Cyanoacrylates for skin closure

Cyanoacrylates (CAs) were not widely adopted for medical use until recently because of lingering concerns regarding the initial tissue toxicities of the short-chain CAs. The medium-chain CAs, primarily butyl-cyanoacrylate, have been widely used in Europe and Canada for several decades and have gone a long way in dispelling any lingering concerns about tissue toxicity. The newer, longer chain CA, octyl-2-cyanoacrylate (2-OCA), now has been approved for multiple uses in the United States and has achieved widespread acceptance by the medical and lay communities. The current authors believe that this is probably only the beginning of the use of 2-OCA and other CAs in cutaneous medicine. This article discusses the use of CAs in their original cutaneous use as glues for the repair of lacerations and incisions and in their more recent use as dressings for the treatment of abrasions and wounds.     

Atraumatic closure of skin defects

A method of atraumatic wound closure published by Ambroise Pare [1] was carried out by suturing of crosstrips (Mefix-M?lnlycke) fixed along and upon the wound margins, combined with intradermal continuous sutures (absorbable monofilament polydioxanone--4-0, Ethicon).     

Investigation of irritant skin reaction by 10% povidone-iodine solution after surgery

We report 19 patients who developed extensive patchy or linear erythema on both sides of the buttocks, the back and the posterior areas of the thighs within a few days following operations or cardioangiography. The erythema was sometimes deeply infiltrative and was also accompanied by bullae and erosion. Patch tests of the patients were strongly positive for 10% povidone-iodine (PVP-I, Isodine) solution; however, they were negative for 10% PVP-I solution with the same amount of 8% sodium thiosulfate and for 5% potassium iodide in petrolatum. In all control individuals, the only positive result was that of a patch test with 10% PVP-I solution within 8 h after application. We diagnosed our patients as having irritant contact dermatitis caused by 10% PVP-I solution during the procedure, which might have drained along the skin to the side of the buttocks or the back. We here indicate that prolonged contact with a large quantity of 10% PVP-I solution should be avoided to prevent this problem.     

In vitro evaluation of skin sensitivity of povidone-iodine and other antiseptics using a three-dimensional human skin model

Povidone-iodine (PVP-I) is an antiseptic which has been widely used in various fields. It was reported to have a weaker skin irritancy than other antiseptics in the Draize skin irritation test using rabbits. Recent increased concern for animal welfare requires us to use skin models in the tests as an alternative to animal testing. Actually, there are some skin models already commercialized, which are available to evaluate skin irritancy caused by e.g. chemical reagents, cosmetics or medicines. In this study, we evaluated the potential of a PVP-I solution and other antiseptics to cause irritation using a cultured human skin model (three-dimensional skin model) under conditions similar to clinical use. This skin model has two layers like a real skin, such as the dermis and epidermis which includes the cornified layer. For the evaluation of skin irritancy in this model, cell viability was evaluated by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay as an endpoint. Antiseptic formulations such as benzalkonium chloride (BAC), benzethonium chloride (BEC), chlorhexidine gluconate (CHG) and alkyldiaminoethylglycine hydrochloride (AEG) were used in this study. As a result, PVP-I showed a significantly weaker skin irritancy compared to the other antiseptics. The present in vitro study results revealed a correlation with the results of previously conducted in vivo skin irritancy tests using rabbits.     

Three point-advancement closure for skin defects

BACKGROUND: Circular skin defects are common following Mohs' surgery. Traditional closure (primary, flap, or graft) may involve extensive surgery. Multidirectional advancement closures such as the purse-string closure have been advocated as another useful tool in such cases. OBJECTIVE: To describe a variation on purse-string closure that, in certain cases, is an excellent alternative to other reconstructions, and will provide good cosmetic and functional outcome. METHOD: A three-point anchoring suture is placed after undermining to advance the surrounding tissue toward the centre, creating a "Mercedes Benz" or tripod closure following removal of "dog-ears." RESULTS: Circular wounds in designated areas can be more easily closed, creating well-tolerated, favourable scars. CONCLUSION: Large wounds may be closed with the advantage of avoidance of larger flaps, of decreased wound healing compared to second intention, and of minimizing removal of healthy tissue. An initial trial of closure with this method does not limit subsequent use of other repairs should it be less than satisfactory.     

Simplified atraumatic wound closure of skin defects

A simplified technique of atraumatic tape-suture wound closure was performed by means of horizontal and vertical fixation of Squibb Dermahesive strips along and upon the wound margins; this method was combined with various suture techniques (i.e. interrupted sutures, vertical mattress sutures, half buried/mattress sutures, subcuticular and subcutaneous sutures).     

Excision of skin tumours without wound closure

Sixty-two patients with 67 large or poorly defined skin tumours predominantly on the head and neck (58 basal cell carcinomas) were treated by excision of the lesion and allowing the defect created to heal by second intention. Histological control of the adequacy of excision was monitored using routine vertical sections of formalin-fixed tissue. Further re-excisions were performed in 17 patients in whom tumour extended up to or within 1 high power field (approximately 0.44 mm) of the excision margin. The formalin-fixed specimens ranged from 6-60 (mean 21) mm in diameter and 2-12 (mean 5) mm in depth. After one excision the time to complete re-epithelialization was directly proportional to the surface area (r = 0.73) and ranged from 13 to 60 days (mean 33 days). Measurements of the movements of fixed reference points tattooed at the wound edges in six patients showed that movement of surrounding tissue into the defect accounted for 39-62% (mean 45%) of the reduction in surface area of the defect during healing. Post-operative complications were rare and the cosmetic results were considered good or excellent in 48 patients, fair in nine and poor, i.e. requiring corrective surgery, in three patients. Poor results were due to distortions of free margins, e.g. lower eyelid and nasal margin. The major benefit of this technique is the ease with which further excisions can be performed when histologically indicated.(ABSTRACT TRUNCATED AT 250 WORDS)     

Mixture of sugar and povidone-iodine stimulates healing of MRSA-infected skin ulcers on db/db mice

The topical application of a mixture of sugar and povidone-iodine (PI) has been reported to accelerate the healing of cutaneous wounds and ulcers by promoting reepithelialization and granulation tissue formation, as well as by having an anti-microbial effect. In order to clarify the efficacy of a 70% sugar and 3% PI paste (U-PASTA™)(SP) on infectious skin ulcers, we made a bacterial infection model using methicillin-resistant Staphylococcus aureus (MRSA) on the skin of diabetic db/db mice, and investigated the effect of the paste on the healing process of wounds. Full-thickness wounds were made on the backs of female diabetic mice, (C57BL/ksJ db/db) and inoculated with S. aureus. SP was applied to the closed wounds for 8 days. The degree of repair was evaluated using three histological parameters: The degree of reepithelialization was given a percentage value of 0–100%; the amount of granulation tissue was quantified by measuring the area of granulation (mm²); and the number of capillary lumens in the granulation tissue was counted in the complete wound cross-section at 100× magnification. In addition, the colony-forming units (CFU) of MRSA on the wounds were counted. Continuous MRSA infection in the wounds of db/db mice was demonstrated with macroscopic and histopathological images. Wounding and infection caused by MRSA on the back of the diabetic mice significantly induced delayed reepithelialization, granulation tissue formation with inflammatory cell infiltrate and increased CFU on wounds (P < 0.01, respectively) compared to those of the MRSA-infected normal mice. Application of SP significantly accelerated reepithelialization (P < 0.01) and decreased CFU (P < 0.05) of the ulcers in the MRSA-infected wounds, compared to the non-treated group. Histopathological evaluation and CFU on this animal model revealed no significant difference between Methicilin-sensitive Staphylococcus aureus and MRSA infection. These results indicate that wounding on db/db mice provides a useful animal model of bacterial skin infections, and that SP is an effective topical agent for the treatment of diabetic skin ulcers.     

Ocular applications of povidone-iodine

Ocular infections can have devastating consequences and may lead to blindness. Povidone-iodine (PVP-I) has many potential advantages over the currently used drugs, including a broader antibacterial spectrum, it turns the surface of the eye brown for a few minutes, bacterial resistance has not been seen and it is cheaper than other agents. PVP-I has made a significant contribution to pre- and postoperative ocular surgical prophylaxis, ophthalmia neonatorum prophylaxis and treatment of bacterial conjunctivitis. Scientific support for these applications includes studies conducted over the past 17 years, which are reviewed.     

A review of sutures and other skin closure materials

Abstract

More than ever, dermatologic surgeons are faced with a multitude of suture and other closure materials when evaluating a surgical wound. Given there is no single material that is ideal for all situations, the physician must decide which material is best suited for that particular closure. This review seeks to summarize the major properties of common suture materials as well as other closure materials including adhesive tapes, glues and staples.     

Wound closure in the care of small skin defects

We give a survey on the present situation regarding the methods and indications of punch biopsy as well as similar operations, including the design, orientation, and execution for the repair of small skin defects.     

The Fixomull skin support method for wound closure in patients with fragile skin

We report the Fixomull (BSN Medical, Hamburg, Germany) skin support technique for wound closure, a novel method for closing elliptical incisions in patients with fragile skin. After the lesion of concern is excised, a strip of Fixomull is applied to the skin adjacent to the wound edge with an approximately 2 mm gap between the Fixomull and the incision edge. The wound is then closed with interrupted sutures through the Fixomull, with care to ensure wound edge eversion. Fixomull provides extra tensile strength. The sutures are removed at approximately 14 days, and the patient given a prophylactic course of oral antibiotics only if at high risk of infection. This is a simple, time efficient, inexpensive and effective measure to avoid skin grafts and reduce skin tears and trauma in patients with thin, fragile skin. In our practice there have been no significant skin infections using this technique.     

Gene therapy and dermatology: more than just skin deep.

BACKGROUND: Recent advances in the molecular characterization of dermatologic disease have substantively augmented the understanding of the pathogenetic processes underlying disorders of the skin. This new knowledge coupled with progress in gene delivery technologies has paved the way for introducing cutaneous gene therapy into the dermatologic therapeutic armamentorium. OBJECTIVE: This review article includes an overview of the current strategies for delivery of gene therapy with an emphasis on the potential role of cutaneous gene delivery in the treatment of skin and systemic diseases. CONCLUSIONS: Accessibility for gene delivery, clinical evaluation, and topical modulation of gene expression render the skin a very attractive tissue for therapeutic gene delivery. However, there are several key hurdles to be overcome before cutaneous gene therapy becomes a viable clinical option. These include difficulties in inducing sustained expression of the desired gene in vivo, the challenge of targeting genes to long-lived stem cells, and the difficulty in achieving specific and uniform transfer to different compartments of the skin. However, these problems are not insurmountable and will likely be resolved in conjunction with ongoing advances in delineating gene expression profiles and other molecular properties of the skin, strategies for stem cell isolation, and improved approaches to regulating gene delivery and expression. These advances should create the framework for translating the enormous potential of cutaneous gene therapy into the clinical arena and, thereby, substantively improving the management of both cutaneous and systemic disease.     

Rosacea,not just skin deep: Understanding thesystemic disease burden

Rosacea is a common inflammatory skin condition with four main clinical subtypes: erythematotelangiectatic, papulopustular, rhinophymatous, and ocular. Although several genetic and environmental factors have been linked with triggering rosacea, the pathogenesis still remains poorly understood. There is an increasing evidence in the literature to support that rosacea is a harbinger of several systemic comorbidities and may represent a chronic, systemic, inflammatory state. We have provided the most up-to-date evidence on the association between rosacea and several systemic diseases, discussing that rosacea is not just a skin disorder but a systemic disease process.     

Clinical application of povidone-iodine oral antiseptic 1% (Betadine mouthwash) and povidone-iodine skin antiseptic 10% (Betadine solution) for the management of odontogenic and deep fascial space infection

Treatment of infections largely encompasses the field of dental medicine. Prevention and management of infection in the oral and maxillofacial region involve every facet of dental care that may be necessary due to caries, periodontal disease, pulpal pathology, trauma, reconstructive and surgical implants. One of the first surgical procedures in the treatment of localized infection commenced with the opening of bulbous abscesses with sharp stones and pointed sticks. The principles for the management of infection basically remain the same although the surgical technique has remarkably improved. It takes a qualitative and quantitative amount of bacterial insult to produce a certain degree of infection that may eventually lead to facial swelling, asymmetry, discomfort and loss of function. In the oral cavity and its surrounding structures, the predominant organisms such as the staphylococci and streptococci release enzymes responsible for the breakdown of fibrin (connective tissue ground substances) and lyse cellular debris, which facilitates a rapid spread of infection. At the University of the Philippines, Philippine General Hospital Medical Center, where I have served for 18 years, 90% of dental consultations from the outpatient department and emergency room complex concern infection, and 85% of facial swelling is dental in origin. A typical odontogenic infection is a dentoalveolar abscess that spreads deeply into the soft tissue rather than exiting superficially through the oral and cutaneous route, consequently involving the fascial spaces. Following the path of least resistance through connective tissue and along fascial planes, infection may diffuse quite distantly from its dental source, causing damage to the surrounding structures. Appreciation not only of the anatomy of the face and neck is necessary to predict sufficiently the pathway of spread of these infections, but also knowledge of how to drain these spaces adequately.     

Not just skin deep: a case report of multiple endocrine neoplasia type 1

Multiple endrocrine neoplasia (MEN) type 1 is characterized by mainly a triad of pancreatic, pituitary and parathyroid involvement. This is a case report of a 41-year-old male in whom recognition of collagenoma and gingival papule led to the identification of MEN type 1. Often the recognition of such dermatological manifestations help in the presymptomatic diagnosis of complex syndromes.