Review Article

Newer Hemostatic Agents Used in the Practice of Dermatologic Surgery

Table 5

Hemostatic agents.

Hemostatic agentProduct informationMechanism of actionPotential side effects

Caustic agents
Zinc chloride
(Moh’s paste)
Paste that can be applied topically. Used infrequently, but is effective in providing hemostasis to metastatic cutaneous wounds [53].Precipitates proteins causing coagulation of small vessels [48]. Left on for up to 48 hours.Can be very painful and irritating to the patient [53].
Ferric subsulfate (Monsel’s solution)Solution can be applied with a cotton tipped applicator or gauze pad [48, 54].Precipitates proteins intravascularly and oxidizes tissues. Less expensive, more accessible, and easy to apply [48, 54]. Being used less due to intradermal ferruginous deposits causing tattooing of the skin after use [48, 54].
Aluminum chlorideSolution can be applied with a cotton tipped applicator after shave biopsy [48].Precipitates proteins causing coagulation of vessels [48]. Easily accessible and easy to apply.Can be painful and irritating to the patient [48].
Non-caustic agents
Gelatin (Gelfoam, Surgifoam)
Gelfoam Plus (Gelatin combined with human thrombin)
Comes in a sterile powder or sponge. Porcine derived [48].The gelatin is able to absorb more than 45x its weight, providing a matrix for the clotting cascade in addition to providing a physical barrier. Absorbed by the body in 4–6 weeks [48, 55, 56]. Can interfere with healing of wound edges, generally not recommended for use in skin incisions. Can facilitate bacterial growth leading to infection or leading to foreign body reactions when left in the tissue. Can increase in size leading to compression of surrounding structures, including nerve damage. When combined with thrombin can lead to allergic/anaphylactic reactions [48, 55].
Polyethylene glycol Hydrogel (CoSeal)Liquid composed of two PEG polymers that polymerize and cross-link in the tissue [57, 58]. Increases platelet adherence, providing quick hemostasis [57]. Swells up to 4x its size potentially causing damage to the surrounding tissues [58].
Microporous polysaccharide spheres (Arista)Comes in a white powder that is 100% plant based. Formed by cross-linking of purified plant starch [52, 58, 59].Dehydrates the blood, concentrating RBC’s, platelets, proteins, promoting adherence to the gel matrix. Also causes a physical barrier in the tissue [52, 58, 59].Causes immediate swelling, has the potential to cause damage to surrounding structures. Use cautiously in diabetics due to potential to increase glucose load [58].
Microfibrillar collagen (Avitene, Helistat)Bovine collagen formed into flour, sheets, or sponges [48]. Collagen framework promotes platelet aggregation and coagulation cascade [48]. Side effects are rare. Allergic and foreign body reactions have occurred [48].
Cellulose (Surgicel, Oxycel)Oxidized cellulose arranged into sheets, gauze, or smaller strips. Can durably be placed in the tissue [48, 60]. Physically acts to tamponade the vessels and provide a meshwork for the fibrinolytic cascade to occur. Becomes gelatinous in 24–48 hrs and is absorbed by the body by 1–6 weeks. Relatively inexpensive [48].Can cause granulomatous reactions and should be used carefully in closed spaces due to increased risk of swelling in the tissues, can cause compression of surrounding structures [60].
Pro QR powderCombination of a hydrophilic polymer and potassium salt packaged into a powder [48, 51]. Available over the counter, relatively inexpensive and easy to apply.Forms an eschar in body in <60 seconds, due to the polymers dehydrating the blood and the potassium salt binding to the positively charged red blood cells [48, 52]. Few side effects reported.
Thrombin (Thrombin-JMI, Recothromb, Evithrom, Floseal)Can be bovine derived or human recombinant thrombin. Comes in a powder or solution. Floseal is composed of a gelatin matrix and thrombin and comes in two separate compartments that are not mixed until time of use [48, 60]. Promotes body’s physiologic clotting cascade by actively converting fibrinogen into fibrin. Should not be used in patients that have decreased fibrinogen levels [48, 57, 60]. Bovine thrombin has been shown to cause coagulopathy weeks after use, due to antibodies forming against factor V. Human thrombin although cleansed thoroughly, has the potential to transmit viruses [48, 57, 60].
Fibrin sealant (Tisseal, Crosseal, Evicel)Human and bovine derived forms. Can be formed from autologous plasma or pooled from donors. Also comes in an aerosolized form [5]. Entails different methods of preparation depending on the product. Can be frozen in premixed form for up to two years, can be heated, and stirred for 20 minutes prior to use [48, 60]. Can also be sprayed directly to the area in the aerosolized form [5].Comes in a two compartment syringe with one compartment containing fibrinogen, factor XIII, fibronectin, and fibrinolysis inhibitors (aprotinin), and in the other is thrombin and calcium chloride [5, 48, 60]. When combined, thrombin becomes activated and activates the clotting cascade and enhances conversion of fibrinogen to fibrin. Absorbed from the body within 5–10 days [48]. Very effective in patients with coagulopathies.Pooled donor plasma and older sealants containing bovine derived aprotinin increased the potential to cause hypersensitivity reactions and to transmit infectious diseases such as prion-related diseases [5, 58].
Octyl-2-cyanoacrylate (Dermabond)Comes as a topical liquid adhesive best used for smaller lacerations. May have some antibacterial properties. Good in pediatric population and people with cognitive deficits who cannot tolerate/understand stitch removal. Moderately expensive [4749]. Polymerization creates a physical barrier, tamponading the vessels [4749].Small risk for inflammatory reactions and fibrosis [48].

Abbreviations: PEG: polyethylene glycol.