Keywords
ostomy - phytotherapeutic - irritating dermatitis
Palavras-chave
estomia - medicamentos fitoterápicos - dermatite irritante
Introduction
The word stoma, comes from the Greek stóma, meaning “mouth” or “opening”, and it is used to name a surgical intervention to
communicate a hollow organ with the external environment.[1]
The main causes of intestinal stoma are colorectal neoplasms, primarily abdominal
trauma, and inflammatory bowel diseases.[2]
In 2018,[3] it was estimated that, in the State of Minas Gerais (MG), Brazil, for every 100
thousand inhabitants, the incidence of malignant neoplasms of the colon and rectum
as the primary location would reach 1,510 new cases among men and 1,650 among women.
In the state capital, the incidence would be of 310 among men and 390 cases among
women for every 100 thousand inhabitants.
The stoma can seriously limit the quality of life of the patients who are forced to
live with this new condition, which can be a mutilating and traumatic event, causing
emotional and physical damage.[4]
The type of complication most commonly found in the literature is peristomal dermatitis,
with an emphasis on dermatitis associated with moisture, which results from exposure
of the skin to intestinal or urinary effluents.[5]
In a study[6] performed in Denmark in 2006, the authors found that 92% of the patients had an
intestinal stoma, and 45% had peristomal skin disorders.
Peristomal dermatitis may have an irritating origin, due to the contact of proteolytic
enzymes present in the effluent, which cause a chemical reaction and corrosion. The
alkaline pH of watery stools, in the case of ileostomy, favors a change in the defense
mechanisms of the skin, which develops erythema, hemorrhage, and pain. In colostomy,
although the pH is less harmful to the skin, the continuous contact when leaking causes
irritation and, consequently, dermatitis.[7]
Powdered synthetic resin is one of the recommended protective skin barriers as an
adjunctive therapy in the care for people with stomas. It is indicated in cases of
peristomal moisture-associated dermatitis to promote a better adaptation of the adhesive
barrier.[8]
The peel and pulp of the banana have been identified as potent antioxidants, and they
have a high dopamine content.[9]
Green banana (Musa sapientum) is one of the most consumed fruits in the world; it originated in Asia, and it is
cultivated in tropical countries.[10]
The green banana extract not only increases the density of the mucosa, but also increases
the incorporation of thymidine into the DNA, promoting cell multiplication, which
potentiates the healing effects of the extract.[11]
In a randomized study[12] performed with rats, the authors found that there was an increase in the percentage
of vascular proliferation in a discrete to marked amount, in lesions in which the
gel composed of the green burro banana peel was used, with significance regarding
the acute inflammatory reaction. The best response to the healing process was obtained
using a gel composed of 10% of green banana peel,[13] when partial re-epithelialization and reduction of the wound area was demonstrated.[14]
Based on the assumption of efficacy in the healing process of open wounds, the use
of a powder composed of 10% of green banana peel in peristomal dermatitis was assessed,
mainly due to the ease of production of the powder and its low cost compared to that
of products already available in the market for this purpose. Considering that such
injuries need a product that does not interfere with the adhesion of the pouching
system plate, and that the products available for sale are in the form of powders,
we decided to use the manipulated green banana skin in powder form.
Thus, the present study aimed to develop the powder containing green banana peel and
evaluate its effectiveness regarding the healing time inperistomal dermatitis.
Methods
The present research followed the ethical principles of resolution n° 466, of the Brazilian National Health Council (Conselho Nacional de Saúde – CNS,
in Portuguese), which defines the ethical procedures for research in human beings.
The work was initiated after approval by the Ethics in Research Committee of Universidade
do Vale do Sapucaí, under opinion n° 2.381.904/CAAE: 57362316.8.0000.5102.
Data collection was performed at the Ostomy Care Service (Serviço de Atenção à Saúde
de Pessoa Ostomizada – SASPO, in Portuguese), which is part of the Brazilian Unified
Health System (Sistema Único da Saúde – SUS, in Portuguese), also known as Stomatherapy
Outpatient Clinic, located in the city of Pouso Alegre (MG).
The SASPO provides specialized nursing care and the distribution of collecting supplies
to 25 municipalities in the region.
The present was a clinical, analytical and longitudinal study conducted between February
2018 and July 2019 using convenience sampling.
The sample was composed of 44 participants with intestinal stoma who had peristomal
dermatitis diagnosed after a consultation at the service. They were divided into two
groups: the study group used the powder containing 10% of green banana peel, and the
control group used ostomy powder.
The ostomy powder, a product manufactured and sold by international laboratories and
offered by the SUS, is composed of synthetic resin.
The study included people with intestinal ostomy, of both genders, aged > 18 years,
who had peristomal dermatitis and agreed to participate by signing the informed consent
form (ICF).
Minors with urinary stomas, who had any known allergy to the product and who refused
to participate in the study were not included.
Participants who did not return to the consultation for the evaluation of the dermatitis
and those who did not follow the relevant guidelines for the use of the powder were
excluded.
The powder was obtained from the peels of green bananas of the species M. sapientum, according to the scale of Von Loesecke,[15] which classifies the ripeness of bananas by the color of their rind.
Green bananas were used due to the alteration of the properties of the fruit during
the ripening process, and they were selected by the researcher directly from the producer,
to guarantee the ideal quality of the fruit.
The bananas were sent to the Botany Laboratory at Universidade do Vale do Sapucaí
(UNIVÁS) for processing and final preparation.
The peels were separated from the pulp, washed, and placed on a drying bench. After
total dehydration, they were ground and then crushed with the aid of a pestle and
mortar, and sifted using a voile strainer to obtain a fine and homogeneous powder.
For better handling of the final product, gelatin was then used, which was also crushed
in the pestle and morter and sieved. The final product, which was stored in 30-mm
dropper bottles, contained 45% of gelatin, 45% of carboxymethyl cellulose, and 10%
of the green banana peel powder.
For the classification of peristomal dermatitis, the SACS (Convatec, Inc., Reading,
Berkshire, UK) instrument was used to assess the time in days it took for the lesion
to heal according to the number of affected quadrants in each appointment after using
the powder.
All participants who presented dermatitis after a pilot test were classified as L2
(erosive lesion).[16]
For the distribution of the groups, we estimated the number of enrollments to the
study that could occur during the proposed data collection period. After 22 people
had enrolled to form the study group, the control group, which was provided by the
State, was later formed.
All participants received free bottles of the powder, and both groups were intructed
to apply it at home using the same method.
After and explanation about the research, the subjects agreed to particpate, signed
the ICF, and attended a consultation previously scheduled with the stoma nurse, according
to the routine of the service.
The SASPO has an exclusive office with a bathroom adapted for ostomy patients, according
to directive n° 400/2009 of the Brazilian Ministry of Health ([Figure 1]).
Fig. 1 CONSORT 2010 Flow Diagram.
To proceed with data collection, the participants were evaluated in the first consultation.
The type of complication related to the stoma was identified. With the permission
of the patients, the cases of dermatitis were photographed, classified according to
the SACS, the conduct was recorded in the medical record of the type of collecting
supply and adjuvant therapy (powder) prescribed.
The powder was applied by the researcher during the first consultation after the evaluation
of the dermatitis.
Accompanied by a family member or caregiver, the participants were instructed about
the research and about how to care for the stoma, for the correct use of the product
at home when changing the collection bag, which would occur every four days on average,
until the reassessment in the service.
Data were tabulated in Microsoft Excel (Microsoft Corp., Redmond, WA, US), version
2016, spreadsheets and subjected to statistical analysis using measures of central
tendency for the quantitative variables and absolute and relative frequency for the
categorical variables.
The Minitab (Minitab, LLC, State College, PA, US) software, version 18.1, and the
Statistical Package for the Social Sciences (SPSS, IBM Corp., Armonk, NY, US), version
22.0, were employed. The level of significance was set at 5% (p <0.05). For the analysis of the results, we used the two-sample t-test to study whether there was a difference in the mean healing time between the
two study groups.
Results
A total of 95 patients were evaluated, 49 of whom had dermatitis at the time of the
consultation.
Both study groups had the same characteristics, such as diverse age range, most of
them with stomas from intestinal neoplasms, with no fixed standardization of the interval
between consultations due to the same logistical difficulties, all had moisture-associated
dermatitis, and the surgeries were performed in the same hospitals. Some surgeries
were elective, and others were emergency procedures.
In the control group, there were initially 27 participants, but 5 were excluded according
to the aforementioned criteria. One particpant did not follow the guidelines for the
change of the collection bag and application of the powder, and the others missed
the subsequent consultation; therefore, the study group was composed of 22 participants.
By the second appointment, the dermatitis showed 100% of healing in most of the participants
In the control group, 4 participants required 3 consultations until total healing
of the dermatitis was observed; in the study group, 3 patients required 2 consultations,
and 1 required 4. Data on the number of consultations required until total healing,
as well as on the gender and age of the participants, is presented in ([Boxes 1] and [2]). The study group was composed of 99% of men, with an average age of 62.4 years,
and the control group was composed of 56% of men, with an average age of 59 years.
Box 1
Classification of the dermatitis in the study group according to the SACS intrument
|
Participants (P)
|
Gender
|
Age (years)
|
1st SACS collection
|
2nd SACS collection
|
3rd SACS collection
|
4th SACS collection
|
|
P1
|
Male
|
82
|
L2 TII TIII
|
100% healing
|
|
|
|
P2
|
Male
|
65
|
L2 TV
|
L2 TII TIII TIV
|
L2 TII TIII
|
100% healing
|
|
P3
|
Male
|
66
|
L2 TV
|
100% healing
|
|
|
|
P4
|
Male
|
62
|
L2 TV
|
100% healing
|
|
|
|
P5
|
Male
|
73
|
L2 TV
|
100% healing
|
|
|
|
P6
|
Male
|
61
|
L2 TV
|
100% healing
|
|
|
|
P7
|
Male
|
63
|
L2 TI TIII TIV
|
100% healing
|
|
|
|
P8
|
Male
|
52
|
L2 TI TIII TIV
|
L2 TIV
|
100% healing
|
|
|
P9
|
Male
|
34
|
L2 TV
|
L2 TI TII
|
100% healing
|
|
|
P10
|
Male
|
67
|
L2 TV
|
100% healing
|
|
|
|
P11
|
Male
|
59
|
L2 TII TIII TIV
|
L2 TIV
|
100% healing
|
|
|
P12
|
Female
|
52
|
L2 TV
|
100% healing
|
|
|
|
P13
|
Male
|
66
|
L2 TV
|
100% healing
|
|
|
|
P14
|
Female
|
54
|
L2 TV
|
100% healing
|
|
|
|
P15
|
Male
|
81
|
L2 TV
|
100% healing
|
|
|
|
P16
|
Male
|
67
|
L2 TV
|
100% healing
|
|
|
|
P17
|
Male
|
59
|
L2 TV
|
100% healing
|
|
|
|
P18
|
Male
|
61
|
L2 TV
|
100% healing
|
|
|
|
P19
|
Male
|
52
|
L2 TV
|
100% healing
|
|
|
|
P20
|
Male
|
73
|
L2 TV
|
L2 TI TIV
|
100% healing
|
|
|
P21
|
Male
|
60
|
L2 TV
|
100% healing
|
|
|
|
P22
|
Male
|
65
|
L2 TIII TIV
|
100% healing
|
|
|
Box 2
Classification of the dermatitis in the control group according to the SACS instrument
|
Participants (P)
|
Gender
|
Age (years)
|
1st SACS collection
|
2nd SACS collection
|
3rd SACS collection
|
|
P1
|
Male
|
70
|
L2 TV
|
100% healing
|
|
|
P2
|
Male
|
62
|
L2 TV
|
L2 TIV
|
100% healing
|
|
P3
|
Male
|
60
|
L2 TV
|
L2 TIII TIV
|
100% healing
|
|
P4
|
Male
|
74
|
L2 TII TIII
|
100% healing
|
|
|
P5
|
Male
|
42
|
L2 TII TIII
|
100% healing
|
|
|
P6
|
Female
|
75
|
L2 TIII
|
100% healing
|
|
|
P7
|
Female
|
61
|
L2 TV
|
L2 TII TIII
|
100% healing
|
|
P8
|
Male
|
44
|
L2 TV
|
100% healing
|
|
|
P9
|
Male
|
82
|
L2 TV
|
100% healing
|
|
|
P10
|
Female
|
69
|
L2TI
|
100% healing
|
|
|
P11
|
Female
|
59
|
L2 TV
|
L2 TI TIII TIV
|
100% healing
|
|
P12
|
Female
|
43
|
L2 TII TIII
|
100% healing
|
|
|
P13
|
Female
|
74
|
L2 TV
|
100% healing
|
|
|
P14
|
Female
|
41
|
L2 TV
|
100% healing
|
|
|
P15
|
Male
|
52
|
L2 TV
|
100% healing
|
|
|
P16
|
Female
|
65
|
L2 TV
|
100% healing
|
|
|
P17
|
Female
|
51
|
L2 TV
|
100% healing
|
|
|
P18
|
Male
|
59
|
L2 TI TIII TIV
|
100% healing
|
|
|
P19
|
Female
|
69
|
L2 TV
|
100% healing
|
|
|
P20
|
Male
|
53
|
L2 TV
|
100% healing
|
|
|
P21
|
Male
|
48
|
L2 TV
|
100% healing
|
|
|
P22
|
Male
|
49
|
L2 TV
|
100% healing
|
|
The evaluation of the healing time for the study group was measured in days, and this
period was shorter than that of the control group (p = 0.022; [Box3]).
Box 3
Average healing time of peristomal dermatitis
|
Participants (N)
|
Average healing time (days)
|
Healing time (days; standard deviation)
|
|
Study group
|
22
|
12.77
|
9.27
|
|
Control group
|
22
|
19.5
|
12
|
|
p
-value
|
0.022
|
Discussion
When analyzing the data, we could identify effective healing of the peristomal dermatitis
in the study group. The participants also reported immediate pain relief in the region
of the injury, comfort after use, and skin protection. The time of permanence of the
pouching system did not differ between the groups.
Adjuvant products such as skin protective barriers, which are available for sale in
the market, as well as collecting supplies, which are indicated for the treatment
of stoma-related complications, according to some guidelines aimed at this care, have
a recommendation with a significant level of evidence (Strength of evidence = B),
by contributing to a better quality of life and rehabilitation for the ostomized individual.[17]
Based on the results of the present study the powder composed of 10% green banana
peel is an excellent option of adjuvant product for the management of peristomal dermatitis,
because, in addition to its effectiveness and shorter healing time in relation to
the ostomy powder, its production is low-cost. It even demonstrated the ability to
absorb moisture, given the durability (average of four days) of the adhesive base
of the collectiong equipment on the participants' skin.
There is no description in the literature of the use of phytotherapeutic cutaneous
protective barriers in powder form, despite the advances in the studies on phytotherapeutic
medicines.
The optimization of material resources, including the equipment and adjuvants used,
is paramount for the effective care for ostomy patients. The use of technology in
health must encompass an evaluation of the costs, but it must also guarantee the principles
championed by the SUS.[18]
We opted for the concentration of 10% of green banana peel powder because previous
experimental works performed in rats and humans obtained satisfactory results with
this concentration.[14] The vehicles used for the final composition of the powder were chosen by composing
powders for ostomies.
The products that offer protection to the skin protectors are sold in the form of
powders, pastes and plates, and they contain hydrocolloids such as gelatin, pectin,
carboxymethyl cellulose and polysobutylene. The powder is specifically indicated for
wet lesions, for it contributes to the protection and fixation of the adhesive bases
of the ostomy pouching system.[19]
In a study[13] analyzing the healing of wounds by second intention in rats and using a gel containing
10% of banana, the desired epithelialization was achieved.
It is also noteworthy that concentrations of the gel at 10% have an anti-inflammatory
effect on the injured tissue and stimulate healing when compared to other gels without
this active ingredient.[14]
The use of the gel based on banana extract in chronic leg wounds demonstrated a reduction
of antimicrobial activity of up to 99% in 80% of the cases, which shows its efficacy
in the management of these lesions.[20]
The declaration of rights of the person with an ostomy states that the ostomy patient
must have unrestricted access to the variety of accessible ostomy products.[21]
It is essential that any equipment or product prescribed for such complications offers
resolvability and reliability to the patient, given the emotional changes caused by
the condition of being ostomized, as already mentioned.
The SUS directive n° 400/2009 establishes as attributions of the services dedicated to the care of ostomized
people the provision of specialized assistance, in terms of assessing the general
biopsychosocial needs of the individual, their family, and the specific needs related
to ostomy and peristomal dermatitis, which include the prevention and treatment of
complications, as well as the prescription of collection equipment and adjuvants.[22]
The results of the present study revealed that the powder not only provided effective
healing, but also reduced tissue repair time, without compromising the adhesiveness
of the collection plate; another advantage is that the powder is easy to produce.
Due to its high productivity an low cost in the most diverse regions of the Brazil,
the M. sapientum banana is an accessible raw material.
The hydrocolloids added to the final product also have reasonable costs, and are used
on a large scale in the food industry.
With its easy production, low cost and effectiveness, the green banana peel powder
is an important option in the care for ostomies, especially when considering the high
cost of the imported industrialized products for the same purpose and the difficulty
in accessing them by patients who live in remote locations. Due to its easy application,
it can also be used in hospitals, outpatient facilities, and at home by the patients
themselves.
Conclusion
The powder composed of 10% of green banana peel of the M. sapientum species showed excellent results in the healing of peristomal dermatitis in patients
with intestinal ostomy. Compared to the ostomy powder, it presented a shorter healing
time.
