Wednesday, April 30, 2008

Suture Allergies Revisited

Over the last few months I have received several e-mails from patients with suture reactions, possibly allergic reactions (photo credit). I say possibly because not being their treating physician I can't verify them, but by the descriptions they seem real. I reviewed this topic last year, but felt the need to revisit it. Hope you don't mind me sharing with you.

Allergic reactions to suture materials are rare and have been specifically associated with chromic gut. However, Johnson and Johnson mention known triclosan allergy as a contraindication for use of certain sutures (see below). Contact allergy to triclosan is uncommon.

Surgical gut suture (Plain and Chromic) is contraindicated in patients with known sensitivities or allergies to collagen or chromium, as gut is a collagen based material, and chromic gut is treated with chromic salt solutions.

MONOCRYL Plus Antibacterial suture should not be used in patients with known allergic reactions to Irgacare MP(triclosan).

PDS Plus Antibacterial suture should not be used in patients with known allergic reactions to Irgacare MP (triclosan).

VICRYL*suture should not be used in patients with known allergic reactions to Irgacare MP (triclosan).

Surgical Stainless Steel Suture may elicit an allergic response in patients with known sensitivities to 316L stainless steel, or constituent metals such as chromium and nickel. Skin staples are surgical steel so should be used with the same precautions.

Dermabond -- Tissue glues should not be used in patients with a known hypersensitivity to cyanoacrylate or formaldehyde.


SO WHAT IS LEFT TO USE

So what is left to use in a patient who may have or has a proven allergy to suture or closure material?

Silk, Dexon, Nylon(monofilament or braided), Prolene, INSORB (absorbable staples), and any of the above listed (in the allergy section) to which the patient in question doesn't react negatively.

The choice of a particular suture material will have to based further on the wound, tissue characteristics, and anatomic location. Understanding the various characteristics of available suture materials will be even more important to make an educated selection.

The amount of suture placed in a wound, particularly with respect to the knot volume, affects inflammation. The suture size contributes more to knot volume than the number of throws. The volume of square knots is less than that of sliding knots, and knots of monofilament sutures are smaller than those of multifilament sutures.

REFERENCES

9 comments:

Amy said...

Thanks for the info! I have sensitivities, (I won't call them allergies) to some suture materials. I was kid when I got stitches, two different times, and in both cases they wouldn't heal, got really flaky and itchy, until some of the stitches popped open. The resultant scars are atrophic, with the whole cigar paper thing going on. My daughter has hypermobility syndrome, so I don't know if my scarring is connected to that or not. I have a couple of big scars.

I've had stitches for episotomy 3 times, I think my doc used vicril, with no problems what so ever with healing.

I do think I'm allergic to stainless steel, although I've never had staples. When I was a kid, I tried to wear various stainless steel posted earrings, and withing a day or so I would have pus in my ear lobes. So I thought I must be getting infection, and I stored them in isopropyl alcohol. I still got infected looking earlobes within about 24 hours. I can wear high quality gold earrings with no problem, so I figure I'm not a good candidate for staples.

Hope I didn't share too much randomness, but I appreciate your post. It's nice to know there are options.

Russell said...

Thanks, that was pretty informative for someone like me who is a newbie in the field of medicine.

Esri Rose said...

Thank you so much for posting this! I recently had a finger laceration stitched in the ER, and after five days, the sutures really started to burn. Everything looked fine except for the area right around the stitches. I have a lot of allergies, and it occurred to me that this looked very much like that kind of reaction, so I Googled and found your article. Seems to me I've had this reaction before, but also had stitches with no reaction (I get a lot of basal-cell carcinomas removed). Now I'll know to ask for whatever suture material is least reactive. Can't tell you how much I appreciate this information.

Happy (belated) Birthday!

Anonymous said...

I just had my 5th ankle surgery, which the reason was due to some type of fluid building up and coming out of my ankle over the past 7 months. When my Dr. opened me up 2 days ago, he was shocked to inform me that I was having an allergic reaction to the sutures that he had put in me last September. He said that he has never seen this before and conferred with other Doctors whom also had never seen this before....just my luck!

AverageJoe said...

Great information (and great quilts!) Dr. Bates. I recently had surgery to repair a bulging vein (AVM) on my forehead. There were dissovling sutures inside the wound and surgical tape of some sort for the exterior, (sorry, don't know specifics on either as yet). The site swelled badly and drained a lot the first few weeks and generally took a long time to heal. My surgeon seemed a little puzzled by the bad reaction but nothing to do but let it heal and monitor for infection, (which it mostly has at this point almost 8 weeks in).

A week into the healing process I developed badly swollen and stiff joints in my hands and feet. I assumed this was unrelated and perhaps related to training and racing bicycles. My PCP and two other ortho specialists are working through these issues (cortisone injections, etc.) but healing is not going well and they all seem a bit puzzled by the condition (rheumatoid, lyme, etc. tests all negative). They each are inclined to think hand and foot issues are not tied but occurence is just coincidental (which I now think is incorrect - it always flares up together). Then I heard about another local patient that now suffers from recurring joint pain in his hands and feet and it was attributed to allergic reaction to a dissolving surgical sponge. I don't yet have details but am told the material in the sponge - which is partly bovine - caused the allergy and the individual now must avoid all beef and pork intake or suffer swollen/stiff joints.

Just wondering if you have ever heard of such a thing with dissolving sutures (or sponges) and if there is a clinical name for such a condition. It seems like a crazy notion to take to my PCP or the ortho docs...just wondering your take before I continue down this line of thinking. I just heard this info today and will start a dietary journal to try and prove disprove the beef/pork intake part. The pain and swelling does fluctuate a lot from day to day so perhaps there was a dietary component I had overlooked.

Thanks in advance for any thoughts.

Limping Around in Delaware.

rlbates said...

Limping in Delaware, no I haven't heard of such. Could be you are allergic to the triclosan depending on which dissovlable suture that was used. Even dissovlables take weeks to months to clear the body. Hope you feel better soon.

Tree said...

Hello Dr. Bates.

I have the rare allergy. I had open abdominal surgery in 2004 and a hernia repair in 2006. 3 weeks post op I spit out 2 of the sutures from the hernia repair and 1 stitch from the surgery 2 years prior. Now I wish I could say I've not had any other problems, but that would just be wishful thinking.

I've developed an abdominal infection trying to spit a suture for a year. Approximately 2 weeks ago I spit out 1 suture and my surgeon literally searched and removed 2 more. Do I think this is the end? NOPE. I've got sutures at the proximal end of the original suture line that are starting to feel hard and painful with pressure.

I've had stitches as a kid and never had problems with them other than a untying a few before they were ready to come out (I was 3 years old).

Just wondering what the actual allergy is to? Is it what the braided suture is treated with? I've been a nurse for 24 years and I've never had anyone else with this situation. And the local surgeons all look at me like I'm nuts... well until now. I can actually show them one of the sutures.

rlbates said...

Tree, I can't say what your particular allergy is to suture material. I don't know what suture was used for sure. Often it is to the triscolan.

Sandra said...

To Tree...

I am going to paste part of a conversation with Ethicon below (2011). I had a mole removed, followed by a deeper/wider excision. 20+ internal dissolvable sutures and 20+ external. The external is what made me react the way non-gold jewelry does; insanely itchy, scabs, pus, etc. Ended up cutting them out after 1-1/2 weeks.

I asked the surgeon what sutures were used and I was told PROLENE. Shouldn't have been a problem, especially since I had a hernia repaired in 2005 using a polypropylene mesh that has never been an issue. Upon pressing that I was told these however, were blue.

I contacted Ethicon who makes them and was told,

"The blue pigment in PROLENE* Polypropylene suture is copper Phthalocyanine. Note that the suture is pigmented, not dyed. The difference is that the pigment is a micro dispersion of solid particles of copper phthalocyanine that are locked into the suture. A dyed suture has the dye dissolved in the suture as a true solution. As such the dye can diffuse out of the suture albeit often at a very slow rate."

My reply,

"I had a very definite allergic reaction to these sutures. (I can send you a photo if you like.) I get the same reaction to any jewelry that is not at least 14K gold. "Hypo-allergenic" earrings, surgical steel, even sterling silver causes the same reaction.

"These sutures were used (about 20 stitches) to close a skin biopsy. About 24-48 hours later my skin began to react. Initially I assumed it was because of the skin starting to heal. But very shortly I recognized that itch. The stitches were kept in for two weeks. Within 24-36 hours of removing them (in addition to cortisone cream), the rash subsided.

"You might find this interesting as well - searching the name of the pigment, I found the manufacturer's website - http://www.first-color.com/, along with the "Material Safety Data Sheet" for this pigment - http://www.first-color.com/Materials/MSDS/B-G/1530.pdf

"On page 6 it states:

SKIN CONTACT:
ACUTE EXPOSURE:
COPPER PHTHALOCYANINE: No data available.

CHRONIC EXPOSURE:
COPPER PHTHALOCYANINE: Repeated contact may cause an allergic reaction."

That makes sense considering my metal allergies/reactions/sensitivities/etc.