Physicochemical Properties and Composition of Peristomal Skin Care Products: A Narrative Review

Abstract

People who have gone through stoma surgery face different problems and difficulties every day, although most of these issues improve significantly with time. The quality of life of ostomy patients has been proven to be strictly related to self-care ability. So, it is essential for patients to properly maintain the ostomy site, including proper daily self-care and regeneration of the skin around the stoma, to avoid stoma-related complications. This review was undertaken using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. The main aim of the literature review was to analyse and present the characteristics of medical products used in ostomy care currently existing on the market. The intervention and management of stoma problems with appliances and accessories are also summarised. This literature review is limited to a critical analysis of the scientific and professional literature and informational materials developed by manufacturers of stoma accessories.

1. Introduction

1.1. Stoma Definition, Classification, and Indications for Creation

A stoma is a small, surgically created opening on the surface of the abdomen that diverts the flow of faeces or urine from the bowel or bladder [1,2,3,4,5].

The need to create a stoma is caused by many factors, among which colorectal cancer, inflammatory bowel diseases, polyposis of the large intestine, and rectovaginal or rectovesical fistulas are the most common. After the procedure, defecation and gas excretion are carried out through the created stoma into a special bag attached to the skin. Depending on the medical condition requiring the ostomy, and therefore the location where the stoma is placed, the procedure can be divided into three types: ileostomy, colostomy, or urostomy (Figure 1) [3,4,6,7]. It is estimated that up to 1 in 500 people have a stoma, which is equivalent to approximately 13.5 million people worldwide living with a stoma [1,2,4,6,8,9,10].

1.2. Ostomy Appliance

Caring for patients who have undergone an ostomy requires the application of a variety of stoma appliances. These include a system of stoma bags (also called stoma pouches) used to collect the contents coming out of the stoma from the intestine or ureter, as well as accessories. A stoma accessory is any product that is used in addition to the stoma bag. These accessories have different functions ranging from aiding in bag adhesion and reducing leakage to helping to protect the skin or improve bag stability. This group includes protective wafers/sheets, seals and washers, flange-securing tape, barrier rings, ostomy belts, agents to prevent pancaking, gelling agents, stoma pouch clamps and soft wire ties, pouch covers, flatus filters, and medical devices formulated as mixtures for hygiene and the care of the skin around the stoma [2,8,11,12,13,14,15].

1.2.1. Ostomy Pouching Systems

An ostomy appliance, or pouching system, is composed of an adhesive part (also referred to as an adhesive barrier, wafer, flange, base plate, faceplate, or skin-protective barrier) and a collecting pouch. The adhesive barrier is applied directly to the peristomal skin, enabling the drainage of stool or urine into the collection pouch. It therefore acts as a protective seal between the effluence and the peristomal skin while enabling the skin around the stoma to breathe freely. The principal components of the stoma appliance are the stoma opening, adhesive skin barrier, adhesive tape, and wafer flange [2,16]. New solutions on the market nowadays include the use of flexible wafer materials that adapt to the varying sizes and shapes of individual stomas. This kind of system creates a secure “turtleneck” effect to effectively control leakage. The barrier absorbs liquid output, swelling around the stoma to ensure maximum security. The adhesive skin barrier also has graduated firmness and convexities to address the variable individual body habitus [2,17,18,19,20,21,22,23,24].

Stoma appliances are available for patients undergoing colostomies, ileostomies, and urostomies and, depending on the type of technology used, may be one-piece systems or two-piece systems (Figure 2) [2,25,26].

The one-piece pouch systems stick directly to the skin and include a hypoallergenic skin-protective barrier. The wafer and the pouch are integrated and must be replaced entirely with each change. Adhesive wafers may have an outer ring of hypoallergenic tape. In contrast, two-piece systems, also known as a faceplate with a separately attached pouch, consist of a base plate or flange with a skin-protective barrier, which may also include an outer area of hypoallergenic tape. As the wafer and the pouch are separate, it is also possible to change the pouch itself while in use. Both the flange and the base plate have a hole that is adjustable to fit the size and shape of the stoma [2,13,25,26,27].

1.2.2. Appliance Adhesion and Absorption

To protect peristomal skin from the stomal effluent and maintain healthy skin, the use of ostomy adhesives is essential [16]. Adhesive bonding to the skin surface is primarily a physical action. Ostomy adhesives spread over the skin, filling crevices and other micro-topographical features. Most adhesive barriers are pressure-sensitive; they contain a special kind of adhesive called pressure-sensitive adhesive (PSA) and develop immediate adhesion when light pressure is applied. In the “keying process”, modest body warmth is helpful [1,2,28].

The effectiveness of an adhesive wafer is determined by several factors. The main factors are the chemical composition of the adhesive, limitation of the transpiration of moisture by the adhesive device, and the risk of irritation and allergic reaction [14,28,29].

The wear time for standard wear systems ranges from 3 h to 3 days, whereas extended wear systems are designed to remain in place around the stoma for up to 6 days.

Due to their short wear time, standard solutions are adapted for easy removal (without stressing or stripping the skin). Additionally, the adhesive part of the stoma appliance is created from skin-friendly materials (ones that do not cause an allergic or irritant reaction or change the skin’s pH) like hydrocolloid dressings [14,28].

The first generation of adhesive wafer was formed from zinc oxide and acrylics, providing only simple skin adhesion to support the ostomy bag during use. The second generation introduced hydrocolloids, which are highly absorbent but exhibit weaker adhesive properties compared to earlier materials. However, during use, these adhesives often dissolved around the stoma, compromising skin protection [2,16].

Modern adhesive barriers use synthetic or naturally occurring raw materials and are developed to be as adhesive as possible with minimal irritation. They are composed of a mixture of adhesive hydrophobic polymers, including elastic and plastic polymers as well as absorbent hydrophilic hydrocolloids (Figure 3).

The combination of different materials makes it possible to achieve enhanced adhesion, erosion resistance, moisture control, adaptability, and simplicity of detachment from the skin [16]. Elastic polymers such as styrene–isoprene–styrene (SIS) polymers and the high-molecular-weight isobutylene–isoprene (butyl rubber) polymers ensure structural support of the adhesive, while plastic polymers enhance the adhesion properties. Low-molecular-weight polyisobutylene (PIB), a synthetic polymer derived from the oil industry, serves as an example of a plastic polymer [16]. Hydrocolloids used in adhesive skin barriers include pectin, gelatin, carboxymethylcellulose, karaya gum, and guar gum [2,16]. Hydrocolloids effectively absorb excess skin moisture, reducing skin irritation and enhancing adhesion. Within the wafer, adhesive molecules absorb moisture, causing them to swell, degrade, and eventually lose their barrier properties. The erosion rate is influenced by the hydrocolloid components in the adhesive formula, as well as the quality and quantity of effluent [2,30,31,32,33].

Silicones are also used as modern adhesive skin barriers. They are mouldable and created to encourage healing of the skin and to prevent leakage. These products may be especially beneficial for high-risk patients with peristomal skin complications (see Section 1.3.1). As each company produces its own adhesive barriers, e.g., Stomahesive^® (Princeton, NJ, USA), SenSura Mio^® (Humlebaek, Denmark), Confidence BE^® (Aston, UK), Genii™ (Skipton, UK), etc., most of these technologies are patented [17,18,19,20,21,22,23,24,25].

The proper use of stoma appliances and accessories by patients ensures greater safety while improving physical and psychological wellbeing. However, when used incorrectly, it can lead to complications and prolong the time required for stoma care, including avoidable product usage [11,27,34].

1.3. Quality of Life of Patient with Stoma

Stoma formation, regardless of the patient’s age or gender, co-existing medical conditions, or skin sensitivity, is a very special and critical moment in the patient’s life. For some, the loss of sphincter control has a negative impact on all areas of life and intensifies the sense of isolation, disfigurement, and mutilation, while for other patients, it represents hope for life extension (ending a life-threatening medical condition) and a chance to live functionally and to achieve their life goals. The surgical procedure brings changes in the body’s physical appearance and functioning. Patients experience emotions, such as sadness, grief, bitterness, and even anger and aggression [35,36,37]. Stoma formation causes difficulties in satisfying basic needs. People with stomas experience problems with absorbing medications, sexual activity, and social rejection. The most commonly reported problems regarding intimate life can include concerns about being rejected by a partner, fears about one’s sexual performance, the effectiveness of contraceptive measures, or, for females, the chances of getting pregnant. Patients also experience shame and insecurity. In some cases, after the surgery and especially during the recovery process, patients experience discomfort or even pain during intercourse and may have problems with libido, which can result in social and family withdrawal [36,38]. The stoma affects sleep and relaxation and alters leisure activities (additional and specific insurance is required when travelling). Furthermore, due to possible gastrointestinal problems, it is recommended for patients to follow a diet, depending on their type of stoma [35,39,40,41,42].

It can take from a few months to two years to adapt to the new situation, depending on the patient’s health, their expertise and skills in self-care, the support of their family, healthcare professionals and support groups, and their ability to return to work and re-enter society, as well as financial factors [36,43,44].

As indicated in the literature [44,45,46,47,48,49,50,51], one of the significant elements related to adapting to the new situation is the necessity to educate patients and their home caregivers pre- and postoperatively to understand their stoma, decrease preventable complications through, among others, acquiring appropriate self-care, and decrease health system resource utilisation. Some of them are not serious and can be overcome with good stoma care, a change in product, or diet and lifestyle adjustment. Stoma care problems can be related to peristomal skin complications, stoma issues, and ostomy appliance issues [41,42].

1.3.1. Peristomal Skin Complications

Peristomal skin complications (PSCs) are the most common skin issues following ostomy surgery. These complications can be presented as both short- and long-term problems, affecting approximately 10–82% of patients with stomas [52]. PSCs significantly impact a patient’s quality of life and contribute to a higher care cost [2,53,54,55,56,57,58]. While PSCs can develop at any time [54], their incidence is highest within the first five years post-surgery [59].

The aetiology of PSCs is complex and multifactorial, depending on factors such as preoperative preparation and postoperative care [26,41,52,53,54,58,60]. Most PSCs arise from moisture-associated skin damage (MASD) and/or medical adhesive-related skin injury (MARSI).

MARSIs are characterised by lesions that persist for 30 min or more after adhesive removal. These injuries may stem from mechanical factors (e.g., skin stripping, tension injuries, blisters, or skin tears), dermatitis (e.g., irritant contact dermatitis or allergic contact dermatitis), or other causes (e.g., maceration or folliculitis) [29,61].

MASD, also referred to as irritant dermatitis, results from prolonged exposure to excess moisture, such as perspiration or leaked stomal output accumulating between the flange and the skin [26].

Besides faecal leakage, mechanical irritation, allergy/hypersensitivity, sweating (fungal and bacterial), and pre-existing skin diseases (such as eczema, psoriasis, and pyoderma) lead to peristomal skin complications. Faecal leakage can be caused by an ill-fitting appliance due to a poorly sized or trimmed pouch, changes in abdominal shape due to weight fluctuations and muscle weakness, development of skin folds and other irregularities, a poorly sited stoma, scarring near the stoma, a complicated stoma, and changes in stool consistency. Mechanical irritation can be caused by the adhesive and kinking of the adhesive material as well as cleaning soaps, materials, and other substances used to clean the skin and achieve depilation of the peristomal area. Allergy/hypersensitivity can be caused by any substances that come into contact with the peristomal skin, i.e., substances used to clean the skin or chemicals used to create the stoma appliance [42,55,58,62,63].

It should be pointed out that the severity of PSCs ranges from mild erythema to eroded or ulcerated skin, with various other skin issues potentially affecting patients with ostomies. The most common complications are candida, contact dermatitis (skin irritation), folliculitis, mucocutaneous separation, peristomal pyoderma gangrenosum (PPG), skin creases, skin stripping, and wet skin [26,41,53,54,64]. The PSCs observed in stoma patients vary in the depth and extent of the damage [42]. They can manifest as very sore skin, itching or white pustules, as in the case of candida, irritation of hair follicles on the peristomal skin in the case of folliculitis, or separation of the stoma from the skin, leaving a visible gap of tissue caused by bowel tension, infection, malnutrition, or steroid use in the case of mucocutaneous separation. Contact dermatitis is often characterised by irritation resulting from ill-fitting appliances, retracted stomas, parastomal hernias, or skin creases and folds. It is frequently accompanied by mechanical skin stripping, which occurs when the appliance is removed, taking the outer layer of skin with it. This leads to an increase in transepidermal water loss, causing overhydration, which affects adhesion, leaving the skin painful, moist, and possibly bleeding. This can lead to leakage by compromising the adhesion between the stoma and the patient’s skin. A peristomal skin condition is characterised by painful, ulcerative, and pustular lesions or is accompanied by pyoderma gangrenosum [41,58,60,63,65].

1.3.2. Ostomy Appliance Issues

Patients with stomas are often concerned about issues such as pouch leakage, as well as noise, odour, and the visibility of their appliance [41,66]. One reason for leaking effluent is the failure of the seal between the skin and the flange. Leakage also happens when the pouch becomes detached; this is a problem for those patients in particular who have had a stoma for a short time and therefore have little experience in changing the stoma pouches.

Two other common issues related to ostomy appliances are ballooning and pancaking [67]. Ballooning occurs when air from the digestive system becomes trapped in the ostomy bag, causing it to inflate. This can negatively affect the user’s quality of life by leading to discomfort or sleep disturbances. Pancaking happens when stool collects around the stoma instead of moving to the bottom of the bag. This may result in seepage between the flange or base plate and the skin. It often occurs when there is insufficient air in the bag, causing the two sides to stick together, and is due to the excessively thick consistency of colostomy output. Topical allergic reactions of the peristomal skin to the appliance material or its accessory ingredients are another potential side effect of using ostomy appliances [40,68,69].

1.3.3. Stoma Issues

Patients with an ostomy should regularly monitor their stoma and the surrounding skin. Changes in that area are often the earliest signs of a problem, which can range from minor concerns to serious complications requiring urgent medical attention [55,70,71].

The stoma is incredibly vascular and can easily bleed, usually brought on by friction and pressure. The skin surrounding the stoma can also be a source of bleeding, often resulting from irritation caused by an ill-fitting stoma pouch. This may lead to leaks or friction, as the pouch rubs against the stoma.

Granulomas are another kind of common stoma problem. Granulomas are red nodules around the edge of a stoma, often causing mild irritation. They are typically the result of friction and/or prolonged irritation.

Stoma necrosis is a much rarer issue, but it is a serious complication of the stoma, causing it to become swollen and discoloured. Usually, this will occur early after surgery.

Sometimes complications like stoma prolapse can occur. These stoma-related issues can lead to aesthetic concerns and challenges with appliance attachment, often caused by a weakened muscle wall due to stoma formation, ongoing constipation, or chronic coughing. While they typically do not cause pain, they can be frustrating for patients, particularly if the stoma becomes elongated enough to disrupt the seal of the ostomy pouch.

Hernias associated with ostomies are a common complication that some individuals may experience. They present as a bulge under the skin near the stoma, caused by the bowel pushing through a gap in the abdominal muscles. This condition can hinder proper appliance adhesion. It is more prevalent in older adults, individuals who are overweight, heavy lifters (whether from weight training or job-related activities), and smokers, as frequent coughing increases the risk [55,66,69,71].

Addressing the problems faced by stoma patients includes changing the appliances, selecting the optimal stoma accessories and stoma care products, modifying the diet, and educating the patients on proper care of the skin around the stoma, how to properly change the pouch, and how to choose appropriate clothing. Stoma nurses are particularly valuable, as they provide both emotional and informative support to patients [10,72,73].

According to Gefen [26], stoma appliances have remained largely unchanged for decades. The persistent prevalence of PSCs highlights the need for a comprehensive re-evaluation of their engineering design, including a critical review of the skin-contacting materials used in the flange. This led to the development of different polymeric materials, such as silicones. It should be noted that stoma care compliance is also more likely when patients feel comfortable with and accept the products they use, such as peristomal skin protectors, adhesive removers, and pouches.

Considering the significant role of stoma accessory-mixed medical products in preventing and solving peristomal skin issues, it is essential to provide a comprehensive summary of the types of peristomal skin care products currently available on the market, along with their chemical composition and physicochemical properties.

2. Materials and Methods

2.1. Aim and Objective

The aim of this literature review was to present the characteristics (physiochemical properties and chemical composition) of medical products used in ostomy care. By categorising these products and characterising their chemical composition and how it directly determines their efficacy, it is expected that nurses and doctors will provide better assistance to the ostomate. An analysis of the currently existing methods of intervention and management of stoma problems with appliances and accessories was also performed. The trade names of the products have been purposely omitted from this review.

2.2. Research Strategy

To prepare a literature review, search engines such as PubMed, MEDLINE, Scopus, Web of Science, Google Scholar, Google Books, and ResearchGate were used. The main search terms chosen were stoma care; peristomal skin care; peristomal dermatology; skin care of ostomy patients; ostomy appliances; accessories in stoma care; adhesive remover; barrier products; filler pastes; skin cleansing preparations; and preparations eliminating unpleasant odours. The search terms were listed independently. Appropriate research was categorised by the function of the products and evaluated according to the study design. Automation tools were not used in the process. PRISMA criteria guidelines for Reporting Items for Systematic Reviews and Meta-Analyses were adhered to in the reporting of this study. To eliminate the risk of bias, the authors independently collected and assessed the quality of all selected data. Any disagreement was resolved by discussion, and a check for duplicates was performed. In the case of original articles, the selection was carried out firstly by reading the titles, abstracts, and then the full texts. The evaluation was based on the author’s knowledge. Reference lists of appropriate articles were also reviewed to identify further studies. The review was not registered, and the protocol was not prepared.

2.3. Inclusion Criteria

This review is restricted to a critical analysis of the scientific and professional literature (including guidelines for ostomy patients, clinical and preclinical studies, and reports of clinical trials) and information materials developed by manufacturers of stoma accessories (brochures and information available on their websites). The inclusion criteria were defined as studies/papers that were authored in English or Polish and published between September 2022 and December 2023. Patents, animal research, basic laboratory-based research, and conference abstracts were excluded.

3. Results

The study flowchart for the selection of the relevant research is presented in Figure 4.

The initial search identified 212 articles and 104 records from websites and citation searching. Upon review, 30 articles were duplicates and removed. A total of 193 articles were excluded because, among other reasons, they do not pertain to the review topic of interest (n = 39) or they did not include details about the composition of peristomal skin care products (n = 54). In the records identified from websites, the majority of the results included information available on the websites of ostomy equipment manufacturers. From these reports, we excluded 89 records that were not relevant for reviewing the topic. In total, 35 studies and reports were included in the review.

3.1. Ostomy Skin Care Products

Depending on their purpose, ostomy skin care products can be classified into adhesive removal, cleansing, protective barrier, sealing, healing, and soothing stoma-related problems, as well as odour neutralisation. Each group of medical devices was analysed in terms of their chemical composition and how it directly determines their efficacy, properties, and purpose [2,8,11,12,13,14,15].

3.1.1. Adhesive Remover

It is necessary to remove the pouch when changing the stoma bag to clean the skin. The pouch can be removed by physically pulling; however, this action removes loosely bound epidermal layers, causing stripping of the skin surrounding the stoma. Such stripping compromises the skin’s barrier properties, exposing deeper layers and making peristomal skin vulnerable to damage from effluents, bacteria, and adhesive ingredients [55].

The removal of the stoma appliance is also uncomfortable for some patients, and residue from the hydrocolloid flange can be left on the skin surrounding the stoma. To facilitate the process of changing the stoma appliance, adhesive removal products are available on the market to help peel off the stoma wafer. These products are intended for removing adhesives from the abdomen quickly, painlessly, and without causing skin damage or trauma when detaching the pouch from the skin [2,8,11,12,26,58,72,74,75].

Based on their chemical composition, adhesive removers fall into three main categories: alcohol- or organic-based solvents, oil-based solvents, and silicone-based removers [55,74].

Alcohol- or Organic-Based Solvents

Alcohol-based adhesive removers work by dissolving certain components of the adhesive, rather than weakening the bond strength at the skin-adhesive interface. The most commonly used alcohol is isopropyl alcohol [76]. According to Berry et al. [28], this is an antiquated and inefficient method of removing an adhesive. Alcohol has a negative effect on the skin’s surface. Alcohol can cause dryness and irritation, and its astringent properties may lead to discomfort, especially when applied to broken skin. Adhesive remover wipes have a particularly negative effect on the skin (compared to adhesive remover sprays), because the wipe must contact the adhesive and skin interface to achieve its impact on the surface [28,55].

Oil-Based Solvents

Oil-based solvents gradually penetrate the interface between the skin and adhesive, effectively releasing the bond between them. The spread of oil prevents the adhesive from reattaching to the surface, making it impossible to reposition. This type of product leaves the skin oily, which consequently causes leakage through ineffective bonding or not adhering to the peristomal skin at all. So, the skin should be thoroughly cleaned with soap and water and then dried before applying a replacement appliance. These adhesive removers are based on simple mixtures of paraffin (e.g., C11–C12 isoparaffin), petroleum (e.g., hydrotreated heavy naphtha or light aliphatic solvent naphtha), emollients (fatty acid isopropyl esters (C14–C18), isopropyl palmitate, isopropyl myristate, or isopropyl stearate), or more complex mixtures of essential oils (lavender, orange, tea tree, or acid-treated distillate oil). These products also contain fragrances (e.g., D-limonene) [2,11,28,55,75,76].

Silicone-Based Removers

The silicone in the preparation process possesses unique properties that allow it to penetrate quickly into the adhesive–skin bond. It spreads efficiently across the peristomal skin surface, penetrating the fine structure of the interface to create an interposing layer. This process disrupts the adhesive’s bond with the skin’s surface, causing it to either peel away or fall off effortlessly. Such products are particularly recommended for use on fragile or damaged skin or in cases where patients are at risk during the adhesive removal process. One example of a silicone used as an adhesive remover is hexamethyldisiloxane [28,55,77]. Preservatives (e.g., phenoxyethanol and methyl-, butyl-, ethyl-, and propylparaben) are also used in the formulation of adhesive removers that contain water.

Each of these adhesive remover types has its own pros and cons. Alcohol-based and organic solvent products dissolve the adhesive wafer hydrocolloids, form a residue after use, and have an astringent effect on healthy and broken skin that causes dryness, irritation, and pain in the stoma area, and their prolonged use can damage the skin. On the other hand, these products do not require further cleansing agents, and they evaporate quickly from the skin surface (dry out), providing a cooling effect. The disadvantages of oil-based preparations, as with alcohol-based ones, are that they dissolve hydrocolloids and form a residue after use. Unlike alcohol- and silicone-based formulations, they require another cleansing product, as they tend to leave the skin greasy enough to adversely affect the adhesion capacity of the wafer. Patients most often need to use soapy water, which is not always possible when travelling, for example. Silicone-based products offer the fewest drawbacks, and of the previously mentioned features, none apply to this group of products. In addition, silicone evaporates quickly, leaving the skin ready to receive the new appliance. They are also inert with the body [28,55].

Another classification criterion for adhesive removers is their physicochemical form. Adhesive remover products available on the market include aerosols, liquid-soaked wipes (gauze pads), and liquid in bottles used to soak the wipes.

Once applied to the adhesive edge, the spray reduces the surface tension, which makes it easier to remove the stoma wafer from the skin. Therefore, this physicochemical form is only available for alcohol- or silicone-based adhesive removers. Typically, the propellant is a propane–butane gas mixture. The adhesive remover in wipes was created in response to the special needs of those who prefer to use small wipes instead of sprays with atomisers. This is particularly convenient when travelling and when changing stoma appliances discreetly and very quickly. These accessories are hypoallergenic products and should neither pinch nor leave a greasy film on the skin that could interfere with the adhesion of the stoma wafer. Some of them may be scented or unscented. After application, the user should wait approximately 20 s and then peel the product off [2,11,26,28,55,75,78].

Wipes are more expensive but may be required for adhesive buildup. Urostomy patients may require wipes as well as sprays since urine can erode the appliance seal, and the texture of wipes can aid removal [79].

Adhesive removers are available as rectangular soaked wipes of various sizes (95 mm × 165 mm–190 mm × 195 mm) and thicknesses (1–3 mm). Due to their large size, most wipes are folded to smaller dimensions and placed in small bags, which are packed individually or collectively (approx. 30 pieces per package). For their production, non-woven fabrics [55] are used. A new product in England, Wales, and Northern Ireland is the eco-friendly adhesive remover wipe, which can be disposed of in the toilet, and the wrapping used to protect the wipe can be sent to recycling facilities. Adhesive skin removers in the form of wipes are also used as cleaning products, as they, besides making it easier to peel off the wafer, are designed to remove adhesive residue and dirt. Cleansing skin wipes are the equivalent of products that remove adhesive residue (pouch or wafer adhesive), ensuring the removal of soiling as well as skin care around the stoma, in the form of wipes based on surfactants [17,18,19,20,21,22,23,24].

3.1.2. Skin Cleansing Formulations

Skin cleansers, as the name suggests, are products designed to clean the stoma and peristomal skin. They are used in daily cleansing when changing stoma appliances. The process of cleaning the skin around the stoma itself should not affect the skin, so the user should make sure to use only those products designed for people with stomas. Commonly available baby wipes, other wet wipes not intended for stoma patients, and toilet soaps should be avoided, as they contain fragrances and moisturisers that may impair the adhesive properties of the wafer or cause irritation and allergic reactions. After cleansing, it is important to dry the skin around the stoma thoroughly. Dry gauze pads, toilet paper (white), or soft kitchen towels can be used for this purpose [42,58,62].

Skin cleansing formulations dedicated to people with stomas offer properties that cleanse the skin of stoma secretions and adhesive residue, while also being soothing and preventing oedema and pruritus, as well as being tightening, nurturing, and protecting. When used regularly, they improve the barrier properties of the skin and prevent peristomal skin complications. The cleaning products should be used before applying any barrier products to the skin [55].

The simplest cleaning agents are soap and water. Sterile water is not necessary for an appliance change, as this is considered a clean procedure, not a sterile one [11].

Other physicochemical forms that are used as alternatives to water and soap include foams, liquids, and wipes. Soaps used by people with a stoma can come in bars (e.g., green soap) or in liquid form. Chemically, green bar soap is a mixture of potassium/sodium salts of higher fatty acids (e.g., sodium palm kernelate, sodium tallowate, and sodium cocoate) without any additives such as colourants or fragrances. In many countries, it is made from soft or liquid Marseille soap, which consists of 72% pure potassium soap (based on olive oil or palm oil). It also contains 0.5% glycerine, 0.4% sodium chloride, up to 0.1% soda, free fatty acids, or tetrasodium etidronate. This soap is recommended by surgeons [80]. The bar soaps dedicated to people with stoma are full of active substances, such as boric acid and nano silver, which have disinfectant and antiseptic effects. These products may contain isopropyl and propyl alcohol.

Liquid soaps, on the other hand, are an aqueous solution of surfactants (e.g., sodium laureth sulphate, cocamidopropyl betaine, coconut oil acid polyglucoside, and cocamide diethanolamine (cocamide DEA)), enriched with foaming agents (e.g., glycol distearate), preservatives (e.g., phenoxyethanol, ethylhexylglycerin, Dimethyl-Dimethyl hydantoin (DMDM hydantoin), methylchloroisothiazolinone, and methylisothiazolinone), fragrances (lavender oil, linalool, limonene, geraniol, and coumarin), pH regulators (citric acid and sodium hydroxide), and possibly antibacterial substances (e.g., colloidal silver).

According to Black [31], it is not advisable to use soaps that are harsh or contain carbolic acid, disinfectants, or other chemicals, as they remove lipids and proteins from the stratum corneum. These products should contain mild surfactants and phospholipids. They should also contain moisturising substances that promote the regeneration of the barrier layer.

Instead of using common bar soaps, it is recommended to use foams. Foams are dispersion mixtures in which a gas is dispersed in a liquid. The formation of foams in liquids is favoured by surfactants, reducing the surface tension and increasing the viscosity of the formulation. Depending on the manufacturer, this product may require rinsing. Foams are light and pleasant in texture. They contain mild surfactants (e.g., coconut glucoside and sodium cocoamphoacetate), preservatives (e.g., sodium benzoate, potassium sorbate, and benzyl alcohol), and pH adjusters (e.g., citric acid). Their formulations include active ingredients that have soothing, moisturising, anti-inflammatory (e.g., sodium hyaluronate, aloe vera gel, plant extracts of calendula, plantain, arnica montana, panthenol, allantoin, ectoin, and troxerutin), and hydrolipid-rebuilding (e.g., type 1 ceramides) effects.

Skin cleansers in the form of a liquid for soaking into non-woven fabrics are called cleansers or lotions by their manufacturers [81,82]. Lotions are most often oil-in-water (o/w) emulsions and rich in active ingredients with moisturising and nourishing properties, e.g., linseed oil, which creates a layer on the skin that protects against excessive water evaporation. Lotions also contain ethanol (solvent), potassium hydroxide (pH adjuster), propyl gallate (antioxidant), and fragrances. Cleansers, on the other hand, are an aqueous solution of surfactants (e.g., disodium cocoamphodiacetate, sodium lauryl sulphate, and sodium laureth sulphate), enriched with soothing substances (e.g., allantoin and panthenol), moisturisers (e.g., propylene glycol), preservatives (e.g., phenoxyethanol and methylparaben), and isopropyl alcohol (solvent).

Most liquid cleansers are simply sprayed and wiped without any need to use soap/water first, but prior to using them, users should be sure to check how they should be used [83].

Skin cleansing wipes can also be an effective substitute for soap and water, as they provide effective and convenient care while helping to remove impurities related to stools or urine [83]. The wipes can contain surfactants, such as those found in liquid soaps or cleansers. Active substances can be used as skin barrier enhancers such as biolin P (a prebiotic mixture of inulin and glucooligosaccharide, which stimulates the growth of beneficial bacterial flora) and preservatives (e.g., phenoxyethanol and ethylhexylglycerin). There are also cleansing wipes on the market that have an additional antimicrobial effect, containing 0.11% polyhexanide. According to patients, some wipes perform poorly on a thick layer of dried adhesive. Wet wipes should only be used occasionally, such as when the patient is out somewhere and requires unexpected cleaning when warm water is unavailable [7,55,81,82].

Most major brands will offer cleansers in alcohol-free formulas, and many are no-rinse too. The best pH for cleansing products is 5.5. The products should not cause any feeling of tightness of the skin, instead cleansing without changing the hydration and elastic properties of the skin. These products can be found on the market in bottles of 50 mL, 200 mL, and even several litres, as well as individually packaged wet tissues [11,55,84].

3.1.3. Barrier Products

Safeguarding the skin surrounding the stoma from exposure to faecal output, urine, and the stripping effects of many adhesives is crucial for maintaining skin integrity and overall health. So far, this protection is achieved through the use of barrier (protective) products, which create a protective film on the peristomal skin prior to the application of the pouch. The protective layer formed by polymer compounds on the skin’s surface is referred to by ostomy nurses as a second skin, as it protects the skin layers from irritation (whether from bowel contents, urine, or stoma appliances), mechanical damage, and drying out. Furthermore, by creating a protective barrier between the skin and the wafer, the retention time of the stoma wafer on the skin is extended. Barrier products do not impair the adhesion of the stoma appliance to the skin and help attach the pouch more effectively when the skin is wet or broken. They are applied to the skin before attaching the pouch, and immediately after cleaning and drying the skin. They are quite often used preventively and can be used to aid the healing process for a variety of skin conditions, including peristomal skin damage. They protect the skin from the outside without delaying or altering the healing process. They have high viscosity and a fast drying time. Like adhesive removers, they are hypoallergenic products [8,17,18,19,20,21,22,23,24,26,33,34,35,55,58].

Originally, organic polymers were used as barrier agents, such as polyvinyl acetate, acrylate terpolymer, methyl methacrylate, isopropyl polyvinyl methacrylate, or cyanoacrylate, which have occlusive and water-repellent characteristics, and isopropyl ethyl alcohol was added to the formulation to accelerate evaporation. Plasticisers that make the film flexible and prevent it from crusting (e.g., dimethyl phthalate) and solvents (e.g., ethyl acetate and isooctane) were also included in the formulation [26,55,78]. The downside of these agents was the need for an organic solvent (organic solvent base) and/or alcohol, which are themselves peristomal skin irritants. Furthermore, removing them from the skin also requires the use of agents similar to skin irritant adhesive removers. They are therefore not recommended for use on irritated skin. As film-forming agents, silicone polymers can also be used as barrier products. They are inert (skin-friendly), do not sting, and dry without leaving a residue [78,85,86]. The most common are hexamethyldisiloxane, poly phenylmethylsiloxane copolymers, siloxane copolymers, blends of silicone copolymers, and dimethicone [55,83]. The first formulations containing silicones were aqueous-based creams and lotions protective against peristomal skin excoriation. A benefit of formulations with silicones is the reduced pain sensation during application compared to preparations with added alcohols [8,11,28,76].

Depending on the type of film-forming substance used, different physicochemical forms of barrier formulations are available. Organic polymers as skin protectants are used in wipes, sprays, and emulsions, while silicones can be used in gels, liquids, sprays, emulsions, and wipes. Barrier formulations with foam applicators (available in 1 mL and 3 mL packs) are a special product based on silicones. The barrier fluid used with the foam applicator creates a transparent, breathable coating that avoids leaving a sticky residue and dries quickly. This allows for more efficient wound monitoring and features a unique terpolymer formula that conforms and adapts to the skin for more natural movement without compromising skin protection and can be applied to areas with curves and creases. Barrier films accommodate a range of body shapes, including areas with creases and folds, and last through movement and position changes. The most common forms are wipes and sprays [8,17,18,19,20,21,22,23,24,75,79].

Wipes (gauze pads) soaked in a liquid (solution, emulsion, or lotion) can also be used as wipes under the adhesive. The fluid used to soak the wipes contains film-forming substances, is viscous, dries quickly, and forms a waterproof, non-sticky protective film on the skin to protect against irritation and skin stripping due to frequent removal of the adhesive barrier, promoting adhesion of the appliance to the skin. The barrier wipes prevent any residual adhesive substance from sticking to the skin, enabling painless wafer changes. The protective film formed on the skin also does not require removal during each pouch change. It soothes irritated and sore skin and reduces itching. Silicone-based wipes are odourless, in contrast to alcohol-based products. They also do not dissolve lipids, dry out, or remove oils from the skin. They protect the skin for up to 72 or even 96 h, and do not cause layers to build up. They are recognised as safe and effective, even when used frequently, and can be used by people who are allergic to latex, and some of the barrier wipes available on the market can be used by children with stomas.

Skin barrier wipes come in both sterile and non-sterile forms. They come in different sizes (29 mm × 29 mm–115 mm × 85 mm), thicknesses (1–3 mm), and shapes (square or rectangle). Like adhesive remover wipes, they are made of non-woven fabric as well as foam. They are packaged either collectively or in small bags. The number per pack is 30–100 items. According to the users, they are convenient, handily packaged for single use, and ideal for travelling or on-the-go use. One of the complaints reported by patients is that they are often too lightly soaked while the wipes themselves have too little or too much surface area. The wipes are intended for short-term use only with a maximum of one wipe per day (two wipes per day for colostomy patients). Skin-protective wipes are often used incorrectly as antiseptic cleaning wipes. They do not contain antiseptic lotion and are not moist enough for cleaning purposes [21,79].

Barrier formulations developed by stoma appliance manufacturers are also available on the market as sprays and pump aerosols. The core of their formulation is the liquid used to soak the barrier wipes. Sprays, just like barrier wipes, are applied directly to the peristomal skin. These products have a very fast drying time; the liquid is sprayed from the aerosol container under the influence of propellants. The physical–chemical form of the spray does not compromise the level of protection (like the wipes, it protects the skin for up to 72 h). Pump aerosols are available in approx. 30 mL bottles and sprays are available in 50 mL bottles. The handy size of the packaging makes it possible to fit it into a pocket, handbag, or backpack.

There are also protective products on the market, based on the principle that the film-forming substance does not form a barrier (protective) film on the skin’s surface, but rather has a skin care effect that reinforces the skin’s natural barrier by increasing the skin’s moisture content and restoring the natural hydrolipidic film. These include foam products (cleansers) and gels (stoma skin care products).

The stoma skin care gel soothes irritated skin around the stoma while creating a suitable micro-environment for natural regenerative processes. The formulation contains moisturisers (e.g., arginine, glycerine, sodium hyaluronate, vegetable oils high in essential fatty acids, such as olive oil, sunflower seed oil, and macadamia oil, and plant extracts, such as Phragmites kharka and Poria cocos) and prebiotic substances, which create a moisturising and protective barrier on the skin. This barrier also prevents the negative impact of pathogenic micro-organisms, protecting irritated skin from infection. By providing the skin with the right level of hydration, protecting it from transepidermal water loss, it restores the appropriate elasticity and minimises the sensation of tension and itching. Auxiliary ingredients are included in the gel formulation, such as gelling agents (e.g., carbomer), antioxidants (e.g., tocopheryl acetate), solvents (1,2-hexanediol), skin conditioners (e.g., caprylyl glycol), or preservatives (e.g., sodium benzoate or hydroxyacetophenone). The gels are available in 50 mL packages [11,18,87].

Barrier creams are designed to prevent chafing by forming a protective film on the skin. They are particularly effective for treating dry and flaky peristomal skin, as they are specifically formulated to soothe, condition, and moisturise. Being non-greasy, they ensure proper adherence of the stoma pouch. Most often, they are in an emulsion form and contain silicones (e.g., cyclomethicone and dimethicone) and other hydrophobic substances (mineral oil, petrolatum, ozokerite, and lanolin oil), thus forming a protective film, as in wipes and sprays. Patented polymer formulations with barrier properties are also included in the formulation of some products. These creams have a skin-friendly pH and allow the appliance to adhere without affecting its adhesion. They are available on the market in 60 mL containers [11,17,74,87].

Regardless of the variety of technological solutions in the group of barrier products, the basis of peristomal skin protection is a properly fitted ostomy system.

3.1.4. Filler Pastes

Filler pastes or stoma pastes are commonly used to fill in skin dips, creases, and crevices between the edge of the opening of the stoma pouch and the mucosal surface of the bowel. Stoma pastes create a flat surface to which the appliance (a bag or flange) adheres. Filler pastes have a similar purpose to barrier seals and rings, which can be moulded around the stoma to enhance the fitting system [2]. The pastes usually have a greasy and sticky consistency. They are made from the raw materials used to produce adhesive skin barriers (e.g., isopropyl ester of polyvinylmethylmethacrylate copolymer, gelatine, polyacrylamide, or pectin). In addition to their sealing and filling effect, they have a protective, healing, and irritation-relieving effect, as they contain allantoin, for example. Depending on the type of skin damage, hydrocolloid-based pastes can heal the skin after as few as several uses. The skin should be washed and dried thoroughly before applying the paste. Some of the formulations available on the market contain alcohol (e.g., ethyl and butan-1-ol) and preservatives from the paraben group. These products absorb moisture. The fast-drying pastes do not stick to the fingers. For better application of the paste, it can be warmed in the hands or placed in warm water. Stoma sealants are available as pastes in tubes (60 g packs) as well as pre-formed strips (a pack contains one 6 g strip) [2,8,11,17,18,19,20,21,22,23,24,25,58,74].

Silicone-based fillers available as gels are a brand-new type of product on the market. These fillers are applied directly from a tube or syringe into the skin’s recesses and sculpted into a flat surface, ensuring a secure flange adhesion. Silicone-based filler gels set within 20 min from application via a process called room-temperature vulcanisation, which was activated by the skin’s moisture and humidity. Silicone gels are waterproof, transparent, and have a tacky texture, enhancing their effectiveness [78,88,89].

3.1.5. Soothing and Healing Formulations

The role of soothing products is to reduce the negative effects of the problems resulting from having a stoma. These products also have healing properties. There are powders, creams, and lotions available on the market.

The healing–protecting powder comes in the form of a fine particle, granulated hydrocolloid (e.g., pectin-based powder, made from karaya gum), which, when in contact with the skin, penetrates its pores [53,74]. The powder is an efficient product recommended for stopping wound exudation (absorbing excess moisture), as, when applied to clean and dry skin, it closes oozing skin lesions, forming a protective layer against corrosive intestinal contents and urine. The powder promotes healing and has a preventive effect against the recurrence of irritation. The powdered skin holds the pouch wafer in place, allowing extended use. Commercially available products in 25 g packs have a specific applicator to facilitate spot dosing of the product or the ability to apply it to a large area of the skin. Excess powder should be removed before the pouch or wafer is applied. The active ingredient included in the powders is aloe vera [2,17,18,19,20,21,22,23,24,49,87]. It is a powder-based paste, which is created from granules in an oil-based paste [2].

Another type of product is a lotion, which soothes irritation and injuries around the stoma, relieves pain, heals, and gives relief. Lotions do not contain alcohol and therefore do not cause a burning sensation. Once absorbed, they do not leave an oily film on the skin but improve the adherence of the stoma pouch. They are available in packs containing approx. 30 mL of the liquid. The lotion should be applied to a dry gauze pad and then spread evenly over the affected and irritated skin [17,18,19,20,21,22,23,24].

The skin under the stoma wafer very often becomes dry and irritated. Dedicated creams can be applied to the skin around the stoma to alleviate these symptoms. These are usually white, non-greasy emulsions that do not adversely affect the adhesion of the wafer to the skin. They are fragrance-free and quickly absorbed, leaving the skin soft and smooth. They can be used each time a wafer or pouch is changed. A thin layer of the cream should be applied to the skin and allowed to fully absorb. The active ingredients in the products are aloe vera and vitamins A, D, and E [17,18,19,20,21,22,23,24,28].

This group of products may also include those mentioned earlier, such as sealing and healing pastes or protective gels, as the products offered to patients may have several simultaneous functions.

3.1.6. Odour Eliminators

The filters in the bag prevent odours from escaping from the bag, but many of the patients with ileostomies or colostomies find the smell of their waste unacceptable [11,19,75]. For extra confidence, some people also use neutralising, odour-absorbing products. These effectively neutralise and remove the bad odours associated with changing stoma appliances. They can be used by everyone with a stoma, regardless of the type. These products do not cause skin irritation, do not damage clothing, and do not stick or stain. The products can be used while travelling [11,74,75].

Drops, liquid deodorants, and sprays are available on the market. The products are often not reimbursed, although if they are, then it is one pack per month [79].

The drops are a colourless, fragrance-free, and completely safe-to-use odour-absorbing liquid. They contain compounds such as aluminium sulphate and zinc sulphate dissolved in purified water. When changing the pouch or emptying it, 1–2 drops are added. Specialist stoma nurses may also recommend odour-neutralising deodorant drops for selected patients, which are a concentrated solution. These provide a longer-acting deodorising effect than sprays and are more discreet [79].

Sprays, on the other hand, neutralise odours on clothing and those in the air. The product can be applied by squeezing the atomiser 3–5 times directly into the stoma pouch before it is attached, taking care not to spray the adhesive. The spray can also be applied to the material of the stoma pouch and in rooms where stoma appliances are being changed or the pouch is being emptied. They come in different fragrances, e.g., apple, lemon, jasmine, cinnamon, Victorian rose, lime, and grapefruit. The product should be shaken before use. Their formula is mainly based on essential oils (pine and eucalyptus) and water and ethanol extracts, e.g., lavender extract, with the addition of such surfactants as sorbitan monolaurate. They are available in 210 mL atomiser bottles or a 50 mL mini version. Their drawback is their high cost for their capacity. As a result, many people advise patients to purchase household air fresheners. In this case, it should be sprayed into the air, as it must not be sprayed directly into the stoma bag [18,79,87].

Liquid deodorant (lubricating deodorant, multi-lubricating effect) is an odour-reducing product that is applied directly to the pouch, replacing the odour with that of a light lotion and, thanks to its long-lasting lubricating effect, allows the bowel contents to move freely to the bottom of the pouch, preventing the bowel contents from settling around the stoma, which also makes emptying the pouch much easier. The name deodorant here has nothing to do with the aerosol product, and the name is simply meant to be associated with patients who are camouflaging and eliminating bad odours. It is available in small bags (7.5 mL) and bottles (240 mL) [17,18,19,87].

3.2. Avoidance and Management of Stoma Problems

Any intact skin around the stoma is indispensable for stoma care, as it is the surface to which the adhesive barrier and collecting pouch are attached. As ostomy appliances need to be repeatedly applied and removed, skin care should be properly carried out to ensure this protects the integrity of the peristomal skin. This is to minimise the risk of peristomal skin complications and to enable proper use of the ostomy appliance, which, as demonstrated earlier, plays a significant role in the quality of life of stoma patients. By proper care, first and foremost, we mean that proper hygiene is maintained. The skin around the stoma is taken care of when changing the stoma pouch, which, if inappropriately applied (e.g., too quickly or carelessly), can lead to a shorter wearing time and cause peristomal skin complications [58].

When PSCs occur, appliance and accessory solutions are applied. For example, in the case of fungal and bacterial infections, it is recommended to use antifungal powder as a skin barrier-protective solution. The management of peristomal candidiasis involves cleansing the affected area with water and soap, followed by thorough drying. Antifungal sprays can also be applied. The use of broad-spectrum systemic antibiotics or antibacterial soaps for skin cleansing can disrupt the normal microbiome. To support the normal skin microbiome, patients and nurses should cleanse the skin with water or, if grossly soiled, a mild non-antibacterial soap and rinse thoroughly [53]. Irritant dermatitis can be managed by applying a pectin-based ostomy powder, which is then sealed to the skin using barrier film or a water-dampened cloth to create a tacky surface. It is also important to reassess the appliance to ensure proper fit and function. If the patient suffers from folliculitis, then an adhesive remover and regular shaving are recommended. Protective powder, paste, or barrier films are suggested as a first solution in mucocutaneous separation and wet skin. Preventing skin stripping requires careful removal of the adhesive parts of the pouch system. Using a non-alcohol-based skin protectant wipe or spray prior to pouch application, along with an adhesive remover wipe, can be beneficial. Patients should also be re-trained on stoma care techniques [41,53].

Stoma accessories, including peristomal skin care products, are also used in overcoming and reducing ostomy appliance issues. For pouch leakage, reviewing the appliance and/or seal and reviewing the body profile, contours, patient technique, and/or output are recommended. Instead of changing the appliance provider, adhesive sprays or glue designed to increase the adhesive properties of the fleece can be used as an effective alternative [11].

In case of topical allergic reactions of the peristomal skin to the appliance material or accessory ingredients, patients should use another adhesive remover, skin barrier, or appliance with a different flange material (silicone/hydrocolloid). In some cases, a reduction in accessory use is indicated. Dietary changes and appliances with an effective filter are recommended for ballooning or an odour issue. If a smell of effluent escapes the pouch, patients can use deodorant, drops, or granules designed to neutralise any odour. These can be introduced into a clean bag before putting it on. To address pancaking, one of the proposed solutions is to cover the filter with a sticky patch to prevent gas from escaping from the bag. Alternatively, placing a small piece of crumpled tissue inside the bag can help keep the sides apart. Lubricating the inside of the bag with baby oil or a specialised gel may also encourage stool to move to the bottom of the bag. For ileostomy output that is excessively loose, which may fill the bag quickly, increase the chance of leaks, and cause dehydration, patients could consider using thickening medications such as loperamide, consuming rehydration solutions, following a low-fibre diet, and increasing their starch and/or carbohydrate intake. There are also thickening sachets on the market for the device [41,68,69].

When the source of bleeding is skin surrounding the stoma, it is more important to ensure that the stoma pouch fits correctly and to cut the appliance’s aperture more accurately. For granulomas, as with bleeding, it is advisable to check that the pouch fits properly. In case of stoma necrosis, a transparent and/or two-piece appliance should be used to allow observation of the stoma. To manage a stoma, prolapse patients can use stoma caps and shields, supportive garments, and belts. Patients should consider the application of alternative appliances to accommodate the stoma’s changing size, a barrier ring to support a wider aperture, a modular flange, and wearing clothes that do not catch or drag the stoma, with loose-fitting or pleated clothes to conceal any bulges. Patients with hernia complications may wear specialised ostomy support belts and garments, do light abdominal exercises, avoid physical strain, and maintain a balanced diet and healthy weight [41,55,69,71].

Many patients with a stoma do not need to use accessories offered by the market. Therefore, in the event of problems with their stoma, such as skin around the stoma or ostomy appliance issues, assistance in choosing the right equipment and accessories is provided by stoma nurses [2,8,11,12,13,14,15]. The interventions and management of stoma problems with appliances and accessories proposed in the literature are summarised in

Table 1. Common peristomal skin issues, ostomy appliance issues, stoma issues, and their therapeutic framework sources.

Issue	Appliance and Accessory Solutions and Treatments	Other Solutions	Sources
Peristomal skin issues
Candida	Apply antifungal powder to the affected area, apply skin barrier film over the antifungal, and let it dry completely before attaching the pouching system	Avoid excess moisture on the peristomal skin by thoroughly drying the pouching system Use antifungal drugs such as miconazole, clotrimazole, and allylamines If compromised, consider a dermatology review	[2,3,48,63,90,91]
Contact dermatitis	Exercise care when using accessory products like adhesives, tapes, adhesive removers, and skin cleansers, as well as antiperspirants or deodorants, as they may act as potential allergens Use barrier film, protective powders, and seals	Review the appliance and resize the aperture; check the patient’s technique Choose a non-adhesive pouching system until the dermatitis has healed	[2,3,22,48,63,90,91]
Mucocutaneous separation	Apply protective powder, paste, and/or seal for superficial cases	Prevent leakage to reduce the risk of infection Use alginate dressing for deeper wounds	[3,48,90,91]
Folliculitis	Apply adhesive remover to avoid pulling hair from follicles, and use a skin sealant to protect the skin Use antibacterial soap when changing the pouching system and cleansing the skin	Shave regularly, avoid straight-edge razors, clean and completely dry the skin prior to using a new pouching system Discuss your problem with your primary healthcare provider regarding a prescription for a topical antibiotic powder	[48,63,90,91]
Pyoderma gangrenosum	None	Steroid treatment and/or dermatological review	[2,3,48,63,90,91]
Skin creases	Fill with filler paste, strip paste, or a seal	Check technique/correct appliance	[3,48,63,90]
Skin stripping	Use adhesive remover to prevent irritation of peristomal skin Apply barrier films or powder to the lesion during each pouching system change	Teach the patient proper techniques for applying/removing the pouching system, tapes, and any adhesive products Consider using the “crusting” technique for severe skin stripping	[3,22,48,63,90,91]
Sore skin	Use protective powder and then apply barrier film or cream	Adjust the aperture size and evaluate the patient’s technique	[2,3,22,90,91]
Wet skin	To dry the area, apply protective powder and then use barrier film	Use a cool hairdryer at a distance	[2,3,48,90,91]
Ostomy appliance issues
Allergies	Use an alternative adhesive remover, skin barrier, or appliance with a different flange material	Consider reducing accessory use	[48]
Pouch leakage	Choose a proper fitting pouching system and use accessories (pastes or seals) to fill in areas of the skin where leakage could occur	Empty the pouch before it is half-full Gas should be released before the pouch fills with air	[48]
Ballooning	Evaluate the appliance for potential improvements, such as upgrading the filter, adding a vent, or opting for a drainable pouch	Employ dietary modifications	[48]
Pancaking	Use stickers for coating the appliance filter	Enhance fluid intake, lubrication, or tissues within the appliance	[3,48]
Odour	Deodorant	Employ dietary changes and more frequent appliance changes	[40,48]
Watery output	Place thickening sachets in the appliance	Use thickening medications, rehydration solutions, and low-fibre diets, and increase intake of starches and carbohydrates	[40,48]
Stoma issues
Bleeding	Better cut the appliance aperture	Use direct pressure, cauterisation, sutures, and silver nitrate	[48]
Granulomas	Better cut the appliance aperture; ensure proper fit of the pouching system Use stoma barrier paste at the mucocutaneous junction	Refrain from wearing tight-fitting clothing or belts over the stoma area Cauterise with silver nitrate	[3,48,63]
Necrosis	Use a transparent and/or two-piece appliance to allow observation	Refashion the stoma	[48]
Parastomal hernia	Level the skin, use flexible convex appliances and hernia supports such as belts and garments, and review the appliance	Perform light abdominal exercises, avoid physical strain, and have a balanced diet	[3,48]
Prolapse	Use stoma caps and shields, supportive garments and belts, barrier film, and alternative appliances designed to adjust to the stoma’s changing size	Wear clothes that do not catch or drag the stoma	[3,48]

.

4. Discussion

With the growing number of initiatives aimed at raising stoma awareness, coupled with the high rates of bladder, colorectal cancer, and inflammatory bowel diseases, the demand for stoma-related equipment and accessories is on the rise [92]. According to predictions, it is projected to grow at a compound annual growth rate (CAGR) of 5.1% between 2021 and 2028 to reach USD 4.8 trillion in 2028. Top stoma appliance manufacturers include Coloplast Corp. (Humlebaek, Denmark), ConvaTec Group Plc (Princeton, NJ, USA), Welland Medical Ltd. (Crawley, United Kingdom), Salts Healthcare Ltd. CliniMed (Aston, UK), Hollister Incorporated (Libertyville, IL, USA), B. Braun Melsungen AG (Melsungen, Germany), 3M (Saint Paul, MN, USA), and others [92]. Stoma care appliances and accessories are in the top 20 prescriptions, so it is essential to optimise their use. Each year, stoma companies continue to invest in the research and development of materials for stoma appliances that are suitable for all stoma patients and all skin types, while being totally disposable [25]. An example of this kind of polymeric material is silicones (polysiloxanes).

Silicones have many unique properties: they are fragrance-free, hydrophobic, permeable to gas, miscible with many substances, biocompatible, and durable (resistant to oxygen, moisture, acids, and salts). Moreover, they are safe, noncomedogenic, hypoallergenic, and water-resistant. Silicones are extremely flexible and have low surface tension. No interference with the stratum corneum’s lipid organisation has been discovered [25,80,88,91,93]. Silicones are ingredients that provide skin protection and promote healing. The protective film formed by silicone oils is not oily, allowing natural skin respiration, and protects against mechanical factors as well as water evaporation [25,46,80,88,91,93]. This is why silicones have been widely used in peristomal skin care, and research is still ongoing to create new silicone compounds designed for contemporary ostomy appliances [46,51,81].

Silicone-based stoma products are created to improve skin integrity and extend the wear time of stoma appliances for many patients. These products include seals, pastes, flange extenders, adhesive removers, skin barrier products, and fillers [51,81,90,94]. Silicone seals can be stretched and shaped to snugly fit around a stoma and then return to their original form, making them particularly beneficial for elderly patients who may not be able to apply a conventional seal with ease and accuracy. These seals maintain their integrity and shape during extended wear while allowing the skin to breathe, reducing the risk of maceration and promoting healthier skin. The range also features flange extenders and silicone gel for filling creases and uneven areas around the stoma.

They are present in adhesive removers to avoid skin stripping, especially if patients also suffer from other conditions, such as skin lesion pyoderma gangrenosum, which is highly painful [46,51,81,94].

New silicone compounds entering the market are expected to overcome the limitations of traditional silicone technologies to provide novel methods of moisture management (MARSI and MASD risk reduction) that have significant clinical advantages over traditional hydrocolloid flanges. New silicone formulations are designed to absorb significant amounts of moisture and body waste, making them more hygienic and practical for stoma care applications. Silicones, unlike hydrocolloids, also do not require a humid environment to ensure adhesion. The immediate adhesion and perfect fit of silicones is due to their low surface energy and high elasticity. Furthermore, the adhesion remains unchanged over time (cross-linked polymers are used), making it easy to remove the adhesive without damaging the skin. Modern silicones retain their integrity and shape when exposed to urine and intestinal contents and can be quickly removed from the skin in their entirety, as they also do not leave contaminants or residues [46,51,81,94].

Stoma companies also provide support for patients through available care programmes and helplines (telephone support for stoma patients). They also send patients free samples of their products.

In contrast to this are the results of research on the needs of stoma patients, where respondents emphasise the fact that they cannot use modern solutions or replace stoma equipment with new (clean) ones in accordance with their needs for financial reasons, such as reimbursement limits [4]. Nearly half of the respondents (45.8%) claimed that they have to spend their own financial resources, in particular on peristomal skin care products, including barrier products and odour-neutralising and sealing preparations [93]. In another study, 54.8% of the respondents declared that they clean their stoma with only saline, and 28.0% use only soap and water [46]. Therefore, it is not necessarily the inappropriate composition or physicochemical properties of the preparations that are responsible for frequent irritations and side effects, but financial constraints.

Basil [94] draws attention to another problem. Many patients with a stoma are well informed and proactive. Some of them actively participate in local support groups, attend events, engage in Internet forums, and benefit from clinics run by stoma care nurses. However, the majority lack adequate information, have irregular access to nurse appointments, and often rely on companies rather than medical professionals for guidance. There should be no financial incentive to push or use additional products. Ostomy accessories should always be provided free of charge, but the current system of healthcare often encourages increased use rather than prioritising what is best for the patients.

There are relatively few research results on patients’ satisfaction with skin care products, and those published in the literature are from before 2010 [12,28]. For example, Rudoni [12] presented the results of survey research on the use of adhesive removers by patients. The findings strongly indicate that patients gain significant benefits from using silicone-based adhesive removers when detaching their stoma pouch.

Saerte et al. [95] emphasise the fact that users need personalised medical intervention and often exhibit strong brand loyalty once they identify a product that meets their needs. However, loyalty can increase the risk of side effects as a patient’s body undergoes changes due to factors such as ageing, weight fluctuations, illness, or allergic reactions. Consequently, the optimal choice of accessories is likely to evolve over time. Additionally, patients’ requirements may shift if their care routines improve or decline, particularly if their ability to manage self-care diminishes [95].

According to EU legislation, the packaging of medical devices must indicate the qualitative composition of the product. Additionally, for devices absorbed by or locally dispersed in the human body, the packaging must provide quantitative details on the main component or components responsible for the primary expected effect [96].

In some cases, the ingredients or the %wt and %vol of peristomal skin care products may not be disclosed due to proprietary considerations [28,55,58,62,74]. However, the lack of information on the composition can be problematic for the consumer when searching for a product with a specific composition, especially when allergies or other adverse reactions occur. This is confirmed by the results of the study performed by Cressey et al. In their study [75], they evaluated stoma skin care products as a cause of peristomal dermatitis. The analysis of the ingredient compositions revealed that several stoma skin care products were identified as triggers for irritating and/or allergic contact dermatitis. Barrier products were the most commonly used stoma skin care accessories and were frequently associated with cases of dermatitis.

Herbal-based preparations, especially cosmeceuticals, play an important role in skin care [97]. However, in the case of ostomy products, the observed development focuses on new adhesive technologies, particularly silicone-based ones, rather than typical skin care products. The literature review indicates that only a few plant-based raw materials, such as aloe vera, calendula, plantain, or arnica montana, are included in these preparations. This is undoubtedly linked to the higher risk of allergic reactions in ostomy patients. Moreover, patients expect high effectiveness and safety from these products. Plant-based raw materials can vary in chemical composition depending on the place of cultivation, climatic conditions, and the processing method. Ostomy preparations have relied on synthetic raw materials for over 70 years. Changes in this area may be slow, and the introduction of new ingredients requires time for appropriate clinical studies.

The literature clearly indicates the significant role of stoma nurses in preventing peristomal skin problems. Hence, articles characterising ostomy equipment and accessories contain guidelines for nurses. However, it should be emphasised that there is a small number of these articles, and they are from the period of 1995–2015. Currently, the main source of knowledge for both patients and ostomy nurses is information materials on the websites of appliance manufacturers and organisations supporting people with a stoma [63,98]. There are also modern solutions such as supportive apps [99], but as indicated in the study, patients were only moderately satisfied with them. A supportive app was most beneficial for patients who had a stoma for less than three years, were experiencing an acute situation, or faced stoma-related issues. However, most patients preferred receiving information either online or in printed form.

After analysing the chemical composition and physicochemical properties of peristomal skin care products, we cannot disagree with Boyles’ [98] opinion that granting patients unrestricted access to products, which may be unsuitable for their needs, warrants consideration. Boyles further suggests that stoma nurses should oversee the recommendation of all these products. Researchers have noted that if a product does not directly affect the stoma and is unlikely to harm peristomal skin, its use could be guided by patient preferences. These products include adhesive remover sprays or wipes, flange extenders, hand-cleansing gels, deodorisers, thickening sachets, anti-pancaking products, and pouch covers. For peristomal skin complications requiring clinical assessment, there is a strong consensus that patients should be referred to a stoma nurse [98].

Morss-Walton et al. [2] also point to the expanding role of dermatologists in managing complex or persistent peristomal skin complications. A comprehensive understanding of the ostomy appliances, accessories, and potential peristomal skin conditions enables dermatologists to recognise and address skin complications early.

Study Limitation

The comprehensiveness and usefulness of the results are influenced by the use of only English-language databases and information published before 2024. Patents, animal research, basic laboratory-based research, and conference abstracts were also excluded from the review.

5. Conclusions

The presented overview of the composition and physicochemical properties of peristomal skin care products indicated that there is a need to continuously evaluate their composition and effectiveness. As shown in the summary, appropriate intervention and management of stoma problems with appliances and accessories can reduce the leakage and skin issues that affect many patients. Helping patients optimise routinely used products can also prevent unnecessary and wasteful prescriptions and reduce the costs of their care. Because of the number of products available on the market, it is necessary to instruct patients on how to use these products properly and to explain all the risks and benefits.

It is also important to keep in mind that only by considering the needs and preferences of patients can the right product be selected to improve the patient’s quality of life.

A new and crucial element of the topic at hand is silicone technology, which helped in the development of modern and effective stoma care products. Silicones are flexible, easy to apply, and leave no residue on the skin around the stoma.

A novelty demonstrated in our research is the lack of widespread availability of information regarding product recipes or the presence of substances with irritating or allergenic potential. Patients with peristomal dermatitis should be evaluated based on the type of skin care products they use to determine whether there is a need to remove or change these products or to examine the individual raw materials included in them. Additionally, manufacturers should be required to disclose all ingredients on product labels and material safety data sheets to facilitate the identification of new allergens and irritants.

Unquestionably, the critical issue that should be solved is the fact that, despite the wide range of products available on the market, financial constraints prevent some patients from fully accessing them.

6. Relevance to Clinical Practice

The market offers a wide range of peristomal skin care solutions. Therefore, it is necessary to categorise these products and characterise their chemical composition and physicochemical properties, application, and proper usage. Such information would enable nurses, dermatologists, and oncologists to provide better assistance to the ostomate. Additionally, the collected data serve as valuable resources for patients, helping them to learn how to properly care for the skin around the stoma.