The eternal question: to crust, or not to crust?
“Crusting” refers to the use of ostomy powder and a skin barrier film to create a dry surface over top of damaged skin around a stoma. It is done in the case of skin breakdown where there is a small amount of moisture present. Crusting allows the affected area of skin around the stoma to become dry in order to stick the flange/barrier and remain stuck, thus providing a more secure seal.
There are lots of types of ostomy powder; almost every ostomy product manufacturer makes one. There’s Brava from Coloplast, Stomahesive from Convatec, and Adapt from Hollister, just to name the big three. They’re all pretty much the same. The job of powder is to absorb moisture that comes from damaged skin as it heals. It is not medicated, it is not healing, it is just like a “million little sponges” to soak up a bit of wetness.
Skin barrier films
There are also lots of types of skin barrier films; each product manufacturer, as well as other companies make one. You might recognize names like No-Sting Skin Prep from Smith & Nephew and Cavilon from 3M. There are also similar products from Salts, Hollister, Convatec and Coloplast. The job of the skin barrier film is to seal in the powder and make a smooth surface for your pouching system to stick to.
The procedure is as follows:
- Clean skin around the stoma with warm water, and pat dry well.
- Squirt or puff some powder onto the red weepy skin around the stoma. (Careful… a lot can pour out at once, so squeeze gently.)
- Use a tissue to gently press the powder onto the damaged skin.
- Then, use the tissue to dust away the excess powder – using a gentle sweeping motion.
- Look at where you’ve put the powder – it will only stick to weepy areas. This is the only place it needs to be. If you gently brush away all of the powder and nothing has stuck, you didn’t need crusting in the first place. Skip ahead to 8 (below) – put on your pouching system as usual.
- Apply barrier film to the powder. If you’re using a spray, spray lightly to cover the powder. Only a spray or two is needed. If you’re using a wipe, dot the corner of the little sponge over the powder you just applied and let the film soak into the powder. Do not use a swiping motion as this will only remove the powder and not achieve your goal.
- Let the film dry a few seconds – you will see the powder turn white again….this is your “crust”.
- Put on your pouching system as usual.
Controversy around crusting
Now, why is this the eternal question? It seems simple enough right? What could the controversy be?
There are several reasons why this stirs up controversy.
There is actually no clinical evidence to show that crusting helps.
The most important factor in letting skin heal is making sure that stool or urine are not sitting on the skin. This most often refers to change frequency – how many days in between changes of your pouching system. Take a look at our page on healing skin for more info. Crusting may buy you a few extra hours, but it won’t heal skin on its own. The pouch must be changed before urine or stool has got between the skin and the flange again.
Crusting is often overused.
Lots of times people will come in to see the ET nurse and they have been taught to use crusting on all of the skin under the flange, or on anything “red” even if there is no skin breakdown, so they end up with a build up of powder and film between their skin and the flange and eventually, barriers simply don’t stick. This reduces wear time because most flanges are designed to be in contact with clean, bare skin – period. Crusting does not help heal skin that is red or irritated (no weepy skin present), and it does not prevent irritation.
Having the tools for crusting can lead to misuse.
As we said above, the majority of modern ostomy products are designed to be applied on clean, bare skin. They adhere by melting into the microscopic pores and folds of the skin. If powder is applied to skin prior to applying the flange, it’s like trying to stick tape to sawdust. The seal will not be sturdy.
If skin barrier film is applied to skin prior to applying the flange, it’s like trying to get a grip on a plate glass window – the barrier film has filled all of the crevices, nooks and crannies of natural skin that the flange would use to stick better. Applying skin barrier film with every change also leads to a buildup of this material on the skin, and results in “things don’t stick to my skin” complaints. This can also cause irritation in and of itself. Removing the buildup is often all that’s needed to solve this particular type of skin irritation.
Sometimes, the crusting “procedure” is reversed. If skin barrier film is applied before powder, it is like putting flour on the counter before you knead the bread…nothing will stick!
It’s an extra step that makes things unnecessarily complex.
When people have ostomy surgery, it takes a while to feel confident and comfortable with the skill of changing the pouching system. It can be an added, and unnecessary, step to do crusting.
Sometimes people forget to stop.
Having a routine makes caring for your ostomy easier. But using crusting on a routine basis does not prevent damage to the skin, and can actually increase the risk of leakage. Deciding when to stop crusting can be hard if you’re a rookie. The key is, if you and your ET nurse decide crusting is for you, stop when the powder stops sticking. Your skin can be lobster red, but if it’s dry, crusting will do no good, and may do harm by preventing a solid seal.
So why am I being taught about crusting?
By now you have probably learned that every ET nurse does things their own way. The great lesson from this is that there is no one “right way” to do things. This leaves room for your own “style” of ostomy care.
Some nurses use crusting for damaged skin, some don’t. Some nurses use a variation on crusting for severely damaged skin. Sometimes your ET nurse will recommend crusting or a modified version to promote healing, in conjunction with an increase in change frequency.
When you’re in the hospital, or being seen by Home Care after discharge, you are being taught skills for the life of your stoma. People who are fortunate enough to have an ET nurse they can see when they have questions or issues may not need to remember when to use crusting and when to stop. But people who do not have access to an ET nurse once they leave hospital may want to use crusting and need to know how to do it.
The bottom line
Crusting is a tool you can use when you have weepy skin. If you have red, dry skin and the powder doesn’t stick, you don’t need crusting, so stop.
If you need to use crusting with every change, you may need to see your ET nurse to re-evaluate the fit of your entire pouching system. Leakage behind the flange causing skin damage should be a once-in-a-while event, like putting your shirt on backwards. If you’re having weepy, irritated skin every time you change, something isn’t right. Let us help you fix it!
This information is intended for general information only, and is not intended to diagnose or treat any condition. Always consult your physician or nurse for information specific to your situation and needs.