VOLUME 36 : NUMBER 2 : APRIL 2013

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Skin glues for wound closure

SUMMARY
Skin glues are a safe and effective method to
close selected wounds.
They are also cost-effective and help prevent
infection.
Ideally, wounds should be less than 4 cm,
not contaminated or infected and have skin
edges that are not under tension. Wounds
should be closed within 12 hours.
Most patients will be children with short clean
wounds.
Dehiscence is slightly higher with skin glues
than with sutures, but the cosmetic outcome
is comparable and skin glues are painless.

Skin glues should be used only for superficial

approximation of skin. With surgical incisions, wound
closure of layers should be performed and ideally
glue should only be used in the skin approximation.
Similarly in all other wounds which are gaping, it is
vital to have skin approximation before applying the
skin glue.

Variable results with some wounds

Without deeper sutures to approximate the skin, using
skin glues to close excision sites is associated with
increased rates of dehiscence.2,9 Glues may be used
over joints only when accompanied by deeper tension
sutures and splinting.1,2 They are generally acceptable
for the treatment of skin flaps.2 Glues do not appear
to compromise circulation further given that the
circulation is often already compromised. Nail bed
repair has been successfully reported.

Introduction

Advantages of skin glues

Closure of wounds is often needed to promote wound

healing and to produce an acceptable cosmetic
result. Traditionally sutures and also adhesive strips
have been used. Skin glues are safe and effective but
wound selection is important.1-4

Applying skin glue is painless. In about 20% of

patients there is a report of a sensation of mild heat
but no actual pain.1 Wound infection rates are low
(less than 3%) and are not increased with skin glues.5

Skin glues are cyanoacrylates. Derivatives with long

chains are less reactive and stronger. They are available
in liquid monomer formulations which react with
formaldehyde on contact with skin or other surfaces.
This polymerisation produces an exothermic reaction
to create a bridge while becoming adherent to the skin.
Todays products are all effective and non-toxic and
produce strong bonds.5 One study has shown that the
current adhesive properties have a bursting strength
equivalent to 4/0 nylon in an intracuticular wound
closure.2

Wound selection
Not all wounds are suitable for skin glues (Box 1) it
is likely that they are only appropriate for 1520%.2
In particular, bites should not be treated with glues.
Wounds should be less than 12 hours old, clean and
free of debris.
Most wounds studied, particularly in emergency
departments, were 16 cm. Some experts believe that
wounds greater than 4 cm should not be closed with
skin glue alone6 while others believe up to 10 cm is
acceptable7,8. A general agreement is that for optimum
results, wounds should be less than 4 cm in length.
Longer wounds have increased rates of dehiscence.

Geofrey Marshall
Director
Emergency Department
Bathurst Base Hospital
Bathurst
New South Wales
Clinical associate professor
University of Sydney
Key words
children, emergency
treatment, skin adhesives,
sutures
Aust Prescr 2013;36:4951

Procedure time is reduced.1,2,5,8 Studies reported that

the time of the actual wound repair in all settings
was less than formal suturing. Sedation, which is
sometimes used in children having sutures, is not
needed with skin glues.
Cosmetic appearance with skin glues is comparable to
outcomes with sutures and strip approximation.1,2,5,7,10
Most of the trials have used a blinding method with
photographs assessed by plastic surgeons, other
doctors and patients themselves. Comparisons were
made of appearance, absence of step-off, margin
irregularities, separation, edge inversion and wound

Box 1 Wounds not suitable for skin glue

Deeper wounds requiring sutures to approximate the
skin edges
Contaminated wounds from animal or human bites
Crushed or infected wounds
Skin over joints or other high tension areas
Wounds which cross muco-cutaneous borders
High friction areas such as perineum, buttocks
High moisture areas
Wounds over 12 hours old

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VOLUME 36 : NUMBER 2 : APRIL 2013

Skin glues for wound closure

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distortion. The results universally recorded that final

cosmetic appearance for skin glues was similar to
sutures, and both were better than adhesive strips.8,9
Skin glues are expensive. However, when compared
with equipment and labour costs as well as the need
for follow-up for suture removal, the overall cost is felt
to be equivalent to sutures.11
Patient satisfaction with skin glues was higher than
with sutures in most studies. Reasons included lack of
pain, ease of wound care and no need for follow-up
and suture removal.
There is no chance of needle-stick injury with skin
glues. They provide a barrier for short-term exposure
to water. Swimming is generally not recommended.

Disadvantages of skin glues

In studies, 4% of wounds reopen with skin glues
compared to 12% with sutures. This was thought
to be due to a combination of poor technique, poor
wound selection, but most importantly breakage
of bonds or sloughing from the skin surface.1,2
Dihescence may cause delayed healing, poor cosmetic
result and possible infection.

Applying the glue

The two most common applicators for skin glues
involve pressure on the container with gravity assisting.
They are difficult to apply upwards on a wound. In
one type (Fig. 1A), the inner glass container is crushed
between the fingers which starts the polymerisation
process. The liquid flows easily from the bottom of the
container by gravity and pressure feed to an outward
nozzle which allows continuous application due to
lower viscosity. The other type (Fig. 1B) requires
scissors to open the feeder and has larger droplets
with higher viscosity to allow droplet application. The
nozzle is then used to spread the coating.

Fig. 1 Skin glue applicators

A Continuous applicator

Patients may not feel that glue alone is adequate.7

This was found generally in active males who felt
there was a higher chance of wound breakdown.
Some patients are allergic to the cyanoacrylate or
residual formaldehyde.

Tips for using skin glues

Accurately applying skin glues is easy (Box 2)
and takes less than an hour to learn. In contrast,
optimising suture usage takes about two years.12 The
wound still needs to be irrigated and prepared before
applying skin glues.
Antibiotic ointments should not be used in
conjunction with the application of skin glues. Care
should be taken not to get the glue near or in the eye.
Eyes should be protected with gauze to prevent eyelid
attachment or corneal deposition. Antibiotic ointment
or petroleum jelly can facilitate removal of glue if
corrections are required.

Box 2 Steps for applying skin glue

1. Select wound carefully
2. Apply antiseptic solution to clean wound as usual
3. Oppose skin edges, usually by pulling slightly on both ends of the wound
4. Apply adhesive to the wound plus 510 mm either side. It usually needs three coats.
5. Allow 3045 seconds for polymerisation with 1015 seconds between layers.
Fanning the wound will not speed up polymerisation.
6. Once dry, cover the wound if the child is likely to pick at it, otherwise leave open
7. Glue will peel off in 58 days

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B Droplet applicator

VOLUME 36 : NUMBER 2 : APRIL 2013

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The skin edges are approximated with fingers of the

other hand, taking care not to include the gloves in
the application process. It is important to practise
controlling the applicator and get used to adhesive
viscosity. The glue should cover the wound plus about
510 mm of skin on either side. Polymerisation takes
3045 seconds. Two additional layers should be used,
with 1015 seconds between each layer. Full strength
is achieved after 2.5 minutes.

Conclusion
Careful wound selection and practice of the technique
make wound closure with skin glue acceptable in
up to 20% of wounds. An increased rate of wound
dehiscence is a potential drawback.
Conflict of interest: none declared

References
1.

2.
3.
4.

5.

6.

Farion KJ, Russell KF, Osmond MH, Hartling L, Klassen TP,

DurecT, et al. Tissue adhesives for traumatic lacerations
in children and adults. Cochrane Database Syst Rev
2009;1:CD003326.
Singer AJ, Quinn JV, Hollander JE. The cyanoacrylate topical
skin adhesives. Am J Emerg Med 2008;26:490-6.
Singer AJ, Thode HC. A review of the literature on
octylcyanoacrylate tissue adhesive. Am J Surg
2004;187:238-48.
Gktas N, Karcioglu O, Coscun F, Karaduman S, Menderes A.
Comparison of tissue adhesive and suturing in the repair of
lacerations in the emergency department. Eur J Emerg Med
2002;9:155-8.
Chow A, Marshall H, Zacharakis E, Paraskeva P, Purkayastha S.
Use of tissue glue for surgical incision closure: a systematic
review and meta-analysis of randomised controlled trials.
J Am Coll Surg 2010;211:114-25.
Lo S, Aslam N. A review of tissue glue use in facial
lacerations: potential problems with wound selection in
accident and emergency. Eur J Emerg Med 2004;11:277-9.

7. Coulthard P, Esposito M, Worthington HV, van der Elst M,

Van Waes OJ, Darcy J. Tissue adhesives for closure
of surgical incisions. Cochrane Database Syst Rev
2010;5:CD004287.
8. Zempsky WT, Parrotti D, Grem C, Nichols J. Randomised
controlled comparison of cosmetic outcomes of simple
facial lacerations closed with Steri Strip skin closures or
Dermabond tissue adhesive. Pediatr Emerg Care
2004;20:519-24.
9. Eaglstein WH, Sullivan T. Cyanoacrylates for skin closure.
Dermatol Clin 2005;23:193-8.
10. Matick A. Use of tissue adhesives in the management of
paediatric lacerations. Emerg Med J 2002;19:382-5.
11. Man SY, Wong EM, Ng YC, Lau PF, Chan MS, Lopez V, et al.
Cost-consequence analysis comparing 2-octyl cyanoacrylate
tissue adhesive and suture for closure of simple lacerations: a
randomised controlled trial. Ann Emerg Med 2009;53:189-97.
12. Lin M, Coates WC, Lewis RJ. Tissue adhesive skills
study the physician learning curve. Pediatr Emerg Care
2004;20:219-23.

FURTHER READING
Singer AJ, Kinariwala M, Lirov R, Thode HC Jr. Patterns of use
of topical skin adhesives in the emergency department.
Acad Emerg Med 2010;17:670-2.

Book review
Therapeutic Guidelines: Ulcer and wound management. Version 1.
Melbourne: Therapeutic Guidelines Limited; 2012.
87 pages
The prevalence of ulcers in the community has been
estimated to be up to 2% and contributes a significant
impost on the health budget. This has led to a
general realisation of the importance of not only
managing, but preventing this potentially chronic
problem. This handbook highlights the importance of
not treating the ulcer in isolation, but also considering
factors that influence healing and the effects of the
ulcer on the patient.
The handbook covers the causes of ulcers and
wounds and their management in an easy-to-read
and informative manner. It gives guidance on the

role of investigations, antibiotics, dressings and, in

particular, management for particular ulcer beds.
Importantly, less commonly addressed issues such as
pain management are outlined.

Mauro Vicaretti
Head of Vascular Surgery
Westmead Hospital
Sydney

The text is supplemented with boxes and figures

which summarise assessment and treatment plans
for individuals with ulcers. The photos used are true
representations of the pathologies described.
The information within the handbook has been
extensively researched and is in keeping with
international consensus guidelines. The handbook
would serve as an excellent adjunct for the specialist,
medic and paramedic who has an interest in wound
and ulcer management.

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