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Nursing guidelines

Perianal care for the paediatric oncology patient



  • Introduction

    Perianal care involves maintaining the integrity and function of the skin and mucosal surfaces of the perineum and anal region.

    The skin and mucosal surfaces constitute the primary host defence against invasion by endogenous and acquired microorganisms. Any factor that bypasses or disrupts this integumentary barrier can increase susceptibility to infection.

    The paediatric oncology patient is extremely vulnerable to alterations in skin and mucosal surfaces due to the adverse effects of chemotherapy, radiotherapy, immunosuppression and alterations in nutritional status.

    To provide recommended perianal care for paediatric oncology patients at the Royal Children's Hospital.  It outlines the prophylactic care and management required for optimal skin and mucosal integrity.

    Assessment

    The perianal skinshould be assessed each shift by a treating doctor or the nurse managing the patient’s care.

    Abnormal findings should be reported to the medical team and documented. Abnormal findings could include discomfort, erythema, burning, itching, swelling, excoriation, broken skin, vesicles, etc.

    Management

    Preventative care for the skin and mucosal surfaces should be initiated proactively when there is an anticipated risk to the perianal area (see chart below).

    • A daily pain assessment is essential. When mucositis is present, analgesia should be administered prior to perianal care to minimise discomfort. Topical analgesia such as Xylocaine® gel 2% may be applied to the external anal area before perianal care
    • Systemic analgesics (e.g. paracetamol or opioids) may also be required and should be administered according to the severity of pain.

    Refer to RCH Nursing Guideline: Pain assessment and measurement guideline for more information.

    Asymptomatic

    Maintaining optimal skin environment:

    Clinical Practice
    • Change nappies frequently.
    • Use nappies made with absorbent gel materials.
    • Gentle cleaning with a soft cloth e.g. Rediwipes and water/saline is sufficient for cleaning the perianal area and pat dry.
    • Apply a thin layer of zinc ointment which contains minimum zinc oxide 15% to protect the skin.
    • Discourage use of commercially available nappy wipes.

    Mild Excoriation

    Continue care as per asymptomatic management above and also include:

    Clinical Practice
    • Care as per asymptomatic management.
    • Daily bath/shower with cup of salt.
    • Apply a thick application of a zinc ointment whichcontains minimum zinc oxide 15% to protect injured skin.
    • It is not necessary to remove the barrier preparation at each nappy change, remove the visible faecal matter and reapply the barrier preparation when required.
    • Discourage use of commercially available nappy wipes.
    • Expose the area to air whenever possible.
    • If excoriation is present apply Stomahesive® powder +zinc oxide 15% ointment barrier+ Stomahesive® powder to create a thick barrier and protect the skin.
    • Use of cleansing foam to remove creams is recommended to aid removal of creams and prevent further skin breakdown.

    Severe Excoriation

    Continue care as per asymptomatic and mild excoriation management above and also include:

    Clinical Practice
    • Care as per asymptomatic and mild excoriation management.
    • Pat dry or administer oxygen via tubing to thoroughly dry the area (using separate tubing for inhaled oxygen and topical oxygen).
    • Expose the area to air whenever possible.
    • Apply protective barrier cream with minimum 15% zinc oxide .
    • If skin loss has occured apply Stomahesive® powder, zinc oxide 15% ointment barrier followed by Stomahesive® powder again.
    • Referral to Stomal Therapy may be needed for worsening symptoms.

    Special Considerations

    • Per rectum (PR) medications or enemas, PR temperatures, rectal examinations or colonoscopies, tampons, pessaries and douches should not be used in the oncology patient. Use indwelling catheters only if unavoidable and the benefits of using one outweigh the risks.
    • Encourage use of disposable super absorbent gel nappies for infants or children to wear lightweight,  cotton (preferably) underwear or pyjamas.
    • Avoid constipation. Chemotherapy agents such as vinca alkaloids (e.g. vincristine, vinblastine) or the use of narcotic analgesics may cause constipation, therefore aperients and stool softeners are often required. Once constipation occurs, it can be very difficult to treat, so prevention with stool softeners must be instituted early to reduce the risk of an anal tear.
    • Intensive chemotherapy regimens (e.g. methotrexate, cisplatin and actinomycin-D), infections or diseases such as graft versus host may cause diarrhoea. Collect stool specimens to exclude infectious causes. Do not administer anti-diarrhoeal agents without fellow/consultant approval.
    • Many chemotherapy agents may contribute to perianal skin problems, producing erythema and desquamation (e.g. high dose thiotepa, cyclophosphamide and carboplatin).
    • Treating team should discuss precautions for sexual activity with adolescent patients.

    Companion Documents

     Children’s Cancer Centre - Document library (RCH only)

    Eczema Management Nursing Guideline

    Eczema Clinical Practice Guideline

    Nappy Rash Kids Health Info Sheet

    Nappy Rash Clinical Practice Guideline

    Neonatal and Infant Skin Care Nursing Guideline

    Pain Assessment and Measurement Nursing Guideline

    Penis and Foreskin Care Kids Health Info Sheet

    Wound Assessment and Management Nursing Guideline


    The development of this nursing guideline was coordinated by Alice Mercer, RN, Kookaburra Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated August 2025.  


      Please remember to read the disclaimer.

      Evidence Table

      Reference

      Source of Evidence

      		Key findings and considerations
      Burdall, O., Willgress, L., Goad, N. ( 2018). Neonatal Skin Care: Developments in Care to Maintain Neonatal Barrier Function and Prevention of Diaper Dermatitis.  Pediatric Dermatology. 1(36). P. 31-35 Literature Review 

      Super-absorbent nappies reduce the moisture at skin level and so reduce nappy rash when compared to cloth alternatives. Barrier creams carry benefit both in prevention and cure but do not substitute for frequent nappy changes.

        Colorectal and Pelvic Reconstruction Service: Buttock Care
        https://www.rch.org.au/uploadedFiles/Main/Content/cprs/CPRS%20Booklet%20-%20Buttock%20Care.pdf
        		 Patient Information Sheet

        Care for excoriated skin:
        • Use of stomahesive powder for excoriated skin
        • Do not forcibly remove any creams that remain in place. Only clean what is soiled, and replenish cream
          Lim, Y.S.L, Carville, K. (2019). Prevention and Management of Incontinence-Associated Dermatitis in the Pediatric Population. Journal of Wound, Ostomy, and Continence Nursing. 46(1). P. 30-37
          		 Literature Review

          • Incontinence-Associated Dermatitis (IAD) can cause unnecessary discomfort, pain and is potentially dangerous to patients who are immunocompromised. 
          • Prevention is the best management for IAD.
          • Lack of robust clinical trials hinder clinician abilities to identify best interventions to prevent and manage IAD.
          • The 2 most consistent findings suggest the use of high absorbency, breathable diapers, as well as additive-free disposable cleanser wipes, with the caveat that the evidence for supporting their use remains conditional at best. Health care institutions should establish structured skin care regimens and patient and caregiver education programs.
            Oakley, A., Gomez, J. (2017). Napkin Dermatitis. DermNet. https://dermnetnz.org/topics/napkin-dermatitis Expert Opinion
            		• The need to keep baby dry and use barrier creams should be emphasised.
            • The caregiver should always wash their hands before and after changing a nappy/diaper. Napkin dermatitis is much less common with modern disposable nappies than with cloth nappies.
            • Clean skin with water and soft cloth. Wet wipes not recommended.
            • Pat dry and allow to air dry
            • Apply protective emollient ointment containing petrolatum and zinc oxide

              Van Vliet, Tissing, W., Rings, E., Koetse, H., Stellaard, F., Kamps, W., de Bont, E. (2009) Citrulline as a marker for chemotherapy induced mucosal barrier injury in pediatric patients. Pediatric Blood Cancer. 7(53). P. 1188-1194. Observational Audit

              Intensive chemotherapy treatment is associated with significant morbidity and even mortality, caused by treatment related side-effects such as mucosal barrier injury (MBI). MBI is associated with severe pain and increased use of analgesics. Appropriate pain relief should be considered for MBI