There are many ways to skin a cat, but how many ways are there to close a cat’s skin? Pretty much, the same number of ways that you can close a human’s skin. Sutures, staples, and tape butterfly closures like steri-strips are common methods, but there’s another one: topical skin adhesive glues.
Topical glues have been around since the 1940’s, but it took more than 3 decades for them to be approved for human use. Since that time, they have become the favorite method of closure for some surgical procedures.
This article will discuss the properties and uses of skin adhesives, especially as they apply to survival scenarios. Therefore, we will forego a discussion of cosmetic results, as they would be less important in austere settings.
Topical skin adhesives (or glues) are liquids made from a mixture of cyanoacetate and formaldehyde called cyanoacrylate. These glues become solid upon contact with skin, thus holding wound edges together.
The original cyanoacrylates (methyl-cyanoacrylate) comprise what is now industrial Super Glue. Medical versions were then developed (octyl- and butyl-cyanoacrylate) that were meant specifically for human skin. Some brands include Dermabond, Surgiseal, Liquiband, and others. These are mostly by prescription only, and are roughly ten times the cost of regular Super Glue.
Benefits of Topical Skin Adhesives
Topical skin adhesives are useful in a number of specific circumstances, and have some benefits not seen with some other methods of wound closure:
• They are quick to apply.
• They are a relatively painless method of closure.
• They don’t leave the “hatch marks” seen with sutures and staples.
• They don’t require removal. Skin glues slough off by themselves spontaneously after 5-10 days.
• They don’t require anesthetic injections, which makes them less problematic to use in children or those afraid of needles.
• They create an environment which speeds healing.
• They decrease the risk of wound infections with certain bacteria (gram-positive like Staph).
Indications for skin closure with glue
Topical skin adhesives are best used for simple cuts such as some traumatic lacerations. Use them for:
• Wounds that are completely dry (no longer bleeding).
• Areas where there is no skin tension (not difficult to pull together manually).
• Hair-free areas .
• areas not inside the mouth.
• children, to avoid pain of local anesthetic injection.
• Short-medium length lacerations
Topical adhesives are not helpful or may be dangerous if used:
• Inside the mouth or other internal cavity.
• In other high-moisture areas such as the groin or armpit.
• Around the eyes without extreme caution.
• On joints (unless immobilized with splints).
• Very long lacerations
• On avulsions (areas where skin flaps have been torn off due to trauma) or very jagged lacerations.
• Infected wounds.
• Wounds with dead tissue, like gangrene.
• In those with known hypersensitivity to the chemical compound.
Comparing skin adhesives to sutures and staples
• The wound strength with glues is less than with staples or sutures, probably only 10 per cent or so in the early going. After several days, the healed skin strength with glue is nearly equal to other methods, especially if used in conjunction with butterfly closures.
• Although anti-bacterial ointments can be applied on top of suture/staple closures, they weaken the strength of skin adhesives.
• Blood or fluid may collect under the adhesive. Although drainage from the wound is acceptable with suture or staple closures (and may be preferable to collection under the skin), infection risk may be increased with glues or even prevent skin healing.
How to use topical skin adhesive glue:
Before using any method of skin closure, meticulous care must be taken to completely flush out debris and bacteria in the open wound. This should be done with an antiseptic solution like betadine or sterile saline. Any bleeding must be completely controlled. If deep layers are needed to close dead space, sutures can be used for this purpose as well as to decrease any tension on the wound edges.
When you are ready to close the skin:
• Approximate the wound edges carefully (best done by an assistant).
• Gently brush the glue over the laceration, taking care not to push any below the level of the skin.
• Apply about three layers of the adhesive over the wound, preferably widening the area of glue to increase strength of closure.
• Once completely dry, consider adding steri-strips to increase the strength of the closure.
It should be noted that some people experience a sensation of heat to the area when the glue is first applied. Encourage your patient to avoid picking at the closure or scratching it.
What about Super Glue for skin closure?
Many underdeveloped countries may not be able to afford the expensive medical glues. In some, like Cuba, emergency rooms have had to resort to industrial Super Glue. As a closure method, it is comparable, but it should be noted that Super Glue closures must be kept dry as they may break down more easily that medical glue.
Some people will experience skin irritation or even mild burns from the industrial version. You can test for this beforehand by having those in your group place a drop of Super Glue on the inside of their forearm. If there is a significant reaction such as redness or itching, avoid this method of closure on that person, or use the prescription version.
In my experience, gel versions of Super Glue are easier to handle due to less dripping.
Of course, standard medical texts will tell you to avoid Super Glue altogether. In a survival setting, you will have to make decisions based upon what you have available. The medic will often have to “make do” with suboptimal methods and equipment, but something is better than nothing. It will be easier to stockpile commercial glue than the more expensive medical skin adhesives.
As the survival medic, you should know how to use all the tools in the medical woodshed. If you learn the pros and cons of every method of skin closure, you’ll be better able to succeed, even if everything else fails.
Joe Alton, MD