While wound dressings and wound closure devices play an important role in postoperative care, serious injuries as a result of the synthetic adhesives found in these products can often cause more harm than good.
Medical Adhesive Related Skin Injuries (MARSI) affect over 1.5 million patients each year and are a leading cause of painful postoperative complications including delayed wound healing, surgical site infections (SSIs) and poor scarring outcomes.
MARSIs are often underreported in medicine, highlighting the critical need for increased awareness and improved preventive measures to address this important patient safety concern.
How do medical adhesive related skin injuries (MARSIs) occur?
MARSIs occur as a result of the improper selection, application or removal of medical adhesives, tapes, or dressings. Skin rashes to medical adhesives can occur up to two weeks after their application and are often underreported by healthcare professionals. The last thing patients should have to worry about after surgery is dealing with additional complications caused by the very products meant to aid their recovery.
Unfortunately, these complications do not have a standardized method for their prevention, reporting or treatment. A survey of 918 wound care health professionals in 2016 found that MARSI was not reported in their facility 71% of the time and only 31% of respondents were aware of the term. Educating both clinicians and patients regarding MARSIs and highlighting the importance of wound dressing selection are crucial measures to mitigate these postoperative complications. These complications lead to the disruption of the epidermal barrier which cause delayed wound healing, inflammation, irritation and increase the susceptibility of the wound to outside pathogens which can cause infections.
Common complications as a result of MARSIs
Adverse events as a result of medical adhesive related skin injuries fall into the following categories:
- Allergic Contact Dermatitis: A skin hypersensitivity reaction to the adhesive or dressing material which causes a rash that may either be localized to the area of exposure or go beyond.
- Irritant Contact Dermatitis: non-allergic contact dermatitis a result of a chemical irritant that occurs in a localized area correlated to the area of exposure.
- Tension Injury or Blister: Separation of the epidermis from the dermis as a result of shear forces that occur when a medical tape or dressing is applied in an area with tension or movement. Often results in blister formation.
- Skin Tear: Removal of one or multiple layers of the skin as a result of dressing or tape removal.
- Maceration: Injury as a result of moisture being trapped against the skin for extended periods of time resulting in the softening and disruption of the skin.
Prevalence of MARSIs
A recent study published in the Aesthetic Surgery Journal Open Forum in collaboration with the Johns Hopkins University School of Medicine and the University of California San Diego found that current synthetic devices such as the Dermabond Prineo Skin Closure System display a range of adverse events associated with MARSI. The study found the rate of severe allergic contact dermatitis to Dermabond Prineo to be 24% (6/25) which a moderate rate of 52% (13/25) in comparison to a 0% (0/25) reaction rate to a natural silk fibroin dressing. The silk dressing significantly decreased skin discomfort (4% vs. 64%) and reduced the need for topical steroids or antibiotics for the treatment of ACD and SSIs (0% vs. 52%).
A prospective study in adult intensive care units found the rate of MARSI to be 42% (n=150) while another prospective cohort study found the rate to be 60.3% (n=136) in congenital heart surgery. The rise of synthetic compounds and materials in modern medicine may be associated with this increase in MARSI reported in the literature.
Despite these reports, the true rate of MARSI remains uncertain due to the lack of standardized reporting and awareness of the issue in healthcare facilities.
Which patients are at the highest risk for MARSI?
Infants and elderly patients are at a higher risk for MARSI due to their delicate and fragile skin which can be hypersensitive to irritants and can be easily damaged by adhesive dressing removal. Patients who are dehydrated or malnourished are also at higher risk due to the lack of moisture and nutrients required for skin integrity. Underlying medical conditions which can also affect the skin include diabetes, infection, renal insufficiency, and immunosuppression. Individuals with dermatological conditions such as eczema and psoriasis which can cause dry and flaky skin are also at increased risk for MARSI.
The relation between MARSI and surgical site infections
The skin is the largest organ of our bodies and serves as the main protective barrier against the outside world and pathogens. After a surgical procedure the role of wound closures and dressings is to promote the natural healing process to allow the regeneration of the damaged tissue. A MARSI serves as a direct disruption to this process and can delay wound healing for weeks to months after the initial procedure. Contact dermatitis, blistering, and skin tearing cause the epidermis to detach from the dermis, leading to prolonged inflammation and an increased risk of Surgical Site Infections (SSIs). SSIs can cost up to $29,000 per incident and increase hospitalization stays an additional 7 to 11 days longer. They also incur cumulative costs of up to $10 billion annually. Reducing the prevalence of MARSIs are crucial in minimizing the serious dangers and costs associated with SSIs.
Treatment and preventative measures against MARSI
The selection of the correct wound dressings and closure devices for patients remains an important factor in preventing MARSIs. Clinicians should consider patient risk factors, skin integrity, patient allergies and the location of the wound. Improper removal techniques can lead to mechanical skin tears. Adhesive dissolvers may be utilized to mitigate this concern. Leaving on occlusive dressings for extended periods of time may also result in MARSI.
Photo: Pramote Polyamate, Getty Images
