The wound that the patient experienced as an outcome of this procedure has several interesting aspects that deserve attention, most notably the skin necrosis and contact dermatitis. Skin necrosis is known to be a pathologic cellular response to multiple factors, some of which are heat, cytokines, irradiation, toxins, pathogens, and ischemia.10 The necrosis that developed in this patient is likely a result of more than one variable. It is possible that the splint over the wound compressed the surrounding vasculature. The splint was a volar resting splint, however, which provided wrist support along the palmar aspect of the hand without subjecting the wound to a hard surface. Nonetheless, the degree of tightness of the wound dressing that was used in conjunction with the splint could have interfered with normal blood flow to the dorsum of the hand. Loss of blood flow to an area of tissue or an organ will ultimately result in ischemia, cell death, and necrosis, and an example of this is commonly seen with chronic diabetic foot ulcers as a result of microvascular damage.11 A study by Kawai et al11 examined perilesional blood flow by measuring skin perfusion pressure (SPP) and highlighted the possibility of predicting wound healing based on measured blood flow to the area; the higher SPP measurements had a greater chance of healing without further operations. With minimal reports of wound issues as a result of this commonly used and widely accepted type of splint, it is less likely that it directly caused wound breakdown and necrosis. However, this patient’s wound was not examined until 7 days after the operation while immobilized within the splint. Examination of the wound within 48 hours may have resulted in earlier detection or even prevention of necrosis.12
Skin necrosis could also have occurred as a result of chemical toxicity. As mentioned previously, 2-octyl cyanoacrylate is a cyanoacrylate monomer that shares properties of other monomers within its class. The histotoxic effects of these monomers on cells and tissues have been examined. An in vitro study by Sulheim et al13 utilized 12 different cell lines and determined that octyl-cyanoacrylate was more toxic than ethyl-butyl-cyanoacrylate. Ciapetti et al14 conducted an in vitro study with mouse fibroblasts and human lymphocytes that concluded that ethyl-cyanoacrylate is most toxic and that butyl-cyanoacrylate is least toxic.
Regardless of the toxicity rankings among monomers, there is evidence that exposure can lead to toxic cellular injury. A case report by DaCruz15 discussed a full-thickness necrosis that developed as a result of the use of superglue, which is also a cyanoacrylate monomer. The cyanoacrylate is degraded into byproducts by cells—one of which is formaldehyde, and this is hypothesized to be the source of histotoxicity to cells.15 Weedon’s Skin Pathology discusses the topic of chemically induced irritant chemical dermatitis as a common subtype of allergic dermatitis.16 There is also discussion about allergic contact dermatitis progressing to purpura, vesiculobullous lesions, and even epidermal necrosis with ulceration.16 The area of skin necrosis in this patient followed the outlines of the adhesive application, supporting the theory that the adhesive caused an irritant contact dermatitis with skin necrosis.
A second aspect of interest in this patient’s wound is the development of severe contact dermatitis. In a retrospective review conducted by Nakagawa et al,17 7 of 100 patients experienced contact dermatitis after the use of 2-octyl cyanoacrylate for surgical wound closure. One interesting finding of this study was that 4 of 7 patients did not experience contact dermatitis initially. Rather, they developed the skin irritation after the second use of the adhesive, suggesting that sensitization had occurred.17 This study also found that patients with a history of acrylate allergy should avoid 2-octyl cyanoacrylate use due to cross-reactivity.17 Additionally, an orthopedic case series presented 3 patients in whom blistering developed within 2 weeks after surgery; in one of these patients, the blistering was complicated by a hematoma. These 3 patients were treated with diphenhydramine, hydroxyzine, and topical triamcinolone.18 In a retrospective study by Chalmers et al,19 treatment methods were recorded in 29 patients in whom contact dermatitis developed after elective orthopedic surgeries. Oral antihistamines were given to 20 patients (69%), topical corticosteroids to 16 patients (55%), and oral corticosteroids to 5 patients (17%).19 The mean time for dermatitis resolution was 22 days.19 The authors of this study also suggest that more severe cases may require more aggressive treatment, such as oral steroids.19 In our case, the contact dermatitis was severe and required administration of oral steroids.
Information to help anticipate potential 2-octyl cyanoacrylate contact dermatitis risk is limited. Cases have been reported after laparoscopic cholecystectomies, breast reconstructions, and orthopedic procedures as well as cases in pediatric and adult populations.20,21
A case report by Bitterman and Sandhu22 looked at the molecular structure of 2-octyl cyanoacrylate for an explanation of contact dermatitis. This report suggested that patients who live in hot, dry environments have a higher incidence of contact dermatitis than those in humid environments.22 In simplistic terms, 2-octyl cyanoacrylate undergoes a polymerization reaction with water, altering the molecular structure from its original form. This new molecular structure prevents the original molecule from being recognized by antigen-presenting cells and therefore also prevents the development of contact dermatitis to the 2-octyl cyanoacrylate molecule. In dry climates, the polymerization reaction is slowed or even thwarted due to the decrease in atmospheric water. The increased availability of original 2-octyl cyanoacrylate molecules enables antigen-presenting cells to cause sensitization and subsequent contact dermatitis.
2-Octyl cyanoacrylate is commonly used and is a quick and easy method for incision closure. With increased use in inpatient and outpatient environments and resultant patient exposure, it may be anticipated that the incidence of dermatologic reactions to 2-octyl cyanoacrylate will increase. In a retrospective chart review of patients with lacerations (N = 755) presenting to a suburban academic emergency department, 667 were closed by primary closure, 88 of which used adhesives.23 This review also found that 2-octyl cyanoacrylate was more likely to be used for closure of facial lacerations and lacerations in pediatric patients.23 Various other studies have concluded that adhesives are preferred over sutures in pediatric patients. There is an average reduction of 37 minutes spent in the emergency department when adhesives are used, and cosmetic outcomes for simple facial lacerations closed with 2-octyl cyanoacrylate are similar to those of lacerations closed with Steri-Strip Skin Closures (3M, St. Paul, MN) or sutures.24,25 As the popularity and utility of 2-octyl cyanoacrylate and other adhesives for wound closure increase throughout the many fields of medicine, clinicians must be alert to the type of adverse reactions that may occur and the potential for an increasing rate of these adverse reactions. Moving forward, more studies are needed to better ascertain the prevalence of persons who are allergic and the incidence of adverse events that are occurring.