Successful Management of Moisture-, Friction-, and Trauma-Associated Skin Damage in the Pediatric and Neonatal Population Using Cyanoacrylate Skin Protectant

Vita Boyar, MD

Disclosures

Wounds. 2022;34(3):83-89. 

In This Article

Results

Of the 15 patients, 11 were infants and 4 were older children. Moisture, maceration, friction, and skin tears were the underlying cause of the lesions treated (Table). Several cases are described in detail herein.

Case 1

A 2-week-old female neonate born at 34 weeks' gestation was evaluated for persistent abdominal distention and feeding intolerance. The diagnosis of long-segment ileal atresia was made, requiring creation of temporary ostomy and mucous fistula before definitive correction. After the ostomy started working and producing effluent, peristomal dermatitis was noted. Persistent surface moisture became an obstacle to long-term, successful ostomy bag wear. Frequent changes contributed to further irritant dermatitis. Initial management included nonalcohol-based skin polymer, powder, and zinc-based cream. None of these modalities was successful in eliminating irritation. Application of CSP was attempted. Denuded, inflamed areas were cleaned with normal saline (Figure 1A), after which CSP was applied and allowed to dry completely. Both mucous fistula and ostomy openings were covered with gauze to catch effluent for the first day to allow skin rest and healing. By day 2, the area was drier and less erythematous. At that point, an ostomy bag was applied. It remained in place for 2 days, about 18 hours longer than the previous appliance. Before the new bag was placed, the patient received a second application of CSP. Figure 1B shows the skin on day 6, after 3 applications of CSP. Erythema was diminished, denuded areas were mostly healed, and much less moisture was noted on the peristomal skin. Complete reepithelization occurred within days. The NIPS scores of this patient were 0 to 2.

Figure 1.

Case 1: (A) Affected areas before treatment. (B) After 3 applications of the cyanoacrylate liquid skin protectant, improvement was noted by day 6.

Case 5 and Case 6

A 5-month-old female infant with multiple congenital anomalies, respiratory failure, and ventilator dependency required tracheostomy. At 3 weeks postoperatively, tracheitis developed and resulted in thin peristomal secretions and skin maceration of the neck. As a result of increased agitation and thrashing, increased tracheostomy tube mobility was noted, which eventually led to the formation of granulation tissue (Figure 2A). The thin, absorbent foam (Mepilex Light; Mölnlycke Health Care) in use was no longer adequate to protect the macerated skin. The CSP was applied to all skin folds of the neck, with care taken to spread the skin and allow the product to dry completely to avoid adhesion of folds to each other. The CSP also was applied to peristomal granulation tissue. Thin foam was applied as typical barrier management over the neck perimeter under the tracheostomy ties. A second application of CSP occurred 3 days later. Maceration resolved completely and flattening of the peristomal granulation tissue was appreciated by day 7 (Figure 2B). The NIPS scores of case 5 were 1 to 3.

Figure 2.

Case 5: (A) Moist, erythematous neck folds. (B) After 2 applications of the cyanoacrylate liquid skin protectant, dermatitis resolution was seen on day 7.

Figure 3 depicts case 6 (Table), in which a similar tracheostomy case was managed successfully with 1 application of CSP. The CSP facilitated drying from oozing skin stripping and moisture-associated dermatitis.

Figure 3.

Case 6: (A) Significant dermatitis noted around tracheostomy, including chin and chest areas. (B) Cyanoacrylate liquid skin protectant was applied. (C) On day 3 after treatment, reduction in erythema and moisture were evident.

Case 7

In a 12-year-old male recovering from hip surgery, inguinal intertriginous dermatitis developed. For the first week, the neonate was not very mobile, resulting in significant maceration and bleeding (Figure 4A) from skin friction, urine, and perspiration. Nonalcohol-based skin polymer and air did not diminish the dermatitis. The CSP was painted on and allowed to dry completely (Figure 4B); sheets of moisture-wicking fabric with antimicrobial silver were placed between the folds. On day 3, CSP was applied a second time. After 7 days, the patient became more mobile and did not require further treatment; interim dryness was achieved, which supported healing.

Figure 4.

Case 7: (A) Intertriginous dermatitis was seen. (B) The cyanoacrylate liquid skin protectant was applied.

Case 10

In a 2-week-old neonate in whom Hirschsprung disease was repaired, the patient developed incontinence-associated dermatitis after cow's milk-based formula was introduced on day 3 (Figure 5A). Standard of care management included zinc, dimethicone, and karaya gum paste combined with every diaper change. The irritation worsened, possibly because of increased stool frequency. The crusting technique was attempted, but the crust did not last long because the neonate produced frequent and watery stools. The CSP was applied and allowed to dry completely, after which it was covered with a thick layer of petrolatum to facilitate easy stool cleaning. A second application of CSP was necessary after approximately 24 hours, but the skin was noticeably drier. On day 4, the third application was done (Figure 5B). Concomitantly, the infant's formula was changed to the hydrolyzed protein type, which also resulted in fewer bowel movements. After 6 days (Figure 5C), standard of care management was reinstated. During application, the NIPS scores were 1 to 2, compared with scores of 4 to 5 before CSP application, indicating a reduction in pain.

Figure 5.

Case 10: (A) Initial presentation of incontinence-associated dermatitis. (B) Improvement in skin erythema after 2 cyanoacrylate liquid skin protectant applications. (C) Resolution of dermatitis after 6 days (and 3 total treatments).

Case 11

A 2-month-old male infant was admitted to the hospital secondary to failure to thrive. He was undergoing preparation for an upcoming bone marrow transplant secondary to severe combined immunodeficiency disorder, specifically, Omenn syndrome. Medication and parenteral nutrition were administered via a central line. Severe allergic contact dermatitis was noted under the central line dressing. Multiple dressings were tried, all of which caused reactive dermatitis. Weepy denuded skin was a concern because the patient was visibly uncomfortable, attempting to scratch the area and crying during examination of the area (Figure 6A). Excessive skin moisture decreased the tackiness and adhesiveness of dressings, thus jeopardizing sterility. On day 1, the CSP was applied over the affected area and loosely covered by sterile gauze to allow skin healing (Figure 6B). On day 2, the secondary dressing was applied. On day 3, mild irritation was still present. A second CSP treatment was applied on day 5. The outer dressing was changed to a silicone-based, smallest available dressing to minimize skin exposure and remove an adhesive irritant; temporary skin healing was achieved after 2 treatments. During application, the NIPS score was 2. Previously, the patient had scores of 3 to 5, reflecting diminished pain.

Figure 6.

Case 11: (A) Irritant contact dermatitis of the chest. (B) Decreased skin moisture noted 1 day after applying the cyanoacrylate liquid skin protectant.

Case 15

A 16-year-old female with a history of myelodysplastic syndrome and a bone marrow transplant 1 year prior was admitted secondary to painful skin lesions under and over her breasts and of the bilateral shins and shoulders; these lesions were in addition to weight loss, nausea, and emesis. Intestinal GVHD complicated the treatment course, requiring prolonged, high-dose immunosuppressants, including steroids. The skin lesions were cultured for bacterial, viral, and fungal sources; these results were negative except for Candida albicans. Biopsy of the skin confirmed the diagnosis of chronic skin GVHD with some inflammatory changes. Despite the use of strong systemic medications, the skin lesions were not healing well. Some lesions exhibited lichenoid, sclerodermatous changes, whereas others exhibited exudative thin slough, as well as a fragile and bleeding wound bed (Figure 7A). Many of the lesions were painful and had a foul odor. Previous care included the use of topical antibiotics, silver, and honey-based products, as well as various dressings. The author of the current study decided to apply CSP every 2 to 3 days on all moist surfaces. Wounds were left exposed to air as much as possible. After 3 treatments, 80% of the lesions were drier and less friable. Most important to the patient, the lesions were less painful and no longer had a foul odor (Figure 7B). The lesions had not healed, but they had improved. The patient was discharged home shortly after this result was achieved, and she returned weekly for outpatient treatment. Several additional applications of CSP were required to address disease flare-ups.

Figure 7.

Case 15: (A) Graft-versus-host disease lesion on presentation. (B) Shoulder lesions, which initially appeared much like the lesions in panel A, were markedly improved after 3 applications of the cyanoacrylate liquid skin protectant.

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