#366 Looking for Closure: Managing simple excisions or wounds efficiently
CLINICAL QUESTION
What are some options for efficiency in wound closure?
BOTTOM LINE
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
- 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.
- Clinician-rated cosmesis (3 RCTs, 173 wounds):3 Standard mean difference reported, not clinically interpretable.
- 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
- 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).
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Useful
Sutures are seem better if larger punch biopsies
This helps in chosing the method of closure. The quicker easier way maybe better for children.