Allergic Contact Dermatitis to 2-Octyl Cyanoacrylate After Total Joint Arthroplasty: A Single-Surgeon Case Series

Abstract

Background

2-Octyl cyanoacrylate is widely used for surgical skin closure in orthopaedic procedures, offering advantages such as ease of application, strong adherence, and favorable cosmetic outcomes. However, allergic contact dermatitis (ACD) is a rare yet recognized complication resulting in topical and systemic treatments and a theoretical risk for superficial and deep periprosthetic joint infection (PJI).

Methods

This retrospective case series analyzes patients who developed hypersensitivity reactions to 2-octyl cyanoacrylate following primary hip and knee arthroplasty performed by a single surgeon between 2017 and 2024. Only cases with photo documentation and a minimum of 6 weeks follow-up were included.

Results

We identified 2,789 (total hip arthroplasty = 1270, total knee arthroplasty = 1516) hip and knee arthroplasty procedures utilizing 2-octyl cyanoacrylate. Among these, 15 patients (0.54%) developed ACD (6 after hip and 9 after knee arthroplasties). The mean onset time was 11.7 days; average resolution occurred at 27.4 days. All cases were managed conservatively with topical and oral therapies. No PJIs or reoperations occurred. Wounds achieved excellent cosmesis with only one patient with persistent skin discoloration.

Conclusions

ACD due to 2-octyl cyanoacrylate skin glue is uncommon and generally self-limiting when appropriately diagnosed and managed and does not go on to superficial or deep PJI. Surgeons should be aware of this complication and educate patients to facilitate early identification and treatment. Hypoallergenic alternatives may be considered in future elective orthopaedic surgery; however, comparative products must also achieve the exceptional safety profile of 2-octyl cyanoacrylate in regard to superficial or deep PJI.

Level of Evidence

Level IV, Case Series.

Introduction

Effective skin closure is a critical component of successful joint replacement surgery. Beyond its role in achieving a cosmetically acceptable incision, proper closure directly influences wound healing, postoperative recovery, patient satisfaction, and the risk of complications such as superficial surgical site infection (SSI) and deep periprosthetic joint infection (PJI). Moreover, early mobilization protocols and outpatient pathways have heightened the need for reliable closure methods that support rapid recovery without compromising wound safety [1]. Advances in closure materials, such as barbed sutures, tissue adhesives, and absorbable subcuticular techniques, aim to reduce operative time, improve cosmesis, and lower infection risk [[2], [3], [4]]. Post-closure, the use of 2-octyl cyanoacrylate provides a watertight barrier that facilitates early mobilization and outpatient protocols and reliable wound healing.

2-Octyl cyanoacrylate has gained substantial popularity in orthopaedic surgery due to advantages including ease of application, strong sealant capabilities, no need for removal at home, and its antimicrobial properties against Gram-positive bacteria [5,6]. It creates a watertight barrier that reduces the risk of persistent wound discharge and subsequent SSI/PJI and allows for a more permissive postoperative protocol, including early showering [7]. 2-Octyl cyanoacrylate tissue adhesives are commercially available from several medical device manufacturers and are widely used as a topical skin sealant. While these products share a similar chemical composition based on 2-octyl cyanoacrylate, they may differ in viscosity, polymerization time, applicator design, and flexibility, which can influence handling characteristics and surgeon preference. Importantly, variability in additives and degradation byproducts has been associated with differing rates of allergic contact dermatitis (ACD), with certain products reported to have a higher incidence of cutaneous hypersensitivity reactions than others, an important consideration when selecting an adhesive for patients with known skin sensitivity or prior reactions [8,9]. While generally well-tolerated, ACD following the application of 2-octyl cyanoacrylate is a recognized complication in orthopaedic surgery, with a reported incidence ranging from 0.5% to 14% [7,10,11].

Previous literature evaluating contact dermatitis associated with cyanoacrylate-based skin closure systems has predominantly focused on Prineo (Ethicon Inc., Johnson & Johnson, Somerville, NJ), particularly in the setting of total joint arthroplasty. Multiple reports and case series have described ACD and hypersensitivity reactions following arthroplasty procedures in which Prineo was used, drawing attention to the role of adhesive mesh components and cyanoacrylate formulations in postoperative cutaneous reactions [11]. In contrast, Dermabond, which does not include a mesh tape, has been comparatively less investigated in the arthroplasty population, with fewer dedicated studies examining its association with postoperative dermatitis, despite its widespread use for surgical wound closure. This relative paucity of data underscores the need for further investigation into dermatitis risk profiles across different cyanoacrylate-based closure products used in arthroplasty surgery and their ultimate clinical outcome in regard to superficial and deep wound complications and cosmesis after healing. This case series details the clinical presentation, management strategies, and postoperative outcomes of these reactions following use of Dermabond as documented by a high-volume single surgeon. Each case includes interval photos showing the onset of the skin reaction until the resolution of symptoms, documenting the progression and resolution of this unique skin reaction.

Material and methods

Data collection

This retrospective study was approved by our institutional review board (Study #2025-0566). All consecutive primary hip and knee arthroplasty cases performed by a single surgeon between January 1, 2017, and November 10, 2024, were identified and collected from our electronic medical record system, Epic (Epic Caboodle. version 15; Verona, WI) using Microsoft SQL Server Management Studio 2017 (Redmond, WA). Patient demographic data including age, gender, race, body mass index (kg/m²), and American Society of Anesthesiologists classification were collected. All patients were followed postoperatively at various time points, including 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively.

Operative details, clinical features of the allergic reaction, and management strategies were collected. Diagnosis of ACD was made clinically, without confirmatory patch testing. Cases were included if clinical records contained photographic documentation of a skin reaction and a minimum follow-up of 6 weeks.

Surgical technique

All total knee arthroplasty (TKA) was performed using an intermittent tourniquet use (exposure and cementation) and a longitudinal medial parapatellar approach, while the total hip arthroplasty (THA) was performed through a posterolateral approach. Each incision was closed in a similar standard multilayer closure. The knee arthrotomy and the iliotibial band fascia were closed with interrupted 0 vicryl sutures followed with Quill barbed running suture (Corza Medical, Westwood, MA). The subcutaneous fatty layer was closed with interrupted 0 vicryl stay sutures followed by interrupted 2-0 vicryl sutures. Intradermic layer was secured running 3-0 Monocryl. Lastly, 2-octyl cyanoacrylate (Dermabond) was applied to the closed skin incision. No Prineo mesh or surgical drains were used.

Data analyses

Data were organized and collected using Microsoft Excel software (Microsoft Corporation, Richmond, WA). Demographic and clinical baseline characteristics of study participants as well as ACD prevalence were described as means with standard deviations for continuous variables and frequencies with percentages for categorical variables.

All statistical analyses were performed using SPSS v25 (IBM Corporation, Armonk, NY).

Results

Of the 2,789 arthroplasty procedures utilizing 2-octyl cyanoacrylate skin adhesive, 1,270 (45.5%) were THA and 1,516 (54.5%) were TKAs.

Fifteen patients (0.54%) experienced superficial hypersensitivity reactions. Of these, 6 occurred following primary THA and 9 following primary TKA. Table 1 summarizes the clinical characteristics of patients who developed reactions. The reaction cohort were all women, with a mean age of 65.9 years (range, 59–84). Reactions were more frequently observed following knee primary TKA than primary THA (60% vs 40%). Most patients were white, and the majority were classified as American Society of Anesthesiologists grade II, indicating mild systemic disease. The average time to onset was 11.7 days postoperatively (range, 4-38), and the mean time to resolution was 27.4 days (range, 7-43). Representative examples of Dermabond-associated ACD following primary THA and primary TKA, demonstrating progression and resolution over time, are shown in Figures 1 and 2.

Figure 2.

Serial clinical photographs demonstrating Dermabond-associated allergic contact dermatitis following primary total knee arthroplasty, showing delayed onset and gradual improvement over time. (a) POD 9 (b) POD 12, (c) POD 14, (d) POD 19.

Table 1.

Clinical characteristics of patients with Dermabond-associated allergic contact dermatitis.

Patient case number	Joint procedure	Sex	Age	Race	ASA grade	Onset (d)	Duration (d)
1	Primary THA	Female	70	Black	2	13	29
2	Primary THA	Female	60	White	2	4	29
3	Primary TKA	Female	59	White	2	7	38
4	Primary TKA	Female	68	White	2	16	23
5	Primary THA	Female	74	White	2	9	43
6	Primary THA	Female	61	White	3	7	34
7	Primary TKA	Female	70	White	2	6	36
8	Primary TKA	Female	59	Black	2	11	16
9	Primary THA	Female	75	White	2	7	31
10	Primary TKA	Female	68	White	2	38	7
11	Primary THA	Female	38	White	1	10	25
12	Primary TKA	Female	60	Asian	2	6	31
13	Primary TKA	Female	70	Asian	2	12	22
14	Primary TKA	Female	72	White	2	13	19
15	Primary TKA	Female	84	White	3	16	28
Average/proportion	Hip: 40%, knee: 60%	Female: 100%, male: 0%	65.9 (range: 59-84)			11.7 (range: 4-38)	27.4 (range: 7-43)

ASA, American Society of Anesthesiologists.

Figure 1.

Serial clinical photographs demonstrating Dermabond-associated allergic contact dermatitis following primary total hip arthroplasty. Images show the evolution of the cutaneous reaction from initial presentation to progressive improvement and resolution over time. (a) POD 7, (b) POD 8, (c) POD 26. POD, post-operative day.

All patients presented with pruritic, eczematous skin changes localized around the incision, without wound drainage or new-onset pain. Management strategies varied, with antihistamine and corticosteroid regimens individualized based on patient history and documented medication tolerance (Table 2). Following diagnosis of hypersensitivity, residual skin adhesive was removed in the office using a sterile saline–soaked sponge. All patients were instructed to cleanse the incision site with sterile saline solution and gently dry the area using a sterile sponge. Fourteen patients received topical corticosteroids to reduce inflammation and localized itching around the surgical site. Two patients required systemic corticosteroid therapy (methylprednisolone dose pack) due to more severe local symptoms. Two patients were prescribed oral antibiotics (cephalexin or cefadroxil) in response to suspected secondary bacterial infection. One patient has been hospitalized for bedside wound care management and discharged after 3 days. No documented cases of prosthetic joint infections or return to the operating room were observed.

Table 2.

Description of pharmacologic therapy for each patient.

Patient case number	Treatment of DAR
1	Fexofenadine 180 mg daily until rash resolved; triamcinolone acetonide 0.1% cream TID
2	Loratadine 10 mg daily;
	Diphenhydramine 25 mg, 1 tab q6h PRN to address the pruritus; triamcinolone acetonide 0.1% TID if itchy, avoid on incision directly; dermatologist-prescribed topical mometasone 0.1% BID
3	Clobetasol 0.05% ointment BID; loratadine 10 mg daily
4	Diphenhydramine 25 mg, 1 tab q6h;
	Hydrocortisone cream 0.1% BID
	Cefadroxil 500 mg BID × 10 days
5	Hydrocortisone cream 0.1% BID; after 3 days transitioned to triamcinolone acetonide 0.1% BID
6	Triamcinolone acetonide 0.1% cream BID;
	Loratadine 10 mg daily;
	Diphenhydramine l 25 mg q6 h prn
7	Clobetasol ointment 0.05% BID;
	Loratadine 10 mg daily;
	Diphenhydramine q8h PRN for pruritus
8	Loratadine 10 mg daily
	Diphenhydramine q6h PRN for itching
9	Loratadine 10 mg daily
	Triamcinolone acetonide 0.1% to BID
	Methylprednisolone dose pack (24 mg-4 mg taper)
	Diphenhydramine q8 PRN for pruritus
10	Triamcinolone acetonide 0.1% BID;
	Cetirizine 5 mg daily
11	Hydrocortisone cream 0.1% BID transitioned to triamcinolone acetonide 0.1% BID;
	Loratadine 10 mg daily
12	Diphenhydramine q6 PRN for pruritus
	Bacitracin 500U/g TID
	Triamcinolone acetonide 0.1% BID followed by topical mometasone 0.1% BID
	Methylprednisolone dose pack (24 mg-4 mg taper)
13	Triamcinolone acetonide 0.1% TID
	Diphenhydramine cream 2% BID;
	Diphenhydramine q6h PRN for pruritus;
	Loratadine 10 mg daily
14	Hydrocortisone cream 0.1% BID;
	Loratadine 10 mg daily
15	Cephalexin 250 mg QID × 10 d; diphenhydramine q6h PRN for pruritus

DAR, Dermabond-associated reaction; PRN, as needed; BID, twice daily; TID, three times daily; QID, four times daily.

All the ointments or creams were not applied to the incision line.

Discussion

With the continued growth of total joint arthroplasty worldwide, efficient and reliable wound-closure techniques have become integral to modern orthopaedic practice. Cyanoacrylate-based skin adhesives are widely adopted because they provide a waterproof barrier, facilitate early mobilization, require no postoperative management, and yield favorable cosmetic outcomes [4,12]. However, it is critical to recognize that not all cyanoacrylate closure systems are equivalent. In particular, Dermabond (liquid 2-octyl cyanoacrylate alone) and Dermabond Prineo (2-octyl cyanoacrylate combined with a polyester mesh) represent distinct products with different application methods, skin contact characteristics, and reported hypersensitivity profiles, an important distinction that has not been consistently emphasized in prior arthroplasty literature [13,14].

In the present series, isolated Dermabond use was associated with an ACD incidence of 0.54% following primary total hip and knee arthroplasty. This rate lies at the lower end of previously reported incidences of cyanoacrylate-associated dermatitis and is notably lower than rates reported in multiple 2-octyl cyanoacrylate combined with a polyester mesh-focused series [8,11,15,16]. Much of the existing orthopaedic literature describing postoperative ACD has centered on Dermabond Prineo, in which the combination of cyanoacrylate adhesive and occlusive mesh may increase skin exposure time, surface area contact, and risk of sensitization [11,13,16]. Several studies have suggested that the mesh component may contribute to prolonged occlusion and increased retention of degradation byproducts, thereby potentiating type IV hypersensitivity reactions [17,18].

Ricciardo et al [13] reported confirmed ACD reactions to 2-octyl cyanoacrylate combined with a polyester mesh in elective orthopaedic procedures, with patch testing demonstrating sensitivity to cyanoacrylate components in all cases. Importantly, reactions resolved following removal of the mesh-adhesive construct and corticosteroid therapy, without compromise to orthopaedic outcomes. Similar findings have been reported in other 2-octyl cyanoacrylate combined with a polyester mesh-based series, reinforcing that much of the reported dermatitis burden in arthroplasty may be attributable to mesh-reinforced adhesive systems rather than liquid cyanoacrylate alone [11,16,19]. In contrast, comparatively fewer studies have specifically evaluated Dermabond without mesh in the total joint arthroplasty population, despite its widespread use.

Our findings help address this gap by isolating Dermabond as the sole skin adhesive used, without mesh or adjunctive closure materials. The lower observed incidence in this cohort suggests that liquid 2-octyl cyanoacrylate alone may carry a reduced risk of hypersensitivity when compared with mesh-based systems [8,18]. This distinction is clinically relevant, as surgeons may incorrectly generalize reported ACD rates associated with mesh-based 2-octyl cyanoacrylate closure to all cyanoacrylate products, potentially leading to unnecessary avoidance of 2-octyl cyanoacrylate in appropriate patients.

Clinically, the presentation of ACD in this series was consistent with a delayed type IV hypersensitivity reaction, characterized by pruritic erythema and eczematous changes localized to the adhesive contact area, typically occurring more than 1 week postoperatively. Importantly, none of the patients demonstrated wound drainage, progressive incisional pain, or systemic signs of infection. Differentiating ACD from early SSI or PJI is essential, as misdiagnosis can lead to unnecessary antibiotic therapy, additional imaging, or even surgical intervention [20]. ACD associated with 2-octyl cyanoacrylate demonstrated a delayed onset, with symptoms developing at a mean of 12 days postoperatively (range, 4-38 days). This delayed presentation is consistent with a type IV hypersensitivity reaction, which typically requires a sensitization period and often manifests well after the immediate postoperative inflammatory phase [21]. The delayed timing is particularly relevant in arthroplasty patients, as erythema or pruritus appearing more than 1 week after surgery may be incorrectly attributed to evolving SSI rather than hypersensitivity.

Equally notable was the self-limited course of symptoms once the diagnosis was recognized and appropriate management initiated. In this series, the mean time to documented symptom resolution was 26 days postoperatively (range, 7-43 days), indicating that symptoms generally resolved within 2-4 weeks after onset. This duration aligns with prior reports describing gradual improvement following removal of the adhesive and initiation of topical or systemic anti-inflammatory therapy [11,22]. Importantly, no patient in this cohort experienced progressive wound deterioration, delayed epithelialization, or secondary periprosthetic complications during the resolution period. The combination of delayed onset and prolonged—but finite—symptom duration underscores the importance of patient education and postoperative surveillance beyond the traditional early follow-up window. Patients were frequently asymptomatic at the routine 2-week postoperative visit, with dermatitis developing shortly thereafter. Awareness of this typical timeline may prevent premature diagnostic escalation, unnecessary antibiotic therapy, or concern for early PJI. Moreover, recognition that symptoms may persist for several weeks despite appropriate treatment can help set realistic expectations for patients and providers, reducing anxiety while reinforcing the benign nature of the condition. These findings align with prior reports demonstrating that early identification and appropriate management of adhesive-related ACD result in favorable outcomes without compromising wound healing or arthroplasty success [11,13,22,23].

This study has several important limitations that should be considered when interpreting the findings. First, the retrospective design inherently limits control over data collection and introduces the potential for selection and documentation bias. ACD was identified based on clinical documentation and photographic evidence within the electronic medical record, which may underestimate the true incidence of mild or self-limited reactions that resolved without formal clinical evaluation or were managed outside the treating institution.

Second, this is a single-surgeon, single-institution case series, which may limit generalizability. Surgical technique, postoperative wound care instructions, and patient education were relatively standardized in this cohort and may differ from those used in other practices. While the distribution and delayed onset of reactions in this series are consistent with cyanoacrylate-associated ACD, the absence of patch testing precludes definitive exclusion of alternative contactants, including skin preparation solutions such as chlorhexidine-based or iodine-based agents, wound dressings, or surgical drapes, as potential contributing or alternative etiologies. Third, confirmatory diagnostic testing, such as patch testing, was not routinely performed. While the clinical presentation and timing were consistent with ACD, the absence of patch testing precludes definitive allergen identification and limits the ability to distinguish between sensitivity to cyanoacrylate monomers, additives, or degradation byproducts. This limitation is shared by many orthopaedic series but remains relevant when interpreting causality.

Fourth, although this study specifically isolates Dermabond use without mesh, we did not include a comparative control group using 2-octyl cyanoacrylate combined with a polyester mesh or alternative closure methods. As such, direct statistical comparison cannot be made within this dataset. Nevertheless, the strength of this series lies in its focused evaluation of liquid 2-octyl cyanoacrylate alone, which addresses a gap in existing literature that is heavily weighted toward mesh-reinforced systems.

Fifth, patient-specific risk factors such as history of atopy, prior cyanoacrylate exposure, occupational acrylate exposure, or known contact allergies were not systematically recorded and therefore could not be analyzed as predictors of hypersensitivity reactions. Future prospective studies incorporating standardized allergy histories may help identify patients at increased risk.

Finally, while no cases of PJI or reoperation occurred in this cohort, the sample size of patients experiencing ACD was relatively small. As such, rare downstream complications related to delayed wound healing or secondary infection cannot be entirely excluded.

Conclusions

ACD following total joint arthroplasty is an uncommon but important complication of cyanoacrylate skin adhesives. Our findings suggest that liquid 2-octyl cyanoacrylate alone is associated with a low incidence of ACD and can be safely used when patients are appropriately counseled and monitored. Clear differentiation between adhesive systems is essential for accurate risk assessment, patient education, and informed selection of wound-closure techniques in contemporary arthroplasty practice.

While no cases of PJI or reoperation were observed in this cohort, the small sample size and relatively limited follow-up period preclude definitive conclusions regarding the long-term relationship between Dermabond-associated ACD and PJI risk. Larger prospective studies with extended follow-up are needed to further characterize this relationship.

CRediT authorship contribution statement

Stefano Ghirardelli: Writing – original draft, Methodology, Investigation, Data curation, Conceptualization. Ittai Shichman: Writing – review & editing, Writing – original draft, Methodology, Investigation, Formal analysis, Data curation. Mohammed El-Hassan: Writing – review & editing, Writing – original draft, Data curation. PierFrancesco Indelli: Writing – review & editing. Peter K. Sculco: Writing – review & editing, Writing – original draft, Visualization, Supervision, Resources, Methodology, Formal analysis, Conceptualization.

Conflicts of interest

P. Indelli is on the speakers bureau/paid presentations for MICROPORT, China; Biomerieux, France; and Paul Hartmann, Germany; receives research support from Biocomposites, UK; is a member of the medical/orthopaedic publications editorial/governing board of KSSTA; and is a board/committee member for ESSKA and PAS. P.K. Sculco receives royalties from Enovis; is on the speakers bureau/paid presentations for Zimmer; is a paid consultant for Enovis and Zimmer; has stock or stock options in Intellijoint Surgical and Parvizi Surgical Innovation; receives research support from Intellijoint Surgical; and is a board member/committee appointments for HSS Journal. S. Ghirardelli is a paid consultant for Biomerieux; all other authors declare no potential conflicts of interest.

For full disclosure statements refer to https://doi.org/10.1016/j.artd.2026.102153.