Contact Dermatitis • Contact Points ALLERGIC CONTACT DERMATITIS CAUSED BY AN ANTISEPTIC • ENGEBRETSEN ET AL.
Allergic contact dermatitis caused by an antiseptic containing cetrimide Kristiane A. Engebretsen, Marianne Hald, Jeanne D. Johansen and Jacob P. Thyssen Department of Dermato-Allergology, National Allergy Research Centre, Gentofte University Hospital, University of Copenhagen, Niels Andersens Vej 65, DK-2900 Hellerup, Denmark doi:10.1111/cod.12303
Key words: allergic contact dermatitis; antiseptic; cetrimide; chlorhexidine; patch testing.
Antiseptic solutions are used to reduce the levels of pathogenic microorganisms on the skin prior to surgical interventions. Chlorhexidine is widely used for such purposes, as it is active against both gram-negative bacteria and yeast, but in particular against gram-positive bacteria. Chlorhexidine allergy, either immediate type I (1) or as delayed type IV allergic contact dermatitis reactions, is well known (2). Notably, in a French study evaluating patients suspected of having contact allergy to antiseptics, it was found that 18.7% of 75 patients were allergic to chlorhexidine (3). Cetrimide may be combined with chlorhexidine to enhance its action. Cetrimide, a mixture of different quaternary ammonium salts, of which the primary surfactant is cetrimonium bromide, is active against both gram-negative and gram-positive bacteria. In addition, it breaks down surface tension, permitting wetting of the surface, enabling disinfection
Correspondence: Kristiane A. Engebretsen, Department of DermatoAllergology, Gentofte University Hospital, Niels Andersens vej 65, DK-2900 Hellerup, Denmark. Tel: +45 39773145; Fax: +45 39777101. E-mail: [email protected] Funding: Jacob Thyssen and Kristiane Engebretsen are financially supported by an unrestricted grant from the Lundbeck Foundation. Conflicts of interests: The authors have no conflict of interest to disclose.
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of the skin (4). Allergic reactions to cetrimide are very uncommon, but irritant contact dermatitis has also been reported (5–7). We report a case of severe allergic contact dermatitis affecting the scrotal and penile skin caused by an antiseptic containing a combination of chlorhexidine and cetrimide, and in which patch testing clarified the culprit allergen.
Case Report A 68-year-old non-atopic man was referred from the Department of Urology because of a suspected allergic skin reaction. He had recently been diagnosed with prostate cancer, and 2 days after a biopsy procedure he developed severe swelling and redness of the scrotal and penile skin. Suspected allergens included the tape from the surgical dressing and chlorhexidine from the antiseptic solution [chlorhexidine/cetrimide (Klorhexidin/cetrimid SAD) 0.2%/0.1%]. Patch testing was performed with an extended European baseline series, a local anaesthetic series, an additional fragrance allergen series, plastic and glue series, and cetrimonium bromide 0.5% pet. (Chemotechnique, Vellinge, Sweden). Finn Chambers® (8 mm; SmartPractice® , Phoenix, AZ, USA) on Scanpor® tape
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Contact Dermatitis, 72, 59–63
Contact Dermatitis • Contact Points ALLERGIC CONTACT DERMATITIS CAUSED BY AN ANTISEPTIC • ENGEBRETSEN ET AL.
there was no reaction to chlorhexidine 0.5% aq. alone (Fig. 1). The test result for serum-specific IgE against chlorhexidine was negative. All positive patch test results, except those obtained with cetrimide/chlorhexidine and cetrimide, could be explained by previous exposure and cross-reactivity, and were not relevant to the present skin problem. The patient was informed about his contact allergy to cetrimide, and provided with a card on which this was stated. He was also instructed to inform all healthcare personnel about his allergy in future encounters.
Discussion Fig. 1. Positive patch test reaction to cetrimonium bromide.
(Norgesplaster A/S, Alpharma, As, Norway) were used. The patch tests were applied to the upper back and occluded for 2 days. Readings were performed on D2, D3, and D7, according to ICDRG recommendations. Positive test reactions were observed to a range of substances already known by the patient, including: p-phenylenediamine (2+), budesonide (2+), clioquinol (1+), Myroxylon pereirae (1+), fragrance mix I and fragrance mix II (2+), farnesol (1+), isoeugenol (1+), formaldehyde (1+), benzyl alcohol (1+), and textile mix (1+). In addition, there were strong positive test reactions to chlorhexidine/cetrimide (0.2%/0.1%) (2+), and to cetrimonium bromide 0.5% pet. (2+), but
This case illustrates that allergic skin reactions following the use of antiseptic solutions containing a combination of chlorhexidine and cetrimide can be caused by cetrimide rather than chlorhexidine. Previously, there have been reports of severe irritant reactions, such as chemical burns and cutaneous necrosis (5–7), to topical antiseptics containing cetrimide. Little has been reported about true allergic contact dermatitis caused by cetrimide. The French study showed that only 1.3% of patients reacting to antiseptics were sensitized to cetrimide (3). Our case illustrates the need for patch testing following suspected allergic skin reactions to an antiseptic. In our case, the patient could potentially have been incorrectly labelled as allergic to chlorhexidine, which could have led to unnecessary avoidance in the future, and also potentially have led to re-exposure to cetrimide.
References 1 Garvey L H, Krøigaard M, Poulsen L K, Skov P S, Mosbech H, Venemalm L, Degerbeck F, Husum B. IgE-mediated allergy to chlorhexidine. J Allergy Clin Immunol 2007: 120: 409–415. 2 Toholka R, Nixon R. Allergic contact dermatitis to chlorhexidine. Australas J Dermatol 2013: 54: 303–306.
3 Barbaud A, Vigan M, Delrous J et al. Contact allergy to antiseptics: 75 cases analyzed by the dermato-allergovigilance network (Revidal). Ann Dermatol Venereol 2005: 132: 962–965. 4 Haidar Z. An adverse reaction to a topical antiseptic (cetrimide). Br J Oral Surg 1978: 16: 86–89.
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Contact Dermatitis, 72, 59–63
5 Inman J K. Cetrimide allergy presenting as suspected non-accidental injury. Br Med J (Clin Res Ed) 1982: 284: 385. 6 August P. Cutaneous necrosis due to cetrimide application. Br Med J 1975: 1: 70. 7 Mercer D. Cetrimide burn in an infant. Postgrad Med J 1983: 59: 472–473.
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This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
Allergic contact dermatitis caused by an antiseptic containing cetrimide Kristiane A. Engebretsen, Marianne Hald, Jeanne D. Johansen and Jacob P. Thyssen Department of Dermato-Allergology, National Allergy Research Centre, Gentofte University Hospital, University of Copenhagen, Niels Andersens Vej 65, DK-2900 Hellerup, Denmark doi:10.1111/cod.12303
Key words: allergic contact dermatitis; antiseptic; cetrimide; chlorhexidine; patch testing.
Antiseptic solutions are used to reduce the levels of pathogenic microorganisms on the skin prior to surgical interventions. Chlorhexidine is widely used for such purposes, as it is active against both gram-negative bacteria and yeast, but in particular against gram-positive bacteria. Chlorhexidine allergy, either immediate type I (1) or as delayed type IV allergic contact dermatitis reactions, is well known (2). Notably, in a French study evaluating patients suspected of having contact allergy to antiseptics, it was found that 18.7% of 75 patients were allergic to chlorhexidine (3). Cetrimide may be combined with chlorhexidine to enhance its action. Cetrimide, a mixture of different quaternary ammonium salts, of which the primary surfactant is cetrimonium bromide, is active against both gram-negative and gram-positive bacteria. In addition, it breaks down surface tension, permitting wetting of the surface, enabling disinfection
Correspondence: Kristiane A. Engebretsen, Department of DermatoAllergology, Gentofte University Hospital, Niels Andersens vej 65, DK-2900 Hellerup, Denmark. Tel: +45 39773145; Fax: +45 39777101. E-mail: [email protected] Funding: Jacob Thyssen and Kristiane Engebretsen are financially supported by an unrestricted grant from the Lundbeck Foundation. Conflicts of interests: The authors have no conflict of interest to disclose.
60
of the skin (4). Allergic reactions to cetrimide are very uncommon, but irritant contact dermatitis has also been reported (5–7). We report a case of severe allergic contact dermatitis affecting the scrotal and penile skin caused by an antiseptic containing a combination of chlorhexidine and cetrimide, and in which patch testing clarified the culprit allergen.
Case Report A 68-year-old non-atopic man was referred from the Department of Urology because of a suspected allergic skin reaction. He had recently been diagnosed with prostate cancer, and 2 days after a biopsy procedure he developed severe swelling and redness of the scrotal and penile skin. Suspected allergens included the tape from the surgical dressing and chlorhexidine from the antiseptic solution [chlorhexidine/cetrimide (Klorhexidin/cetrimid SAD) 0.2%/0.1%]. Patch testing was performed with an extended European baseline series, a local anaesthetic series, an additional fragrance allergen series, plastic and glue series, and cetrimonium bromide 0.5% pet. (Chemotechnique, Vellinge, Sweden). Finn Chambers® (8 mm; SmartPractice® , Phoenix, AZ, USA) on Scanpor® tape
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Contact Dermatitis, 72, 59–63
Contact Dermatitis • Contact Points ALLERGIC CONTACT DERMATITIS CAUSED BY AN ANTISEPTIC • ENGEBRETSEN ET AL.
there was no reaction to chlorhexidine 0.5% aq. alone (Fig. 1). The test result for serum-specific IgE against chlorhexidine was negative. All positive patch test results, except those obtained with cetrimide/chlorhexidine and cetrimide, could be explained by previous exposure and cross-reactivity, and were not relevant to the present skin problem. The patient was informed about his contact allergy to cetrimide, and provided with a card on which this was stated. He was also instructed to inform all healthcare personnel about his allergy in future encounters.
Discussion Fig. 1. Positive patch test reaction to cetrimonium bromide.
(Norgesplaster A/S, Alpharma, As, Norway) were used. The patch tests were applied to the upper back and occluded for 2 days. Readings were performed on D2, D3, and D7, according to ICDRG recommendations. Positive test reactions were observed to a range of substances already known by the patient, including: p-phenylenediamine (2+), budesonide (2+), clioquinol (1+), Myroxylon pereirae (1+), fragrance mix I and fragrance mix II (2+), farnesol (1+), isoeugenol (1+), formaldehyde (1+), benzyl alcohol (1+), and textile mix (1+). In addition, there were strong positive test reactions to chlorhexidine/cetrimide (0.2%/0.1%) (2+), and to cetrimonium bromide 0.5% pet. (2+), but
This case illustrates that allergic skin reactions following the use of antiseptic solutions containing a combination of chlorhexidine and cetrimide can be caused by cetrimide rather than chlorhexidine. Previously, there have been reports of severe irritant reactions, such as chemical burns and cutaneous necrosis (5–7), to topical antiseptics containing cetrimide. Little has been reported about true allergic contact dermatitis caused by cetrimide. The French study showed that only 1.3% of patients reacting to antiseptics were sensitized to cetrimide (3). Our case illustrates the need for patch testing following suspected allergic skin reactions to an antiseptic. In our case, the patient could potentially have been incorrectly labelled as allergic to chlorhexidine, which could have led to unnecessary avoidance in the future, and also potentially have led to re-exposure to cetrimide.
References 1 Garvey L H, Krøigaard M, Poulsen L K, Skov P S, Mosbech H, Venemalm L, Degerbeck F, Husum B. IgE-mediated allergy to chlorhexidine. J Allergy Clin Immunol 2007: 120: 409–415. 2 Toholka R, Nixon R. Allergic contact dermatitis to chlorhexidine. Australas J Dermatol 2013: 54: 303–306.
3 Barbaud A, Vigan M, Delrous J et al. Contact allergy to antiseptics: 75 cases analyzed by the dermato-allergovigilance network (Revidal). Ann Dermatol Venereol 2005: 132: 962–965. 4 Haidar Z. An adverse reaction to a topical antiseptic (cetrimide). Br J Oral Surg 1978: 16: 86–89.
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Contact Dermatitis, 72, 59–63
5 Inman J K. Cetrimide allergy presenting as suspected non-accidental injury. Br Med J (Clin Res Ed) 1982: 284: 385. 6 August P. Cutaneous necrosis due to cetrimide application. Br Med J 1975: 1: 70. 7 Mercer D. Cetrimide burn in an infant. Postgrad Med J 1983: 59: 472–473.
61
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
