Managing simple excision and wounds

Clinical question

What are options to close wounds efficiently?

Bottom line

Punch biopsies 4 mm in depth do not require closure but 8 mm biopsies do. Skin glue is similar to tape or sutures for simple wounds, as measured by clinician-rated cosmesis and patient satisfaction, with similar infection rates of 4% to 7.6%. Dehiscence occurs in about 4.5% of wounds closed with skin glue versus 1.3% with sutures. Absorbable sutures have similar outcomes as nonabsorbable ones.

Evidence

Results were statistically different unless indicated.

• Punch biopsy: In an RCT (N=77), two 4-mm or 8-mm punch biopsies were performed on the arms, legs, or trunk; wounds were closed by suture or secondary intention.¹ At 9 months, there was no difference in clinician-rated cosmesis. For patient preference, there was no difference for those with 4-mm biopsies; for those with 8-mm biopsies, 14% preferred secondary intention and 53% preferred suture (no preference among remainder).

• Skin glue (adhesive) vs sutures: A systematic review (33 RCTs, 2793 lacerations) of incisional wounds found wound dehiscence (17 RCTs, N=1225) occurred in 4.5% of wounds closed with skin glue vs 1.3% with sutures.² Time to closure (5 RCTs, N=407) was not pooled; results were inconsistent. There were no differences in clinician or patient satisfaction, or in infection.

  • - A second systematic review included nonrandomized studies and found no difference in wound cosmesis.³

• Skin glue vs tape: In 2 systematic reviews (16 to 33 RCTs, 2793 to 9783 lacerations) of children and adults with lacerations or incisions,^2,3 standard mean difference was reported for clinician-rated cosmesis (3 RCTs, 173 wounds),³ but was not clinically interpretable.

  • - An RCT (N=86) had similar results⁴: 2-month wound cosmesis (100-point visual analogue scale [VAS], higher scores better) had a VAS score of 56 for skin glue versus 63 for tape (difference not likely clinically meaningful).⁵

  • - There were no differences in patient satisfaction, dehiscence, infection, or time to perform closure.³

• Skin glue vs tape, staples, or sutures: In a systematic review (13 RCTs, 1322 lacerations)⁶ of adult and child lacerations, pain VAS scores (100-point, lower scores better) (1 RCT, 136 patients) were 11 points lower with skin glue.

  • - Time to perform closure (6 RCTs, N=584): 4.7 minutes faster with skin glue. There were no differences in cosmetic appearance, dehiscence, or infection.

• Absorbable vs nonabsorbable sutures: In 2 systematic reviews (7 to 11 RCTs, N=702 to 751) of those with lacerations or incisions,^7,8 there were no differences in cosmesis, patient satisfaction, or dehiscence.

• Adverse events: No difference in infection (4% to 7.6%).³

• Limitations: Differing rating scales and outcomes, and blinding of assessors unclear or unknown.^3,4

Context

• Simple lacerations: Clean with tap water⁹ and repair with clean nonsterile gloves (without increased infection).¹⁰

• Skin glues: octyl cyanoacrylate or butyl cyanoacrylate.

Implementation

Glue is appropriate for noncontaminated wounds. The wound should be cleansed; topical lidocaine with epinephrine 1:1000 can provide hemostasis. Topical antibiotics disintegrate glue. Approximate edges manually or with forceps. Brush first layer of glue across (not into) the wound, hold for 30 seconds, then apply 2 more layers. Maximal bonding strength occurs after 2.5 minutes. Loosen excess glue with topical antibiotics. Patients can shower and pat dry but should avoid prolonged immersion.¹¹