Allergic Contact Dermatitis (ACD) to Topical Products in Orthopedic Surgery: Clinical Characteristics and Treatment Strategies

Abstract

The potential for many of the commonly used surgical site wound adhesives, skin antiseptic solutions, topical antibiotics, and suture materials to sensitize and subsequently result in allergic contact dermatitis (ACD) has become increasingly recognized within orthopedic surgery. Particularly with subsequent exposure to the offending allergen, the cutaneous allergic reaction may present in a similar fashion to cellulitis, thus making early differentiation between the two etiologies to initiate the appropriate and timely treatment crucial. Recognition of the characteristic appearance and severity of ACD surrounding a surgical wound often drives the initial management. This typically consists of anti-histamines, topical corticosteroids, and possible removal of the offending allergen for low grade findings and oral steroids and prophylactic oral antibiotics for the more severe reactions. Multidisciplinary care, including the expertise of a dermatologist or wound care specialist when faced with this challenging clinical scenario is critical and elective patch testing may be indicated to ascertain the exact allergen involved, particularly in patients with a prior history of wound issues. Finally, any clinical cases of ACD following an orthopedic procedure should be documented in the patient's chart so that exposure can be avoided with any future surgery.

Keywords: Allergic contact dermatitis; Orthopedic surgery; Topical products.

Figure 1

Clinical image of 78-year old female who presented 3 weeks status post excision of right acromioclavicular joint ganglion cyst and distal clavicle excision with incision closed with 3-0 Monocryl sutures and Dermabond. The primary complaint was itchiness in the absence of fevers. (a) Clinical images at 3 weeks. Note the vesicles at the proximal portion of the incision with the cutaneous changes outlining the Dermabond; (b) Image demonstrating resolution of skin findings 4 weeks after removal of Dermabond, use of diphenhydramine and prophylactic Keflex

Figure 2

Image depicting the Prineo Skin Closure System (Ethicon Inc., Somerville, NJ, USA). The kit contains a mesh dispenser, in addition to the Dermabond (Ethicon Inc, Somerville, NJ, USA) adhesive applicator device

Figure 3

Image depicting Mastisol (Ferndale Laboratories, Ferndale, MI, USA) liquid adhesive

Figure 4

Image depicting the DuraPrep (3M, St. Paul, MN, USA) preoperative skin preparation applicator which contains iodine povacrylex and 74% isopropyl alcohol

Figure 5

Image depicting the ChloraPrep Hi-Lite Orange (Becton Dickinson, United Kingdom) preoperative skin preparation applicator which contains 2% chlorhexidine gluconate in 70% isopropyl alcohol, in addition to FD&C yellow #6 dye

Figure 6

Image depicting Vicryl Plus (Ethicon, Inc, Somerville, NJ, USA) coated antibacterial undyed braided sutures using triclosan

Figure 7

Image depicting chromacized catgut (Ethicon, Inc, Somerville, NJ, USA) suture