A mysterious rash around surgical wounds

Introduction Contact dermatitis (CD) that occurs shortly after a surgery is often caused by a direct irritant effect of medical products or, infrequently, a delayed type hypersensitivity. Various agents have been reported to cause CD including topical medications, surgical instruments, and surgical glue. We present a patient who developed rash around surgical wounds. Skin patch testing identified the causative agent of his CD. Case Description A 15-year-old male presented with new onset of pruritic papulovesicular rash three weeks following Nuss procedure, a minimally invasive pectus excavatum repair using a metal bar. The rash initially appeared on upper extremities and chest wall around surgical wounds (Figure 1A). Later, new erythematous lesions occurred on foreskin of penis. Patient denied other systemic symptoms or prior history of metal or medication allergy. A delayed hypersensitivity to nickel or other components of stainless steel used in the pectus bar was suspected. Surgical removal of the bar was contemplated. A trial of oral prednisone 30mg BID led to resolution of the rashes (Figure 1B). Blood test for metal-lymphocyte proliferation assay was unremarkable. Skin patch test was negative to nickel and metal disc, and confirmed a reaction to 2-octyl cyanoacylate (surgical glue) (Figure 1C). Discussion Delayed-type hypersensitivity to surgical glue should be considered in patients who develop rash around surgical wounds. Evaluation of surgery-related CD requires a thorough understanding of procedure steps and potential exposures to medical products. Patch test can aid in identification of the offending agent and allow a recommendation of alternative products to avoid recurrence. Figure. A. Rash around surgical wounds Figure 1B. Improvement of rash after a 5-day course of prednisone 30 mg BID treatment Figure 1C. Positive patch test to 2-octyl cyanoacrylate (Dermabond® surgical glue)