To Glue, or Not to Glue, That is the Question

Skin glue is a godsend for those of us working in the emergency department. It allows for quick closure of small wounds and significantly decreases the discomfort of laceration repair which is especially handy when working with children. While short, superficial lacerations are easy to identify as glue-worthy wounds, where do you draw the line? And, will wounds closed with skin adhesive really heal as well as those that are sutured?

Let's take a look at skin adhesive and the guidelines for using glue as opposed to sutures for wound repair

What is skin adhesive, anyway?

Skin adhesives are typically made of a substance called cyanoacrylate, a material that forms a small, flexible bond when coming in contact with the moisture of the skin. Heat is generated during the chemical reaction that occurs when cyanoacrylate comes in contact with the skin and may be felt by the patient. Cyanoacrylate has been used for 25 years and is sold under the brand names Dermabond and Ethicon. 

Cyanoacrylates have also been shown to have antimicrobial properties. As a result of these findings, in 2001 the FDA approved Dermabond for use as a barrier against bacterial infection.

When can skin adhesive be used for wound closure?

In general, skin adhesives can be used on wounds that require sutures 5-0 or smaller. They may be used on wounds to the face, extremities, or torso. Wound adhesive it not ideal in highly mobile areas such as joints as it cannot withstand as much tension as sutures. If using skin adhesive on a highly mobile area, keep the body part immobilized with a splint to prevent the adhesive from peeling away from the wound. 

Which wounds cannot be closed with skin adhesive?

Skin adhesive may not have sufficient strength to close long or deep lacerations. In some cases, longer or deeper wounds may be closed internally with subcutaneous sutures, then externally with skin adhesive. Tissue adhesive should also be avoided on contaminated lacerations such as animal bites, mucus membranes such as the oral cavity, or in areas if high moisture such as the groin or axilla. When closing a scalp wound with tissue adhesive, it is essential to take care that excess adhesive does not run into the hair. 

How is skin adhesive applied?

Similar to suturing, the first step to closing a wound with tissue adhesive is to clean and irrigate the wound thoroughly. Due to the ease of skin adhesive use, this step is sometimes overlooked by providers and can lead to infection. 

After cleansing the wound, it should be dried and positioned to prevent glue from dripping or running onto other areas of the skin. The edges of the wound must then be held in an approximated fashion. 

Skin adhesive comes packaged in a single-use package. The outside of the tissue adhesive tube is plastic and contains an inner glass ampule. Once the wounds edges are held in approximation, crush the tissue adhesive ampule. The adhesive mush be used immediately or the adhesive will begin to harden on the tip of the applicator. Gently squeeze the vial, slowly applying adhesive to the wound. Glue should not be permitted to enter the subcutaneous area as this can result in inflammation. Once application is complete, hold the wound together for at least 30 seconds. Three layers of adhesive should be applied to ensure maximum strength. Allow at least two and one-half minutes for drying. Wounds covered with multiple layers of adhesive may require even longer to try. Fanning or blowing on the wound does not speed up the reaction that hardens the adhesive. 

Tissue adhesive allows for a 10 second "grace period". Should any adhesive liquid run off the wound, it can be wiped away promptly with gauze. 

How does healing of sutured wounds and glued wounds compare?

When used appropriately, the results of long-term healing with tissue adhesive and sutures are comparable. Rates of infection between wounds that have been sutured and those that have been skin adhesive do not significantly differ. 

What instructions do I need to give patients whose wounds are repaired with skin adhesive?

Skin adhesive does not need to be covered with a bandage as it provides it's own protective coating to the skin. Patients may shower normally, patting the area dry after bathing. Children should not be allowed to take baths or swim as excessive exposure to water can loosen the top layer of skin causing the adhesive to peel off early. Topical antibiotic ointments break down skin adhesive prematurely, so medications such as Neosporin should not be applied to the area. 

Tissue adhesive spontaneously falls off in five to ten days. Patients should avoid picking at the area for best healing. 

 

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