Tools for Practice Outils pour la pratique


#366 Looking for Closure: Managing simple excisions or wounds efficiently


CLINICAL QUESTION
QUESTION CLINIQUE
 What are some options for efficiency in wound closure?

BOTTOM LINE
RÉSULTAT FINAL
 Punch biopsies 4mm do not require closure but 8mm do.  Skin-glue is similar to tape or sutures for simple wounds for clinician-rated cosmesis and patient satisfaction with similar infection rates of 4-7%.  However, dehiscence occurs in ~5% with skin-glue compared to 1% with suture. Absorbable sutures have similar outcomes to non-absorbable sutures.


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EVIDENCE
DONNÉES PROBANTES
  • Results statistically significant unless otherwise stated.
  • Punch biopsy: One randomized controlled trial (RCT), 77 patients, two 4- or 8-mm punch biopsies on arm/leg/trunk, one sutured and other closed by secondary-intention. Assessed at 9 months.1
    • Clinician-rated comesis: No difference.
    • Patient preference:
      • 4mm: No difference.
      • 8mm: 14% preferred secondary-intention versus 53% preferred suture (remainder: no preference).
  • Skin-glue (adhesive) versus sutures: One systematic review (33 RCTs, 2793 lacerations) of incisional wounds:2
    • Wound dehiscence (17 RCTs, 1225 patients): 4.5% skin-glue versus 1.3% sutures
    • Time to closure (5 RCTs, 407 patients): Not pooled, results inconsistent.
    • Clinician/patient satisfaction, infection: No difference.
    • Second systematic review3 included non-randomized studies: No difference in wound cosmesis.
  • Skin-glue versus tape: Two systematic reviews (16-33 RCTs, 2793-9783 lacerations), children/adults with lacerations/incisions:2,3
    • Clinician-rated cosmesis (3 RCTs, 173 wounds):3 Standard mean difference reported, not clinically interpretable.
      • RCT4 (86 patients) with similar results, 2-month wound cosmesis [100-point visual analogue scale (VAS), higher=better]: 56 skin-glue versus 63 tape (difference not likely clinically meaningful).5
    • Patient satisfaction, dehiscence, infection, or time-to-perform-closure:3 No difference.
  • Skin-glue versus tape/staples/sutures combined: One systematic review (13 RCTs, 1322 lacerations),6 adult/children lacerations:
    • Pain VAS (100-point, lower=better) (1 RCT, 136 patients): 11 points lower with skin-glue.
    • Time to perform closure (6 RCTs, 584 patients): Skin-glue 4.7 minutes faster.
    • Cosmetic appearance, dehiscence, infection: No difference.
  • Absorbable versus non-absorbable sutures: Two systematic reviews (7-11 RCTs, 702-751 patients), children/adults with lacerations/incisions:7,8
    • Cosmesis, patient satisfaction, dehiscence: No difference.7,8
  • Adverse events:3 No difference in infection (4-7.6%).
  • Limitations: Differing rating scales/outcomes, blinding of assessors unclear/unknown.3,4
CONTEXT
CONTEXTE
  • Simple lacerations can be cleaned with tap water9 and repaired with clean non-sterile gloves without increased infection.10
  • Skin-glue: Octylcyanoacrylate (DermabondTM) or butylcyanoacrylate (KrazyglueTM).

Augustine Opara May 31, 2024

Useful

Bruce Zimmermann June 7, 2024

Sutures are seem better if larger punch biopsies

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Author(s)
Auteur(s)
  • Jennifer Young MD CCFP-EM
  • Jennifer Potter MD CCFP

1. Christenson L, Phillips P, Weaver A, et al. Arch Dermatol. 2005 Sep; 141(9):1093-9.

2. Dumville J, Coulthard P, Worthington H et al. Cochrane Database Syst Rev. 2014 Nov 28; 2014(11):CD004287.

3. Tandon S, Smale M, Pacilli M, et al. J Pediatr Surg. 2021 May; 56(5):1020-1029.

4. Zempsky W, Parrotti D, Grem C et al. Pediatr Emerg Care. 2004 Aug; 20(8):519-24.

5. Quinn J, Drzewiecki A, Stiell I et al. Am J Emerg Med. 1995 Mar; 13(2):229-31.

6. Farion K, Osmond M, Hartling L et al. Cochrane Database Syst Rev. 2002; 2002(3):CD003326.

7. Gillanders S, Anderson S, Mellon L et al. J Plast Reconstr Aesthet Surg. 2018 Dec; 71(12):1682-1692.

8. Al-Abdullah T, Plint A, Fergusson D. Pediatr Emerg Care. 2007 May; 23(5):339-44.

9. Allan, M. Lacerations: Sterile Gloves and Water? Tools for Practice #2. Accessible at https://cfpclearn.ca/tfp2/. Accessed May 3, 2024.

10. Steve E, Allan M. All You Need is Glove: Are non-sterile gloves safe for excisions in the office? Tools for Practice #178. Accessible at https://cfpclearn.ca/tfp178/. Accessed May 3, 2024.

Authors do not have any conflicts of interest to declare.