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

Moisture-associated skin damage occurs in 4% to 37% of the pediatric population, with the highest incidence reported in neonates.¹ Incontinence-associated dermatitis, peristomal breakdown, and intertriginous and periwound maceration commonly arise from excessive moisture, friction, inflammation, and trauma. Diaper dermatitis is among the most common neonatal nuisances.² Bodily effluent, whether from ostomy, gastrostomy, or tracheostomy, commonly leads to irritation, dermatitis, erosion, and significant pain. Most of these cutaneous injuries are challenging to heal because the skin surfaces are uneven and small, and it may be difficult to achieve adherence of dressings and keep them in place. Numerous adhesive devices are attached to neonatal patients; these, together with friction, sheer, and moisture, contribute to skin breakdown. Certain injuries, such as skin tears from birth trauma or epidermal stripping caused by removal of adhesive products, require immediate attention, with the goal of an easy, one-time application of a product to minimize further wound development. Additionally, certain cutaneous side effects of systemic illnesses or treatments may manifest as moist, eroded wounds, such as injuries to the skin from graft-versus-host disease (GVHD) after a bone marrow transplant.³

Currently, management of moisture-, friction-, and trauma-associated skin damage in pediatric patients varies, with traditional emollients and zinc creams used for incontinence-associated dermatitis, absorptive barriers for peristomal irritations, topical antibiotics for birth injury, and various absorptive dressings for exudative wounds in patients with systemic conditions.^4-6 The location and size of certain injuries in neonate patients can make applications of products or dressings challenging. Skin immaturity and increased percutaneous absorption preclude the use of certain topical products. Because of the risks of bacterial and fungal overgrowth in neonate patients, especially for those housed in heated humidified isolettes, traditional emollients and topical antibiotics are a less desirable choice.

Cyanoacrylate polymers offer another option in the physician’s armamentarium for protecting the skin and promoting healing. Cyanoacrylates are acrylate polymer derivatives that exist as monomers in a liquid form; when exposed to moisture on a surface, however, that moisture undergoes rapid polymerization, forming a flexible, strong film on the skin via a chemical bond with the outer epidermis.⁷ The current study evaluated the use of cyanoacrylate-based liquid skin protectant (CSP; Marathon; Medline Industries, Inc) to treat patients with various pediatric and neonatal wounds. It was hypothesized that epidermal protection coupled with ease of application, lack of bulky dressings, and lack of thick, occlusive emollients would result in favorable outcomes by supporting the healing of moisture damage, stabilization of the epidermis in skin tears, and granulation tissue recession.

This single-center, retrospective case series evaluated 15 pediatric and neonatal patients treated with CSP for wounds of diverse etiologies. The Table summarizes patient demographics and wound characteristics. Prior to CSP application, some patients underwent different treatments deemed necessary by the treating practitioner according to hospital protocols.

Cyanoacrylate liquid skin protectant is purple in color and has the active ingredients 2-octyl cyanoacrylate and n-butyl cyanoacrylate. It is available in a small-sized and large-sized ampoule with a foam tip applicator; when the vial is squeezed, the liquid immediately adheres to the skin, especially on a moisture-containing surface. A thin coat is applied across the affected area in an even, sweeping motion. Care should be taken to ensure that opposing skin folds do not adhere to each other while the liquid dries. The product takes approximately 1 minute to dry upon application. One coat is usually sufficient for an application, but the treating clinician should ensure that the desired area is completely coated. In this series, multiple applications at different time intervals were done as needed, depending on the skin condition and in accordance with the manufacturer’s recommendations. In neonates, it may be necessary to apply CSP daily, because frequent bowel movements and cleaning may facilitate product removal. Physiologically, the outer epidermal layer desquamates in neonates every 2 to 3 days; this rate is more frequent than in older children or adults, resulting in shorter intervals between treatments. The parents or guardians of each patient provided written informed consent to publish the case details and images. Written consent for the treatment was not necessary, because it is standard of care in the treating unit.

A neonatal behavioral pain scale (Neonatal Infant Pain Scale; NIPS) was used to assess potential pain or discomfort upon CSP application. It ranges from 0 to 7 and consists of the following 6 indicators: facial expression, cry, breathing pattern, arms, legs, and state of arousal. A score of 0 to 2 is considered mild to no pain, 3 to 4 is mild to moderate pain, and 4 or higher is severe pain.

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.

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 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.

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.

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.

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.

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.

Cyanoacrylate (monomer) technology has the biochemical property of immediate polymerization on contact with moist, denuded skin, forming a flexible, breathable, continuous barrier to outside moisture and friction.^7,8 In laboratory testing, CSP has been shown to decrease transepidermal water loss (TEWL), similar to solvent-based nonalcohol-based polyacrylate skin protectant (Cavilon; 3M Health Care).⁹ Chakravarthy et al⁹ demonstrated equivalent TEWL between the 2 barriers 1 to 2 hours after application, which indicated that both serve as an excellent protective barrier; however, skin treated with CSP returned to baseline TEWL values after 2 hours despite the visible barrier, which indicates superior breathability of this technology. The researchers also demonstrated superior thickness of CSP compared with the polyacrylate skin protectant. Under microscopic evaluation, CSP had a tight binding to the outer epidermis and no visible gaps between the skin and solution. Woo and Chakravarthy¹⁰ compared the same 2 products in human participants and demonstrated laboratory evidence of stronger protection afforded by CSP against moisture loss with washing and abrasion using a sponge. Clinical data from studies of adult patients support the efficacy of CSP in peristomal irritation, resulting in epidermal resurfacing and increased longevity of ostomy wafer use.¹¹ Intact tracheostomy site, without breakdown, was reported with cyanoacrylate use and reduced maceration in adults¹² with wet venous leg ulcers¹³; CSP was used to prevent peritracheostomy breakdown. Vlahovic et al⁸ reported successful resolution of pedal skin fissures, with excellent patient satisfaction, no stinging, and fast pain resolution after treatment with CSP.

The current study supports the efficacy of CSP against moisture-associated skin damage seen in an ostomy and gastrostomy-associated dermatitis, peritracheostomy maceration, incontinence-associated dermatitis, and allergic contact dermatitis. Cyanoacrylate liquid skin protectant suppresses granulation tissue growth, likely by to diminished friction and allowing healing. In addition, progression of skin tears (Figure 8) and epidermal stripping were halted with 1 application of CSP. Challenging denuded and moist wounds resulting from various illnesses can benefit from the drying effects of CSP as demonstrated by improvement in difficult-to-manage GVHD lesions. The patients in the current study represented various ages, from preterm neonates with fragile, underdeveloped skin to extremely immunocompromised teenagers with multiple lesions affecting their body image and quality of life. Neonatal and pediatric pain scale scores reflected comfortable application of CSP, and older patients confirmed a lack of stinging, burning, or pain.

The main limitation of this study is that it is a retrospective, single-center case series with a limited number of patients. Outcomes reported reflect the author’s experience.

Cyanoacrylate liquid skin protectant is a fast-drying, nonstinging, and efficacious option for protecting skin against moisture-, friction-, and trauma-associated damage. The author recommends considering CSP for use as a standalone therapy in any moisture- or friction-associated wound or in addition to the existing standard of care. It should be considered for preventative use in any high-risk areas.

Authors: Vita Boyar, MD

Affiliation: Steven and Alexandra Cohen Children’s Medical Center, Neonatal-Perinatal Medicine, New Hyde Park, NY

Disclosure: The author discloses no financial or other conflicts of interest.

Correspondence: Vita Boyar, MD, Director of Neonatal Wound Services, Steven and Alexandra Cohen Children’s Medical Center, Neonatal-Perinatal Medicine, 269-01 71 Avenue, New Hyde Park, NY 11040; vboyar@gmail.com