A novel use for botulinum toxin A in the management of ileostomy and urostomy leaks.

PURPOSE: To assess the efficacy of Botulinum toxin A (BoNT-A) in the treatment of patients with hypercontractile stomas resulting in repeated pouching system failures and leaks. DESIGN: Prospective case series. SUBJECTS AND SETTING: Ten consecutive patients who presented to the outpatient stoma clinic with actively contractile stomas that shortened spasmodically resulting in leaks were offered treatment with BoNT-A if treatment with other measures had been unsuccessful. METHODS: Following an observed reduction in the peristalsic shortening of a stoma after intradermal injection of BoNT-A for hyperhidrosis, we conducted a prospective case series of 10 patients with pouch adhesive failures attributed to spasmodic shortening of the stoma. Ten patients, 3 with urostomies and 7 with ileostomies, were offered BoNT-A injection. The first was treated cautiously with 15 units of BoNT-A injected into the muscularis layer, followed by an additional 25 units injected 1 month later. Subsequent patients received doses varying from 50 to 100 units. Ongoing treatments ranged 50 to 100 units every 3 to 6 months. RESULTS: Seventy percent (n = 7) of patients reported a useful reduction in leakage and pouching system seal failures. In these 7 patients, the frequency of pouch changes changed from an average of 2.18 to 0.44 per day (over all 10 patients this was a change from an average of 2.35 per day to 1.16 per day). No adverse side effects were reported. CONCLUSION: Findings from this clinical case series suggest that BoNT-A may be a promising treatment in the management of patients with leaks caused by actively contracting stomas.

Correction of skin contour defects in leaking stomas by filler injection: a novel approach for a difficult clinical problem.

BACKGROUND: Stomal leaks can be associated with significant social, psychological and physical morbidity for ostomy patients. Poor fitting of the stoma appliance due to irregularities of skin contours is one cause of stoma leaks which commonly result in secondary irritant dermatitis prompting presentation to a dermatologist. In addition to skin-directed topical therapy and review of stoma appliances, correction of contour defects with intradermal injections of filler materials is one possible treatment to improve adhesion and reduce leaks. CASES: We report eight cases of ostomy patients, who presented with stoma leaks and associated dermatitis, who were treated with intradermal injections of the porcine collagen (Permacol™) or subcutaneous injections of polyacrylamide hydrogel (Aquamid Reconstruction™) for correction of skin contour defects. Resolution or improvement of symptoms was achieved for five patients, and no complications were noted as a result of treatment. CONCLUSIONS: This report represents the largest series of ostomy patients treated for correction of peristomal skin contour defects with injection therapy. Treatment was well tolerated and performed in the outpatient setting under local anesthetic. Attempted correction of peristomal skin contour defects using injection of filler materials represents a potential alternative to surgical intervention and can result in significant benefits for the patient.

Acute Kidney Injury Due to Interaction of Methyl-1-testosterone with Ciclosporin Metabolism in a Patient with Severe Atopic Dermatitis.

Ciclosporin is widely used in a number of inflammatory disorders and has the potential for drug interactions. We report here a case of acute kidney injury due to the interaction of ciclosporin with methyl-1-testosterone. This has not been previously reported and it is relevant as methyl-1-testosterone can be purchased online. Physicians should be aware of any over the counter or online purchased "supplements" and consider possible drug interactions.

Primary adenocarcinoma in peristomal skin: a case study.

Primary adenocarcinoma at an ileostomy site is an exceedingly rare occurrence but has been documented at the peristomal skin of patients with a long-standing ileostomy. Chronic irritation and resultant metaplasia is thought to be a key underlying mechanism for this phenomenon. Biopsy of newly developing lesions in the peristomal area of long-standing stomas is essential in order to avoid delayed diagnosis and limit complications. A 37-year-old man with a history of ulcerative colitis and ileostomy surgery 18 years prior presented with an asymptomatic polypoid lesion at the mucocutaneous junction. Initially diagnosed as pyogenic pranuloma, the lesion was treated using topical silver nitrate. This did not resolve the lesion but ulceration and bleeding were observed. A biopsy showed evidence of primary adenocarcinoma arising from the ileostomy site. The lesion was removed surgically, an ileo-anal J pouch was created, and the patient is currently receiving long-term follow-up and monitoring for any possible future complications. This case study is one of several in the literature suggesting that a high index of suspicion is warranted when ileostomy patients, especially those with a history of ulcerative colitis, present with unusual peristomal lesions.

The distribution of estrogen receptor beta is distinct to that of estrogen receptor alpha and the androgen receptor in human skin and the pilosebaceous unit.

Both estrogens and androgens play important parts in skin and hair physiology, although studies of estrogen action in human skin have been rather limited. Recently, a second estrogen receptor (beta) has been identified in many nonclassical target tissues, including androgen-dependent tissues. Therefore, we have revisited the role of estrogens in human skin and hair by comparing the pattern of expression by immunohistochemistry for both estrogen receptors (alpha and beta) and the androgen receptor. Immunolocalization of androgen receptors was only seen in hair follicle dermal papilla cells and the basal cells of the sebaceous gland. Little specific staining of estrogen receptor alpha was seen anywhere except the sebaceous gland. In contrast estrogen receptor beta was highly expressed in epidermis, blood vessels, and dermal fibroblasts, whereas in the hair follicle it was localized to nuclei of the outer root sheath, epithelial matrix, and dermal papilla cells. Serial sections also showed strong nuclear expression of estrogen receptor beta in the cells of the bulge, whereas neither estrogen receptor alpha or androgen receptor was expressed. In the sebaceous gland, estrogen receptor beta was expressed in both basal and partially differentiated sebocytes in a similar pattern to estrogen receptor alpha. There was no obvious difference in the expression of either estrogen receptor in male or female nonbalding scalp skin. The results of this immunohistochemical study propose that estrogen receptor beta and not estrogen receptor alpha is the main mediator of estrogen action in human skin and the hair follicle. Further studies with androgen-dependent skin are required to determine whether estrogen receptor beta has a regulatory role on androgen receptor expression in the hair follicle in parallel with its role in other androgen-dependent tissues.

Multidisciplinary care of skin problems in stoma patients.

Skin integrity is essential for the normal usage of a stoma appliance. There is little published on the prevalence, prevention or management of stoma skin problems. Allergic contact dermatitis is often cited as the cause, usually without evidence from formal investigations. The authors approached, by postal questionnaire, 525 patients who had had a stoma formation in the last 10 years. A total of 325 responded. All those who described a skin problem were invited to attend a multidisciplinary clinic for further investigations and appropriate treatment of their peristomal skin. This may be severe and debilitating as well as socially restricting. However, with a multidisciplinary approach a number of conditions can be recognized and easily treated, thus improving the quality of life for stoma patients.