the epidermis from the dermis (McNichol,
2013). This type of injury may manifest itself in a number of
ways; from the removal of layers of the stratum corneum (so-
called skin stripping) and maceration from trapping moisture
next to the skin for prolonged periods, to tension injuries such
as blisters or tears. While there may not be any visible trauma,
there is a cumulative removal of epidermal cells that over time
will result in a compromise to the skin barrier function, that will
in turn result in the mounting of an inflammatory and wound
healing response.
There are a number of factors that lead to the mechanism of
injury.These include the energy required to remove the adhesive,
the composition of the adhesive and the occlusiveness of the
adhesive.The moisture that gets trapped underneath an occlusive
dressing leads to maceration and irritation of the skin, which
increases the risk of mechanical trauma. Hydrocolloid adhesives
trap moisture over time, meaning the skin becomes macerated
and more permeable, thereby increasing its susceptibility to
friction and irritants. However, it has been argued that the ability
of hydrocolloid barriers to absorb excess moisture can reduce
these unfavourable side effects when compared to other occlusive
barriers (Zaih and Maibach, 2002).
McNichol et al (2013) postulated that MARSI constitutes
‘a significant negative impact on patient safety.’ Aside from the
obvious physiological effect of skin damage leaving wounds that
require healing, associated pain, an increased risk of infection and
further skin breakdown, there are also psychological ramifications.
Patients with skin damage can suffer compromise to their
quality of life through interference with their normal physical
activities.This can lead to social isolation, increased anxiety and
even depression (Herlufsen et al, 2006; Woo et al, 2009; Boyles,
2010a; McMullen et al, 2011; Salvadalena, 2016). Add to this the
financial implications of treating this type of injury-not only in
terms of supplies but also service provision and time-then the
multifaceted negative effects of this type of injury will soon mount.
Intrinsic factors contributing to peristomal
skin breakdown
There are various intrinsic factors that can have an influence
on how skin behaves when exposed to the various stressors
brought about by both the stoma and appliance.
As skin ages, it becomes more susceptible to damage and
breakdown as a result of the following factors:
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■■ Loss of the dermal matrix
■■ Loss of subcutaneous tissue
■■ Epidermal thinning
■■ Reduction of the cohesion between dermal and
epidermal layers
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■■ Reduced vascularity
■■ Reduced elasticity
■■ Reduced tensile strength
■■ Less moisture (Lober and Fenske, 1991; Cutting, 2008;
Wysocki, 2012).
Ethnicity is also being shown to have an effect on how
skin is affected by exposure to adhesives. Differences in
percutaneous absorption rates and the level of stratum corneum
lipid (ceramide) content and tensile mechanical properties of
the dermis (skin rigidity) across skin tones all play a part. This
concept is still emerging, but there is some evidence to show
that darker skin tones tend to have a higher degree of rigidity
than lighter skin tones that may make it more prone to injury
(Evans et al, 2012), while ceramide levels have been found to
be higher in Asian skin types and lowest in darker skin types
(Richards et al, 2003).
Additional intrinsic factors can also increase the risk of skin
damage.These range from comorbidities, such as diabetes, renal
failure, immunosuppression, hypertension and peristomal varices,
to other conditions such as psoriasis, eczema, malnutrition and
dehydration. Extrinsic factors including dry skin, maceration,
radiotherapy, friction from the appliance or clothing, as well as
certain medications, also have an effect on the skin that increases
the risk of MARSI.
Quality of life and wellbeing
There are a variety of reasons why a stoma may be formed.
The raising of a stoma will always be part of a wider disease
or disorder process, which means that people will arrive at
that point from a range of physical and psychological places.
Regardless of the reason for stoma formation, it will always have
a multifaceted impact on how people live their lives.
Quality of life is generally concerned with two aspects of
information: functional status and how patients judge their
health to affect their quality of life (Muldoon et al, 1998).
Relating health to these physical and mental parameters allows
the assessment of two factors: objective functioning (the ability
to perform tasks) and subjective wellbeing (how an individual
evaluates their state of health).
The concept of objective functioning can relate to a range
of physical tasks, from the ability to walk a certain distance
to the ability to resume a normal sex life, while it may also
encompass an individual’s ability to perform cognitive and
social tasks. In terms of stoma care, it can be more related to
achieving a level of confidence to resume normal routines,
such as work and social activities, as well as being physically
capable of going back to a job that requires a certain level
of physical activity. In a study by Nugent et al (1999) 8% of
colostomists and 11% of ileostomists changed their job as a
result of surgery, but within the same group, 50% of respondents
reported that their stoma had little or no effect on their ability
to find work. In terms of sexual function within the group,
© 2016 MA Healthcare Ltd
45% of ileostomists and 43% of the colostomists experienced
problems after surgery. Nordstrom and Nyman (1991) reported
that 90% of male urostomists experienced impotence, while
the female participants reported little or no sexual activity
after surgery. However, it is worth noting that those patients
British Journal of Nursing, 2016 (Stoma Supplement), Vol 25, No 17S19
SKIN HEALTH
within the group who had undergone surgery for intractable
incontinence reported an increase in sexual activity.The concept
of sexual function covers both paradigms under consideration
here, and it is worthy of note that while physical problems may
stop some patients from fulfilling their normal sexual function,
other more subjective issues such as self-perception and body
confidence also exert their influence.
The incidence of stomal complications holds a great influence
over patients’ objective functioning. Nordström and Nyman
(1991) found that higher incidences of complications and
practical problems with stoma care made patients more likely
to stop work and restrict social activity.This was consistent with
the group studies by Pitmann et al (2009), who found that the
severity of complications, such as sore skin and appliance leaks,
had a direct correlation with the severity of the impact which in
turn led to problems with adjustment postoperatively. Gooszen
et al (2000) also found this within their study group.They also
revealed that the link between the incidence of complications
and degree of isolation was stronger where people had a pre-
existing level of social constraint. Of these participants 17%
were unable to achieve a level of self-care, meaning they had
lost their independence and were reliant on others for help. It is
worth noting that this study group were living with a temporary
stoma. Other studies of similar groups showed uncertainty and
worries over disclosure, coping strategies, looking for practical
solutions to complications and difficulties with exercise, sleep,
sex, pouch management and clothing, (Neuman et al, 2011;
Danielsen et al, 2013). Many patients report a good quality of
life despite stoma related difficulties (Neuman et al, 2012), but
there seem to be differences between how these patients and
those living with a permanent stoma perceive their quality of life.
For those living with a permanent stoma, Feddern at al (2015)
found there was little or no impact on how patients perceived
their quality of life. Nair et al (2014) saw a dip at 2 weeks
postoperatively that returned to preoperative levels by 3 months,
and Chambers et al (2012) found a response shift towards good
quality of life. Campos-Lobarto et al (2011) compared those
undergoing abdominoperineal excision (APER) and formation
of permanent colostomy with those undergoing low anterior
resection. The APER group had a lower start point at time of
surgery; at 6 months, the differences between the groups was
not significant and had disappeared by 36 months.
It is easy to see that living with a stoma has some inevitable
effects on how people view themselves and live their lives.
Complications such as sore skin appear to have a direct negative
impact on patient outcomes in this area, but there are wider
issues that are worthy of note. In terms of money, the cost
of prescribed stoma care products in England for 2015 was
£280 million, of which £74 million was on accessories. To
give this figure some context, the total cost of dispensed
prescriptions in that year was £9.27 billion (Health and Social
Care Information Centre, 2016).As this cost is purely related to
the materials needed for stoma care, these figures do not take
into account any extra costs that treating complications may
incur.These may include additional medications or treatments,
referral on to other specialities, such as dermatology and,
importantly, nursing time and resources needed to assess and
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KEY POINTS
■■ The trans epidermal water loss (TEWL) process is significantly reliant on
ceramides, which play an essential role in minimising water loss
■■ Ceramides ensure the moisture level of the stratum corneum is optimised
and maintain skin health and protection
■■ A stoma will always have a multifaceted impact on how people live their
lives
■■ Intact peristomal skin is the cornerstone to promoting positive outcomes
for patients with a stoma
treat patients, and any issues they encounter often over a
period of years. However, it is essential to keep in mind that
any costs have to be weighed against the wider social and
economic implications of patients being able to manage their
stoma reliably and regain their confidence to resume their
normal lives, as persistent complications can have immense
physical, psychological and financial implications (White and
Hunt, 1997; Persson and Helstrom, 2002; Williams, 2006;
Boyles, 2010b).This was also examined by Rudoni and Dennis
(2009) who questioned patients and stoma nurses over the use
of accessories to manage problems. Both groups prioritised
sore skin and skin damage in the top three reasons to use
accessories. Furthermore, 91% of stoma nurses and 72% of
patients felt these accessories were essential and beneficial to
patients’ social and emotional wellbeing.
The consistent thread running through this particular strand
of the patient pathway, however, is the presence of clinical
nurse specialists (CNS). As expert practitioners, the CNS is
an accessible way for patients to be assessed, evaluated and
using a sound evidence base, recommend and implement a
path of management for an ever-widening range of issues.
The CNS role means they are best positioned to provide care
across organisational boundaries, implement regular review and
follow-up, have a sound knowledge of product choices and have
a strategic knowledge of the issues facing both patients and the
wider NHS.This means they are able to advocate for change and
improvements to patient care in a challenging organisational and
financial landscape. This, in turn, ensures care remains centred
around those who need it and remains relevant to their needs
in terms of positive outcomes, products and timing (Bass et al,
1997; Bekkers et al, 1996; Pittman et al, 2009).
Conclusion
Intact peristomal skin is the cornerstone to promoting positive
outcomes for patients with a stoma.While many patients will
have to deal with problematic skin at some point, it should not
be considered the acceptable norm as it can have profound
impact on an individual’s optimal physical, psychological and
social functioning. Good skin health means that pouch barriers
can function reliably, which in turn leads to consistent stoma
care. By placing the patient at the centre of that care, delivered
in a timely way and with a basis in robust evidence, the CNS
remains key in championing these positive outcomes. This
enables patients to concentrate their efforts on building their
confidence and wellbeing freer from the concern of pouch
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failure, the embarrassment of leaks and the self-assurance in
their products and technique they need to take their normal
place in the world.  BJN
Declaration of interest: this article was supported by Hollister
Acknowledgements: the authors thank Edwin Chamanga, Tissue
viability service lead, Hounslow and Richmond Community Healthcare
NHS Trust, for his help with the preparation of the manuscript
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 SKIN HEALTH

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CPD reflective questions

■■ What would be your priorities in caring for a patient with a stoma? Have these changed as a result of reading this
article?
■■ How can you begin to address the psychological impact that can follow on from experiencing practical problems with
stoma management?
■■ Do you feel that your knowledge has improved in regards to skin anatomy and physiology since reading this article?
Has this knowledge increased your understanding of peristomal skin management principles?

Helping nurses treat common skin conditions

Dermatology Differential Diagno

About the book

Skin problems are one of the
most common reasons for
people to seek help from a nurse
or GP in general practice. This
handy reference guide is the

This practical and user-friendly book is made up of articles from a popular series in Practice
essential collection of common
dermatological cases encountere
d in everyday practice with concise
content on the aetiology, diagnosis,
management and prevention
so that healthcare practitione
rs can effectively treat their patients.

Nursing and covers: the aetiology, diagnosis, management and prevention of most common Importantly, this book also examines
patient care, with considerat
ion for how
other issues that impact
factors impact patients and treatment social and psychological
of skin conditions.

dermatological cases; social and psychological factors and their impact on patients and This book comprises updated
highly popular series published
articles from a long running and
in the Practice Nursing journal
the differential diagnosis of dermatolo on

treatment of skin conditions.

gical conditions. It has been
highly illustrated with colour
pictures provided throughout
*Low cost for landlines and mobiles

diagnosis. The chapters have to aid

been presented in a user-friend
format making this a highly practical ly
text for nurses and GPs.
sis

Highly illustrated, with colour pictures throughout, helps to aid diagnosis. Each chapter is About the author
Dr Jean Watkins is a retired GP

Dermatology
and remains an active member
Practice Nursing Editorial Board of the

presented in a user-friendly format making this a highly practical text for nurses and GPs.
and, in April 2004, was awarded
Fellowship of the Royal College a
of General Practitioners.

ISBN-13: 978-1-85642-401-1; 297 x 210 mm; paperback; 200 pages; publication 2010; £29.99 Differential
© 2016 MA Healthcare Ltd

Diagnosis
Jean Watkins

ISBN 1-85642-401-4
Jean Watkins
Order your copies by visiting or call our Hotline 9 781856 424011

www.quaybooks.co.uk +44 (0) 333 800 1900*

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