What is the plan of care for a patient with a pruritic adhesive reaction from surgical adhesive?

Management of Prineo Adhesive Reaction Following Surgery

For patients experiencing a pruritic reaction to Prineo surgical adhesive, prompt removal of the adhesive followed by topical corticosteroids and oral antihistamines is the recommended first-line treatment approach.

Assessment and Diagnosis

When evaluating a patient with suspected adhesive reaction:

• Examine the surgical site for characteristic signs:

  • Erythema, pruritus, and possible blistering limited to the area where adhesive was applied
  • Eczematous reaction pattern that follows the outline of the adhesive
  • Onset typically within 2 weeks post-surgery (can range from 3-14 days)
  • Absence of purulent discharge, significant warmth, or systemic symptoms that would suggest infection

• Differentiate from surgical site infection:

  • Contact dermatitis from adhesives typically presents with pruritus and eczematous changes without purulence or significant local heat 1
  • The reaction is confined to the area where adhesive was applied

Treatment Algorithm

Grade 1 (Mild reaction - limited area, minimal symptoms)

1. Remove the adhesive completely if still present

2. Apply topical corticosteroids:

   • Medium-potency (triamcinolone 0.1%) for body areas 2
   • Mild-potency (hydrocortisone 1%) for face or sensitive areas 3
   • Apply twice daily for 7-10 days

3. Oral antihistamines for pruritus relief:

   • Non-sedating options: cetirizine 10mg daily or loratadine 10mg daily 4
   • For nighttime relief: diphenhydramine 25-50mg at bedtime 5

Grade 2 (Moderate reaction - 10-30% BSA or more significant symptoms)

1. All treatments from Grade 1, PLUS:
2. Consider adding:
   • Higher potency topical corticosteroids for body areas
   • Neuromodulators for persistent pruritus: gabapentin (300mg 1-3 times daily) or pregabalin (75mg twice daily) 4, 2
3. Reassess after 2 weeks - if not improving, proceed to next level of treatment 4

Grade 3 (Severe reaction - extensive area, blistering, or severe symptoms)

1. Dermatology consultation is strongly recommended
2. Consider short course of systemic corticosteroids:
   • Prednisone 0.5-1 mg/kg/day for 3-5 days with taper over 1-2 weeks 2
3. Intensify topical therapy with high-potency corticosteroids
4. Monitor for secondary infection and treat with appropriate antibiotics if present 2

Prevention of Secondary Complications

• Apply emollients regularly to maintain skin barrier function
• Avoid scratching to prevent excoriation and secondary infection
• Monitor for signs of secondary infection (yellow crusting, pustules, increasing pain)
• Consider prophylactic antibiotics only if evidence of secondary infection

Special Considerations

• Documentation: Record the reaction in the patient's medical record and alert surgical team to avoid similar adhesives in future procedures
• Future surgeries: Consider alternative closure methods (traditional sutures, staples, or hypoallergenic tape) for subsequent procedures
• Patient education: Inform patient about the nature of the reaction and importance of reporting similar reactions with future exposures

Epidemiology and Pathophysiology

Contact dermatitis to surgical adhesives occurs in approximately 0.5-14% of patients 6. Specific studies of Prineo adhesive system report a 2.8% incidence of contact dermatitis 1. The reaction is typically a type IV delayed hypersensitivity reaction to components in the adhesive, most commonly to cyanoacrylates or methacrylates 7, 5.

The diagnosis is primarily clinical, based on the characteristic distribution of the reaction corresponding exactly to the area where the adhesive was applied, and the timing of onset (typically within 2 weeks of application).