Os Styloideum Resection Complicated by Severe Contact Dermatitis to 2-Octyl Cyanoacrylate: A Case Study

Os styloideum is an accessory wrist bone at the base of the second and third metacarpals that can cause chronic pain. Symptomatic cases are most commonly due to the extensor carpi radialis longus and brevis tendons slipping over the bone, irritation following trauma, or degenerative changes leading to osteoarthritis. Although the etiology of an os styloideum is uncertain, it is often attributed to a physiologic response to altered forces on the wrist secondary to repetitive use as seen in various athletes.¹ In a retrospective study of professional hockey players, 13 of 16 randomly selected players (81%) were found to have an os styloideum.¹ There is also a reported case of an elite athlete who suffered acute os styloideum injury after traumatic flexion of the wrist joint.² It is also thought that an os styloideum can arise from non-fusion of primordial cartilaginous units.³ Males and females are affected equally, with an incidence rate of 0.3%–1.6% in the general population and a mean incidence age of 32.³ Initial treatment involves splinting and steroid injections in an attempt to prevent the inflammatory process and subsequent pain.⁴ However, once an os styloideum becomes symptomatic, the patient may require surgical resection and appropriate incision closure.⁴ 

Various methods for incision and skin closure exist in the surgical world, including a variety of sutures, staples, and adhesives. Dermabond (Ethicon, Somerville, NJ) is an adhesive wound closure device composed primarily of 2-octyl cyanoacrylate. This adhesive device is commonly used in conjunction with deep dermal stitches to provide strength and a protective barrier. It has been shown to be an effective alternative to staples and sutures in randomized control trials and retrospective studies, with low incidence of adverse events and high patient satisfaction.^5–7 However, side effects have been reported with its use, including contact dermatitis. In a recently published prospective study by Nigro et al, 102 patients underwent breast surgery with 2-octyl cyanoacrylate placed over the incision as an occlusive dressing.⁸ Twelve patients (12%) developed contact dermatitis to the 2-octyl cyanoacrylate during the postoperative period.⁸ The results of this study point out that although 2-octyl cyanoacrylate and other adhesives are effective, contact dermatitis is an important concern and the prevalence of contact allergy is likely higher than previously suggested.⁸ 

Patient testing for allergies to adhesives and their components are usually not conducted preoperatively. Rather, self-reported episodes seem to be the most common way that allergies to adhesives are recorded. Nonetheless, of the 12 patients who had contact dermatitis in the study performed by Nigro et al, all were confirmed allergies by subsequent allergy tests.⁸ In a study performed by Cook et al,38 patients with a history of contact dermatitis to cyanoacrylate-containing adhesives were patch-tested.⁹ Although not all 38 patients tested positive, this study found that a higher percentage of positive test results was seen in the patch-tests that used higher concentrations of the compound as well as those using octyl-cyanoacrylate (50%) versus ethyl cyanoacrylate (29%).⁹ We present a case of severe contact dermatitis that occurred after the use of 2-octyl cyanoacrylate for incision closure following an os styloideum resection.

The patient was a 29-year-old male surgical resident and golfer with a firm right dorsal hand mass that had been slowly increasing in size for 18 months (Figure 1). As the mass continued to increase, the pain associated with motion also increased. The patient initially tried conservative management that included splinting of the radiocarpal joint to decrease mobility and local steroid injections to reduce inflammation caused by repetitive tendon irritation and arthritic degeneration. These methods provided minimal relief, and the patient elected to proceed with mass resection. 

The patient underwent a successful resection of the dorsal hand mass, which confirmed the preoperative diagnosis of os styloideum (Figure 2 and Figure 3). The patient’s incision was closed with buried Monocryl sutures (Ethicon, Somerville, NJ) and a 2-octyl cyanoacrylate adhesive for skin closure. A volar resting splint was put in place to decrease motion of the joint and incision site. The patient was instructed to keep the extremity out of water until removal of the splint. 

Six (6) days after the resection, the patient experienced discomfort underneath the splint. The splint was removed, revealing a well-demarcated area of dermatitis on the dorsum of the hand accompanied by erythema, bulla, and necrosis (Figure 4). The overlying skin sloughed off on postoperative day 7, revealing a full-thickness injury over the incision as well as a partial-thickness wound on the ulnar aspect of the hand. The remaining adhesive was removed and local wound care was started, which consisted of wound cleanings and the application of Xeroform (Cardinal Health, Dublin, OH) with dry gauze for the dressing. The patient received a 6-day course of methylprednisolone, starting with a dose of 24 mg and tapering by 4 mg each day, which resulted in stabilization of the wound (Figure 5). The patient underwent a second procedure on the wound 25 days after the initial operation, which resulted in excision of the necrotic tissue and reapproximation of skin over the region of full-thickness tissue loss (Figure 6 and Figure 7). The remaining wound continued to heal over a period of weeks, ultimately resolving with complete resumption of functionality and minimal cosmetic impairment (Figure 8).

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.¹⁵Weedon’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.

The purpose of this study was to present a case of severe contact dermatitis to 2-octyl cyanoacrylate following the removal of an os styloideum. This case report not only discussed the encountered complications and management, but also examined previous literature on contact dermatitis to 2-octyl cyanoacrylate. Such literature shows an incidence of contact dermatitis to 2-octyl cyanoacrylate that is higher than suspected, multiple factors that may contribute to the severity of contact dermatitis, and the widespread use of 2-octyl cyanoacrylate that is not limited to the field of surgery. Tactics to prevent severe cases of contact dermatitis to 2-octyl cyanoacrylate include asking patients about prior exposure and reactions, educating patients on wound care, and early inspection of wounds. For cases of severe contact dermatitis, with or without necrosis, removal of residual glue, local wound care, and administration of corticosteroids should be considered as a reliable treatment option in the appropriate patients.

Portions of this manuscript and an abstract related to this case were presented as a poster at the 2020 AFMR Southern Regional Meeting in New Orleans, LA. Additionally, the rights and dignity of the patient being presented in this report were upheld by obtaining full consent for the disclosure of the patient’s medical history for educational and research purposes. 

Dr. Googe is a PGY-V plastic surgery resident, and Dr. Cushing is a plastic surgeon, both in the Division of Plastic Surgery, University of Mississippi Medical Center, Jackson, MS; Bobby May is a fourth-year medical student at the University of Mississippi School of Medicine, Jackson, MS. Please address all correspondence to: Benjamin Googe, MD, University of Mississippi Medical Center, Division of Plastic Surgery, 2500 N State Street, Jackson, MS 39216; email: bgooge@umc.edu.