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Foreign-Body Reaction to Wound Seal

Foreign-Body Reaction to Wound Seal Wound Seal (Biolife LLC) is a product composed of a hydrophilic polymer and potassium iron oxyacid salt that aids in hemostasis in wounds that are left to heal by secondary intention. We report a foreign-body reaction that results in the dermis following its use. Report of a Case An 89-year-old white man had a 2.4 × 2.3-cm squamous cell carcinoma (SCC) excised from his left anterior lower leg via Mohs micrographic surgery. Owing to its large size and anatomic location, the defect was left to heal by secondary intention. Hemostasis was achieved with spot electrocoagulation followed by application of Wound Seal to the base of the wound. At his follow-up visit 4 months later, he was found to have a 1.5-cm pink nodule near the now well-healed scar from excision of the SCC, which was biopsied to confirm the diagnosis of SCC. Six weeks following the biopsy, he underwent excision via Mohs micrographic surgery. Histologic examination of frozen section specimens revealed a granulomatous infiltrate in the dermis with multinucleate giant cells surrounding large, geometric, basophilic foreign-body particles along with smaller golden-brown particles (Figure 1 and Figure 2). These findings are consistent with a foreign-body reaction to Wound Seal, which was applied to his previous wound for hemostasis. The large, geometric basophilic particles likely correspond to the hydrophilic polymers, and the smaller golden-brown particles to the potassium iron oxyacid. View LargeDownload Figure 1. Frozen tissue specimen showing dermal scar and granulomatous infiltrate surrounding geometric, basophilic foreign-body particles (hematoxylin-eosin, original magnification ×4). View LargeDownload Figure 2. Frozen tissue specimen (hematoxylin-eosin, original magnification ×10). This specimen shows a granulomatous infiltrate with multinucleated giant cells surrounding geometric, basophilic particles of varying size and shape and smaller golden-brown particles. Discussion Wound Seal is an over-the-counter product composed of a hydrophilic polymer and potassium iron oxyacid salt that aids in hemostasis via protein coagulation and agglomeration and fluid dehydration.1 It is used for hemostasis in wounds that are left to heal by secondary intention. Foreign-body granulomatous reactions are seen not uncommonly when prior surgical sites are rebiopsied or excised. Mohs surgeons and dermatopathologists are familiar with reactions to ferric subsulfate (Monsel solution), aluminum chloride (Drysol; Person and Covey Inc), and suture material. Specimens from tissue exposed to ferric subsulfate demonstrate coarse granular brown pigment in macrophages or around collagen and fibroblasts with a surrounding fibrohistiocytic tissue reaction.2 Aluminum chloride is seen as basophilic granules in the cytoplasm of macrophages, which can resemble parasitized histiocytes, although the aluminum chloride particles have more variability in their size and shape than organisms seen in parasitized histiocytes.3 The appearance of a suture granuloma depends on the suture material used. Braided sutures resemble a “bundle of filaments,” which seen in cross-section appear as homogeneous round to oval bodies, while silk has a green to black color, is birefringent under polarized light, and often has a brisk surrounding inflammatory infiltrate.4 It is important for Mohs surgeons and dermatopathologists to be aware of the appearance of this foreign-body material and to recognize it and its associated tissue reaction so as to avoid confusion and misdiagnosis. Back to top Article Information Correspondence: Dr Lester, University of Texas Medical School at Houston, 6655 Travis St, Ste 980, Houston, TX 77030 (laura.j.lester@gmail.com). Conflict of Interest Disclosures: None reported. References 1. 510(k) Premarket notification. http://www.accessdata.fda.gov/cdrh_docs/pdf8/K080210.pdf. Accessed August 11, 2012 2. Olmstead PM, Lund HZ, Leonard DD. Monsel's solution: a histologic nuisance. J Am Acad Dermatol. 1980;3(5):492-4987217377PubMedGoogle ScholarCrossref 3. Elston DM, Bergfeld WF, McMahon JT. Aluminum tattoo: a phenomenon that can resemble parasitized histiocytes. J Cutan Pathol. 1993;20(4):326-3298227609PubMedGoogle ScholarCrossref 4. Hirsh BC, Johnson WC. Pathology of granulomatous diseases: foreign body granulomas. Int J Dermatol. 1984;23(8):531-5386209232PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Dermatology American Medical Association

Foreign-Body Reaction to Wound Seal

JAMA Dermatology , Volume 149 (5) – May 1, 2013

Foreign-Body Reaction to Wound Seal

Abstract

Wound Seal (Biolife LLC) is a product composed of a hydrophilic polymer and potassium iron oxyacid salt that aids in hemostasis in wounds that are left to heal by secondary intention. We report a foreign-body reaction that results in the dermis following its use. Report of a Case An 89-year-old white man had a 2.4 × 2.3-cm squamous cell carcinoma (SCC) excised from his left anterior lower leg via Mohs micrographic surgery. Owing to its large size and anatomic location, the defect was...
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Publisher
American Medical Association
Copyright
Copyright © 2013 American Medical Association. All Rights Reserved.
ISSN
2168-6068
eISSN
2168-6084
DOI
10.1001/jamadermatol.2013.2620
Publisher site
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Abstract

Wound Seal (Biolife LLC) is a product composed of a hydrophilic polymer and potassium iron oxyacid salt that aids in hemostasis in wounds that are left to heal by secondary intention. We report a foreign-body reaction that results in the dermis following its use. Report of a Case An 89-year-old white man had a 2.4 × 2.3-cm squamous cell carcinoma (SCC) excised from his left anterior lower leg via Mohs micrographic surgery. Owing to its large size and anatomic location, the defect was left to heal by secondary intention. Hemostasis was achieved with spot electrocoagulation followed by application of Wound Seal to the base of the wound. At his follow-up visit 4 months later, he was found to have a 1.5-cm pink nodule near the now well-healed scar from excision of the SCC, which was biopsied to confirm the diagnosis of SCC. Six weeks following the biopsy, he underwent excision via Mohs micrographic surgery. Histologic examination of frozen section specimens revealed a granulomatous infiltrate in the dermis with multinucleate giant cells surrounding large, geometric, basophilic foreign-body particles along with smaller golden-brown particles (Figure 1 and Figure 2). These findings are consistent with a foreign-body reaction to Wound Seal, which was applied to his previous wound for hemostasis. The large, geometric basophilic particles likely correspond to the hydrophilic polymers, and the smaller golden-brown particles to the potassium iron oxyacid. View LargeDownload Figure 1. Frozen tissue specimen showing dermal scar and granulomatous infiltrate surrounding geometric, basophilic foreign-body particles (hematoxylin-eosin, original magnification ×4). View LargeDownload Figure 2. Frozen tissue specimen (hematoxylin-eosin, original magnification ×10). This specimen shows a granulomatous infiltrate with multinucleated giant cells surrounding geometric, basophilic particles of varying size and shape and smaller golden-brown particles. Discussion Wound Seal is an over-the-counter product composed of a hydrophilic polymer and potassium iron oxyacid salt that aids in hemostasis via protein coagulation and agglomeration and fluid dehydration.1 It is used for hemostasis in wounds that are left to heal by secondary intention. Foreign-body granulomatous reactions are seen not uncommonly when prior surgical sites are rebiopsied or excised. Mohs surgeons and dermatopathologists are familiar with reactions to ferric subsulfate (Monsel solution), aluminum chloride (Drysol; Person and Covey Inc), and suture material. Specimens from tissue exposed to ferric subsulfate demonstrate coarse granular brown pigment in macrophages or around collagen and fibroblasts with a surrounding fibrohistiocytic tissue reaction.2 Aluminum chloride is seen as basophilic granules in the cytoplasm of macrophages, which can resemble parasitized histiocytes, although the aluminum chloride particles have more variability in their size and shape than organisms seen in parasitized histiocytes.3 The appearance of a suture granuloma depends on the suture material used. Braided sutures resemble a “bundle of filaments,” which seen in cross-section appear as homogeneous round to oval bodies, while silk has a green to black color, is birefringent under polarized light, and often has a brisk surrounding inflammatory infiltrate.4 It is important for Mohs surgeons and dermatopathologists to be aware of the appearance of this foreign-body material and to recognize it and its associated tissue reaction so as to avoid confusion and misdiagnosis. Back to top Article Information Correspondence: Dr Lester, University of Texas Medical School at Houston, 6655 Travis St, Ste 980, Houston, TX 77030 (laura.j.lester@gmail.com). Conflict of Interest Disclosures: None reported. References 1. 510(k) Premarket notification. http://www.accessdata.fda.gov/cdrh_docs/pdf8/K080210.pdf. Accessed August 11, 2012 2. Olmstead PM, Lund HZ, Leonard DD. Monsel's solution: a histologic nuisance. J Am Acad Dermatol. 1980;3(5):492-4987217377PubMedGoogle ScholarCrossref 3. Elston DM, Bergfeld WF, McMahon JT. Aluminum tattoo: a phenomenon that can resemble parasitized histiocytes. J Cutan Pathol. 1993;20(4):326-3298227609PubMedGoogle ScholarCrossref 4. Hirsh BC, Johnson WC. Pathology of granulomatous diseases: foreign body granulomas. Int J Dermatol. 1984;23(8):531-5386209232PubMedGoogle ScholarCrossref

Journal

JAMA DermatologyAmerican Medical Association

Published: May 1, 2013

Keywords: foreign-body reaction

References