Granulomas Around the Stoma

Peristomal granulomas are small, benign, fleshy overgrowths of tissue that appear on the skin immediately surrounding a stoma. They are one of the more commonly encountered peristomal skin complications, affecting people with all stoma types — colostomy, ileostomy, and urostomy alike. Although they are not dangerous, granulomas can bleed with minimal contact, cause discomfort, and interfere with the secure attachment of the pouching system, potentially leading to leaks and further skin breakdown. Understanding what causes them, how they are diagnosed, and what treatment options exist can help ostomates and their caregivers manage this complication effectively.

What Are Peristomal Granulomas?

A granuloma is an area of chronic inflammatory tissue formed in response to a persistent irritant or foreign material. Around a stoma, granulomas typically present as raised, red, moist nodules or polyp-like bumps, ranging from a few millimetres to over a centimetre in size. They are often described as looking similar to proud flesh, and they bleed readily when touched or when the pouching appliance is changed.

It is important to distinguish peristomal granulomas from other peristomal skin conditions such as pyoderma gangrenosum, mucosal transplantation, or mucocutaneous separation. If there is any doubt about the diagnosis, assessment by a stoma care nurse or clinician is essential.

Common Causes

Suture Remnants

One of the most frequent causes of granuloma formation is the presence of non-absorbable or slowly absorbing suture material used during stoma formation. As the body reacts to the foreign material, localised inflammatory tissue proliferates around the suture site. Granulomas arising from this cause are especially common in the early post-operative weeks and months.

Chronic Moisture and Maceration

Prolonged exposure of the peristomal skin to urine, stool, or effluent — often resulting from an ill-fitting appliance — creates a warm, moist environment that promotes overgrowth of granulation tissue. This is a particular concern in people with a flush or retracted stoma, where achieving a reliable seal is more challenging.

Mechanical Irritation

Repeated trauma from the edges of the baseplate or flange, frequent and vigorous removal of the adhesive wafer, or friction from clothing can all act as mechanical triggers for granuloma development. Even small areas of consistent pressure or abrasion are sufficient to initiate the inflammatory response.

Faecal or Urinary Contamination Under the Appliance

Leakage beneath the pouching system exposes the skin to digestive enzymes and irritants, prompting a chronic inflammatory response. Over time, this sustained insult can give rise to granuloma formation, particularly in the area closest to the mucocutaneous junction.

Diagnosis

Diagnosis is primarily clinical, based on visual inspection of the peristomal skin. A stoma care nurse or clinician will examine the size, number, and distribution of the lesions, and assess the fitting and condition of the current pouching system. In rare cases where the appearance is atypical or the lesions fail to respond to standard treatment, a skin biopsy may be taken to exclude other pathology, including rare instances of malignancy at the stoma site.

Treatment Options

Silver Nitrate Cauterisation

The most widely used first-line treatment for peristomal granulomas is topical silver nitrate, applied using caustic pencils or sticks. Silver nitrate works by chemically cauterising the granulation tissue, causing it to shrink and eventually slough away. Treatment is typically carried out by a healthcare professional, with the surrounding skin protected using a barrier film or paste beforehand. Multiple sessions, spaced a week or more apart, are often required for larger granulomas.

Addressing the Underlying Cause

Treatment of the granuloma in isolation is rarely sufficient if the precipitating factor remains. A careful review of the pouching system is essential — this includes assessing the aperture size, the type and frequency of appliance changes, the method of removal, and whether a convex or alternative baseplate profile may achieve a better seal. Suture remnants identified during inspection should be removed by an appropriately trained clinician.

Topical Corticosteroids

In some clinical settings, low-potency topical corticosteroid preparations are used as an adjunct to reduce local inflammation. This approach should only be used under clinical supervision, as prolonged use of corticosteroids on peristomal skin carries its own risks, including skin thinning and increased susceptibility to fungal infection.

Surgical Removal

Surgical excision is rarely necessary but may be considered for very large or recurrent granulomas that have not responded to conservative measures. This decision should involve a colorectal or stoma surgeon, and the underlying cause must still be addressed to prevent recurrence.

Prevention

Preventing peristomal granulomas centres on optimising appliance fit and maintaining healthy peristomal skin:

• Accurate aperture sizing: The opening in the baseplate should closely match the stoma’s dimensions, minimising exposed skin around the mucocutaneous junction.
• Regular appliance reviews: Stoma size frequently changes in the months following surgery, and the appliance should be reviewed accordingly.
• Gentle removal technique: Removing the pouching system slowly, supporting the skin, reduces mechanical trauma.
• Good peristomal skin hygiene: Washing with plain warm water and ensuring the skin is thoroughly dry before reapplying the appliance reduces moisture-related irritation.
• Prompt management of leaks: Addressing any leakage quickly limits the duration of skin exposure to effluent.

Routine follow-up with a stoma care nurse is the single most effective way to identify early skin changes before they become established problems.

When to Seek Advice

Consult a stoma care nurse or clinician if you notice any new raised, red, or bleeding lesions around your stoma; if your appliance is becoming increasingly difficult to keep sealed; or if you experience persistent discomfort or odour that suggests a change in peristomal skin integrity. Do not attempt to self-treat granulomas with unprescribed caustic agents, as this risks significant skin damage.

The Bottom Line

Peristomal granulomas are a manageable and relatively common complication of stoma care. They form in response to persistent irritants — including suture material, moisture, and mechanical friction — and present as raised, bleeding nodules around the stoma. First-line treatment with silver nitrate cauterisation is effective in most cases, but long-term success depends on identifying and correcting the underlying cause. If you notice any concerning changes to the skin around your stoma, speak to your stoma care nurse or clinician without delay; early intervention leads to the best outcomes.