Allergic Contact Dermatitis of the Foot after use of Mastisol® Skin Adhesive: A Case Report

by Al Kline, DPM 1

The Foot & Ankle Journal 1 (2): 2

A case report describes an acute allergic contact dermatitis (ACD) to Mastisol® following foot surgery. A patch test was used to determine whether the patient was allergic to the DuraPrep™ skin prep, Steri-Strips™ or Mastisol® skin adhesive. Reaction to all patch sites with Mastisol® was observed. The contact allergy resolved within 3 to 5 days after starting oral Benadryl®, Medrol® and topical saline compresses. Initial presentation, patch testing and treatments are presented.

Key words: ACD, Allergic Contact Dermatitis, Benadryl®, Mastisol®, DuraPrep™ ,Steri-Strips™

Published online: February 1, 2008

ISSN: 1941-6806/08/0102-0002
doi: 10.3827/faoj.2008.0102.0002

Mastisol® liquid is a clear, non-irritating, non-water soluble, latex-free skin adhesive frequently used in surgery to secure skin strips for incision approximation and closure. It is produced and sold by Ferndale Laboratories of Ferndale, Michigan. Ferndale laboratories have provided Mastisol® since 1963 as a surgical adhesive. (Fig.1) The product is sold in 2/3 cc vials, 15mL and 2 oz. bottles and a 15mL spray bottle. [1] Mastisol® contains Gum Mastic, Styrax liquid, methyl salicylate and alcohol (SDA 23A). [2] The Gum Mastic and Sytrax liquid provides the tackiness and resin-like properties to the liquid.

Figure 1    Mastisol® liquid adhesive (Ferndale Laboratories)

Instructions for use include: 1) Cleaning the skin at least 2 ½ inches around the incision with saline or alcohol. 2) The blister-pak is the placed on a hard surface and the vial is broken in the blister pack. 3) The vial is then delivered using aseptic technique to the operating field. 4) The liquid is then applied 2 inches around the incision taking care not to allow the liquid to come into contact with the incision. 5) Allow 20-30 seconds of drying time and then apply uniformed tape or Steri-Strips™ in contact with the adhesive. Gauze or other materials can also come into contact with the adhesive to stabilize or dress a wound or incision. [2]

A case report is presented describing a contact allergy reaction to Mastisol®.

Case Report

A 37 year old female underwent foot surgery without a history of previous contact allergy. The patient has drug allergies to penicillin and sulfa drugs. She also has a history of childhood asthma. One day after surgery, the patient called our office to report itching and redness to the foot.

Clinical evaluation revealed significant blistering, edema and erythema to the incision sites. (Figs. 2) The patient was seen in the office with a presumptive diagnosis of acute contact allergy. Prior to surgery, the skin was prepped with DuraPrep™ solution. The patient’s subcutaneous tissue was approximated with clear Monocryl™ and the skin incision was closed with Prolene®. The skin edges were buttressed with Mastisol® and Steri-Strips.™

   

Figures 2  Acute contact dermatitis (ACD) following use of Mastisol® liquid adhesive.

The Steri-Strips™ were immediately removed and the foot was washed with saline. Alcohol was used to remove as much of the DuraPrep™ as possible. Treatment also included administration of oral Benadryl® 50mg every 4 hours until the pruritus stopped with saline compresses to the incision sites changed daily. The patient reported significant relief from the cool, saline compresses. A Medrol Dosepak® was also prescribed. In three to five days, the local erythema, pruritus and blistering resolved. (Fig. 3)

Figure 3  The contact allergy subsided and resolved in 3-5 days.  Oral Benadryl®, Medrol Dosepak® and topical saline compresses were ordered.  The blistering, acute erythema and pruritus have now resolved.

Patch Test

In order to determine the contact allergen causing the contact dermatitis, a patch test was performed the following week. Six sites were prepared to the patient’s back. (Table 1) Before applying the contact solutions, the back was cleansed with alcohol.

Patch Test DuraPrep™ (DP)Site 1 Mastisol® (M)Site 2 Steri-Strips™ (SS) Site 3 SS/M Site 4 SS/DP Site 5 SS/DP/M Site 6
Reactive   X   X   X
Non-Reactive X   X   X  

Table 1  All patch sites containing Mastisol® were reactive.

The six sites are listed in Table 1 and shown in Figures 4abc. Within 24 hours, the patient reported considerable ‘itching’ to the back with increased erythema, edema and weeping to the sites containing the Mastisol® skin adhesive. The sites combining the Mastisol® with the occlusive strips appeared to be more acute in nature. The sites containing only DuraPrep™ and the Steri-Strips™ were non-reactive. The same treatment protocol was prescribed with resolution of the allergy within five days.

Figures 4a  The 6 test patch sites are shown here at initial application.

Figures 4b  These are the same 6 test patch sites after 24 hours.  Notice that all the patch sites containing Mastisol® are reactive.

Figures 4c The 6 patch test sites are shown after the patches are removed.  The sites are cleansed with saline and alcohol. The patient is then placed on diphenhydramine and Medrol®.  This reaction subsided in about 3 to 5 days.

Discussion

In this case, the patient experienced an acute contact allergy or contact dermatitis. The contact allergens suspected include the DuraPrep™ solution, Mastisol® adhesive and steri-strip adhesive. The Monocryl™ and Prolene® were not suspected as causing the allergy.

The patch testing confirmed our diagnosis of Mastisol® allergy. All sites (sites 2,4 and 6) containing the Mastisol® were reactive. The patches were left in place approximately 24 hours, but the patient began to have irritation within 2-4 hours of patch placement. The itching and redness was quite intense.

Once the tapes and solution was removed, the patient was placed on diphenhydramine and Medrol® and the reaction began to subside.

It is important to have epinephrine and albuterol available before performing a patch test. In our case, we knew the patient did not have true anaphylaxis, so we didn’t anticipate the need for these drugs. Preparation of the skin should include cleansing the skin with alcohol or a hypoallergenic soap and using non-allergenic tape to hold the patches in place. We applied the contact solutions and Steri-Strips™ and then covered each site with plain gauze and paper tape. Before patch testing, the patient should discontinue antihistamines and other antihistamine agents such as phenothiazine, tricyclic antidepressants, anticholinergic medications and H2 blockers such as ranitidine. [3]

Treatment protocol can vary. In milder cases of contact dermatitis, cool and warm compresses can be used. Aluminum acetate (Burow tablets) can be dissolved in water (1:40) and applied as a cool compress to give a soothing effect. [4] Soaking the foot in Domeboro® tablets mixed with water is also acceptable.

Antihistamines are primarily indicated in cases of both mild to moderate and acute contact dermatitis. 25 to 50 mg of Benadryl® or diphenhydramine can be given every 4 to 6 hours not to exceed 400mg in a 24 hour period.[3,4]  Some forms of Benadryl® tablets contain lactose, so do not give these to patients who are lactose intolerant. Alternatives to Benadryl® include H1 antagonists such as hydroxizine HCl (Atarax®, Vistaril®). [4]

Steroids such as Medrol® and prednisone are used in severe allergic reactions. In acute ACD there is marked edema and bullae. In rare cases, these bullae can get secondarily infected. Oral and systemic antibiotics are rarely required unless a secondary infection is suspected. Topical steroid creams are mentioned in the literature, but appear to be used more for the chronic forms of dermatitis.

Reports of skin allergy to Mastisol® appear to be under reported or very rare in the literature. The contact allergen could be the gum mastic, Styrax liquid or methyl salicylate. In an immediate contact allergy, when the skin is sensitized, the mast cells of the skin release histamine allowing the blood vessels to become porous. This allows fluid to accumulate in the tissues causing the tissues to weep and become swollen. The accumulation of fluid and resulting tissue edema, commonly known as a hive, also sensitize nerve endings and causes pain and pruritus or severe itching. If regions of the skin become reddened and the hives coalesce, it is termed a wheal. When this condition affects small areas of the skin, it is called utricaria. In larger regions of the skin or whole extremities, it is called angioedema.

One report in the literature described a contact allergy to Mastisol® following rhinoplasty five days after surgery. [5]

At this writing, it appears that an allergic contact dermatitis to Mastisol® is rare and should not prevent the surgeon from using the product. In my private practice, I have only seen two of these reactions requiring medical treatment in an estimated 1200 surgical cases.(0.167%)

Treatment using oral antihistamine and steroid is simple, non-life threatening and effective in every case. Certainly, if a patient is sensitive to tapes or adhesives, the product should be avoided. The patch test can be performed to determine allergy to a variety of contact allergens. In this case, the patch test confirmed the diagnosis of contact allergy to Mastisol®.

References

1. Mastisol®, Ferndale Laboratories, Inc. Online product description.
2. Mastisol® Instruction handout. [PDF]
3. Family Practice Notebook: Allergy Screening, [online].
4. Michael, J.A.: Contact Dermatitis, eMedicine, 2005. [online].
5. Mabrie, D.C., Papel, I.D.: An Unexpected Occurrence of Acute Contact Dermatitis During Rhinoplasty. Arch Facial Plast Surg. Vol 1, No. 4, pp. 320-321, 1999.


Address correspondence to: Dr. Al Kline, DPM, 3130 South Alameda, Corpus Christi, Texas 78404. E-mail: al@kline.net 

1 Private practice, Podiatry Staff, Doctors Regional Medical Center. Corpus Christi, Texas, 78411.

© The Foot & Ankle Journal, 2008

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19 responses to “Allergic Contact Dermatitis of the Foot after use of Mastisol® Skin Adhesive: A Case Report

  1. question if patient has allergies to adhesive tape in the past will she possible have a reaction to liquid mastisol with steri strips. noted skin was prep with betadine solution after surgery area washed and cleaned and dressings applyed. thank you for your time and information adam r.n.

  2. The best thing to do is have the patient undergo a patch test using the adhesives in question as described in the paper. This is the best way to determine if the patient is sensitive to the adhesives in question.

  3. Re: Mastisol Adhesive: Yes, I had the above problem last year after surgery of 2 toes and joint of the 2 big toes. My feet swelled up with blisters and hives, which got worse after a second application of the adhesive during the post op check. I was sent to ER and found out that I can’t take benadryl or any ‘mycin’ product as I got very ill and even my face burned and swelled up (antibiotic). Steristips are not the problem, and I don’t use latex bandaids either – the dr. gave me an rx for Elidel cream, and a couple of weeks later things started healing up. Couple all this with the regular post op pain and nerve sensation! It took 3 times as long to heal. Not a fun way to go when you’re on your feet 13 hrs of the day.

  4. Thank You Very Much For Showing This InfoCan You Look At THis? Maliyah tukwp

  5. My daughter had surgery in which Mastisol was used to secure the oxygen tubes during surgery. She does have latex allergy and is sensitive to other adhesives. Immediately after surgery, there was a red line on her face where the Mastisol was. The hospital staff said it was nothing. By the next day, her entire face was red and swollen. She looked like a red balloon. It took 3 days to convince the hospital to give her Benadryl, which did clear things up in about 3 days.

  6. Allergic contact dermatitis(ACD – a delayed hypersensitivity – Type IV reaction) and urticaria or hives (immediate hypersensitivity – Type 1 reaction) are two very different reactions. ACD is a T-cell driven reaction – not histamine. Antihistamines have no effect on the course of an allergic contact dermatitis. The treatment is avoidance of the allergen and topical/oral steroids. If the eruption is bullous then soaks may be necessary.
    Anaphalyxis is a Type 1 reaction. There are few allergens that may lead to both a Type 1 reaction and a Type IV reaction. I suggest you read Fisher’s Contact Dermatitis Text Book for reference.

  7. There can be an argument that this particular reaction had both the features of a Type I and Type IV reaction. You infer that the antihistamines are of no consequence. However, since the world is never black and white, most contact allergies are treated with antihistamines and steroids. This patient had some immediate erythema, urticaria and eruption of bullous lesions on both the foot and the back during the patch test. There is no question that this patient had immediate hypersensitivity and features of a delayed type. I think most physicians would describe this reaction as an allergic contact dermatitis. Thanks for that reference.

  8. I had back surgery in November and the doctor used Mastisol adhesive to secure the bandage on my lower back. The reaction was violent almost immediately. When I bathed several days later and removed the bandage, the skin was blistered, red and itchy. As of now, Jan 8, 2010, the area still itches a lot. Several years ago I had an allergy test and found that I was allergic to BALSAM OF PERU. It was a drying agent used in the application of acrylic fingernails. Could that also be an ingredient of Mastisol?

    • I wrote on this site in Jan of 2010 re: the use of Mastisol on my lower back in Nov of 2009. Even after over a year, my back still itches inordinately. I had another surgery in Dec, 2010 at the same location and reminded my doctor not to use Mastisol. The site healed in just a couple of weeks and I don’t have any itching. So it wasn’t just me or that area of my body! I still wonder, like I questioned last year, if Mastisol contains BALSAM OF PERU, a drying agent used in the application of arcylic nails and years ago as an agent to dry injuries from scapes and cuts (back in the early part of the 20th Century). Anyone ever hear of it using this name before?

  9. I cannot believe my eyes. It looks just like my foot. I am a 52 year old female who just had bunion and hammertoe surgery. The surgery center used mastisol on my despite the information that I gave them that I had had a previous reaction. I also had a bracelet on. 6 weeks after surgery, the blisters are finally dried and falling off. However, I now have small hard bumps on my left hand and foot (surgery foot). Could this be a lingering effect of the mastisol reaction?

  10. I am one week post brachioplasty and on the 5th day, itching became unbearable. I took the wraps off and discovered blisters and heated red spots all around both incision points on both arms. I am now on a regime of prednisone and benedryl. After 24 hours of being diagnosed and still taking meds, there is still itching although not as severe. My worry is how this will affect healing of the wound sites as this surgery was done to firm up my arms.

  11. I had surgery on my wrist recently. I was told to leave the bandage on for 16 days, which I did even though it was driving me nuts itching and burning. Upon removal, my wrist had a large rectangle shaped red-blistered patch. My Dr said, “I’ve never seen anything like that.” He said, “that is the shape of exactly where we would put the mastisol. I was sent home and told to come back in a week if it wasn’t better. I bought topical benedryl and I’m hoping that will help. Now I’m wondering if the fact that I had the mastisol stuck to my skin for so many days will cause any permanent issues.

  12. I had surgery on my breasts two days ago and Mastisol liquid adhesive was used. I started itching and then welts and blisters appeared all over my breasts and also spread all over my body. I started a medrol dose pak and have been taking benedryl. This should be taken off the market. Many people have reported this kind of reaction. I causes so much harm and delays healing. I am starting to get a little bit better since I started the steriods.

  13. I had surgery in Jan-11 on my abdomen involving an 8″ incision. Mastisol was used near the incision site to secure the dressing, and was also used on my back to secure a spinal block. Within a day I was experiencing prickly pain, redness and itching under the dressings. After 6 days the Dr removed the dressing to discover extensive blistering and weeping. Benadryl offered only minimal relief. After 3 weeks I was prescribed a 7 day regimen of Prednisone, which provided immediate relief.
    I subsequently under went allergy testing that confirmed severe contact dermititis from the Mastisol adhesive. In the tests prickly pain was felt within two hours, and blistering and weeping within 32 hours

  14. I had an ankle surgery due to fracture about 10 years ago. After that redness and swelling developed. I did not get quick reply from the office so I went to ER and was treated with Keflex. Recently I had the hardware removed by the same surgeon. Three days later I removed the wrap and found huge blisters with yellow discharge under and along the steri strips. The area was intensely itchy, red and painful. I called the office and was told that I would be ok. Because after the first surgery I removed the steri strips and was told that I should have left them there. So this time I asked them if I could reomve the strips and I was told not to. Anyway I went to the office and another doc prescribed Keflex, Benadryl and Medrol dosepak. None of them gave me relief. I had a follow up appt 12 days after the surgery and the area looked much worse than the picture shown above. The PA removed the strip on one side of the ankle and kept the strip on the other side and wrap it up and that was it. I then went to my PCP and was given doxycycline because keflex gave me hives this time. In one week, blisters dried up and incisions closed up. Now I still have itch and I got bigger bony bumps at the incision sites than before I had hardware in it.

    • It is possible you are allergic to the adhesive in steri-strips also. This could have been a typical tape allergy as well. I have seen this reaction even without the use of Mastisol.

      • The PA did tell me about Mastisol.Ten years ago I went to ER and got treated as cellulitis with IV Keflex. This time I might have an exacerbated allergic reaction.
        Thank you very much for the info.

      • I was supposed to leave the dressing on for four days after knee surgery. Itch was pretty severe, when I removed the dressing I noted skin was extremely erythematous, blstery- rasberry-like and some clear oozing present. Went to Dr. and he told me right away it was related to mastisol, since it was clearly marked as the exact location of where it was applied. Now I’m on Benadryl PO and have been using Hydrocotizone topical as well.

  15. I am so glad to have finally found this article. I had laproscopic surgery to remove my left ovary earlier this week (Monday- 6/18/2012) and my doctor used Mastisol on all 3 incision sites. By Wednesday the itching was getting very intense. I called my doctor on Thursday, but missed his office hours, but a nurse gave me the OK to take Benadryl. I then saw my doctor on Friday, and he immediately recognized it as an allergic reaction to Mastisol- I had the pus-filled blisters/hives, especially around my navel! My doctor said it was the second reaction he’d seen that week! So, I am thinking it is more common than earlier realized. It was washed with alcohol to remove any residual adhesive and I was prescribed Prednisone, which by the second dose has given HUGE relief (thankfully, since I had my sister’s funeral today & needed to be NOT huddled in the corner itching my incisions!!) Anyway, thank you for an informative article, and I hope more cases continue to come forward so doctors are aware that more people may be allergic to Mastisol than originally thought.

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