Instant Wound Closure Finds Its Appeal

Edition: July 2002 - Vol 10 Number 07
Article#: 1290
Author: Laura Thill

No, it's not a futuristic glue stick. But it works just as quickly. Liquid topical skin adhesives, or “skin glues,” are cyanoacrylate tissue adhesives engineered to bind low-tension lacerations, wounds or surgical incisions.


Traditional wound management products – skin strips, sutures or stitches, and staples – continue to maintain a strong foothold in the market. But, liquid adhesives are increasingly drawing the attention of those who value speed and simplicity.


History
Cyanoacrylate tissue adhesives actually have been produced for over 20 years, according to Thomas B. Bruns, M.D. and J. Mack Worthington, M.D. (“Using Tissue Adhesive for Wound Repair: A Practical Guide to Dermabond,” American Family Physician, March 1, 2000). Only recently have they become available in the United States, however. In fact, Ethicon Products (Somerville, NJ), a Johnson and Johnson company, announced FDA approval last January of Dermabond®, a liquid adhesive designed to prevent common infection-causing bacteria from invading wounds and incisions. The product offers 99 percent protection against such bacteria as staphylococcus epidermis, Escherichia coli, staphylococcus aurerus, Pseudomonas aruginosa, and Enterococcus faecium, according to Ethicon.


The first attempts to produce cyanoacrylates in 1949 reportedly had inflammatory effects on skin tissues, according to Bruns and Worthington. By the 1970s, N-butyl-2-cyanoacrylate was developed and proven to be much less harmful to tissue, while offering substantial bonding strength. While this product was not FDA-approved for use in the United States, it has been used in Canada and other countries for the last 20+ years.


The modern version of topical skin adhesives, such as Dermabond®, is manufactured with a 2-octylcyanoacrylate base. Reportedly much less toxic than N-butyl-2-cyanoacrylate products, Dermabond® is found to offer nearly four times the strength with a bonding rate of 21/2 minutes. Freshly bonded Dermabond® is as strong as tissue that has healed for seven days after repair (Bruns and Worthington).


When to Use Liquid Adhesives
While liquid skin adhesives boast conveniences, they are somewhat limited in their applications. Originally marketed as replacement sutures 5-0 or smaller in diameter, according to Bruns and Worthington, they are designed for the right size wounds on the face, extremities or torso. Liquid adhesives are contraindicated for the following wounds:


• Mucosal surfaces or across mucocutaneous junctions (i.e. oral cavity, lips).


• Skin regularly exposed to body fluids or with dense natural hair (i.e. scalp).


• Wounds across areas characterized by tension or unstabilized joints.


• Jagged wounds.


• Bites, punctures or crush wounds.


• Contaminated wounds.


Liquid adhesives also should not be used on patients with known hypersensitivity to cyanoacrylate or formaldehyde. They are most effective when applied to straight-edged wounds in low stress areas, where the skin is not stretched or pulled.


How to Use Them
Once the wound is cleansed and positioned such that the adhesive will not run off and contact other areas, the physician or surgeon may apply the “liquid glue.” The product comes in a single-use vial. Once the physician crushes the vial between his fingertips, the adhesive moves through an applicator tip to mix with an initiator and begin the transition from monomer to polymer. The adhesive must be applied within a few minutes after the vial is crushed, before the polymerization process prevents it from being squeezed out of the container (Bruns and Worthington).


The physician must hold the edges of the wound together evenly and apply the adhesive by gently brushing it onto the wound. Care must be taken to prevent the adhesive from entering the wound lest the patient react to a foreign body. The adhesive usually is applied in three thin layers. By reacting with moisture on the skin's surface, it forms a strong flexible bond within 45 to 60 seconds, and reaches maximum strength in about 21/2 minutes, according to Ethicon. The first layer should achieve its maximum strength more quickly than the next two, since less moisture is available for polymerization, note Bruns and Worthington.


The skin becomes water-resistant, eliminating the need for extra bandages. The wound should not be touched until the area is completely dry. Young children who are prone to fingering the area may require a bandage or covering.


The wound typically heals and the adhesive peels off in five to 10 days. The physician and patient must refrain from applying antibiotics, which might cause the adhesive to break down and peel prematurely. While patients generally can shower and bathe immediately following the procedure, excessive soaking may loosen the top epithelial layer of skin and cause the adhesive to peel off too soon.


Often, the use of liquid adhesives reduces the need for anesthesia, not to mention post-surgical removal of suture or staples. Some physicians believe this can be less traumatic for patients – particularly young children.


Today's wound care market – estimated to reach $2.57 billion in products by the year's end, according to one Frost and Sullivan report – welcomes new technologies that can enhance the quality of treatment. The number of wounds to be treated reportedly increases by 10 percent annually, the report states. A product that can make life easier for patients surely must be what the doctor ordered.


Skin Closure Options



Topical Skin Adhesive
• Works like glue to hold edges of skin together.


• Bandages often are not required.


• Forms a strong, flexible bond quickly.


• The adhesive “sheds” from the skin naturally as the wound heals.


• No stitches to remove.





Skin Strips
• Small, tape-like strips placed on top of the skin to hold the edges of the incision together.


• Usually used for smaller incisions.


• Area usually must be kept dry during healing.


Stitches or Sutures
• Surgical thread “sews” wound together – one stitch at a time.


• Bandages and dressings often are required to protect the incision during healing.


• Areas usually must be kept dry during healing.


• Follow-up visit is required to remove stitches.


Staples
• A fast procedure that uses metal staples applied with a surgical “stapler” to hold together the skin edges.


• Bandages and dressings usually are required for protection, and often must be kept dry.


• Follow-up visit is required for staple removal.


Caring for Wounds Treated with Liquid Adhesives
These instructions must be followed carefully to ensure that the wound heals as well as it can.




Check the appearance of the wound.
Some swelling, redness and tenderness is common with most wounds and will go away as the wound heals. If swelling, redness or discomfort increases, or if the wound feels warm to the touch, this could be a sign of infection. The patient should call his or her physician immediately. The physician should also be called if the edges of the wound reopen or pull apart.


Keep the wound dry and protected.
• Do not scratch, rub or pick at the liquid adhesive, or the film may loosen before the wound is fully healed.


• Take brief showers or baths, but do not soak the wound extensively.


• After showering or bathing, gently blot the wound dry with a soft towel.


• Do not scrub the wound.


• Do not swim, and avoid activities that produce heavy perspiration until the adhesive film has fallen off naturally.


• Avoid prolonged exposure to sunlight and the use of tanning lamps.


The best way to bandage.
• If the wound is bandaged, keep the bandage dry. If it becomes wet, replace it immediately.


• Do not place tape directly over the liquid adhesive because removing the tape may also remove the adhesive.


• Replace the bandage daily with a new dressing or bandage until the adhesive film has fallen off naturally, unless the physician instructs otherwise.


Avoid liquid or ointment medications.
• Do not apply any liquid, ointment or other medication to the wound while the liquid adhesive is in place. Any such application may loosen the adhesive film before the wound has healed.


--Source: Ethicon Products (Somerville, NJ) at www.dermabond.com/care.html.