Allergic Contact Dermatitis to Chlorhexidine-Containing Antiseptics in Infants and Children: The Origin of Sensitization and The Role of The Excipients in This Sensitization (A Series of Ten Cases).

Main Article Content

Kalomoira Kefala, MD, M.Sc Claude Ponvert, MD, PhD

Abstract

The recent COVID-19 pandemic provoked an outstanding increase of infection-control measures, with chlorhexidine becoming an extensively used antiseptic. Allergic contact dermatitis (ACD) to chlorhexidine is considered as a rare event in children, is often difficult to identify, and its diagnosis is often misdiagnosed as other skin diseases.


Thus, we aimed to explore the sensitization to chlorhexidine-containing antiseptics (CCA) in infants and children to determine the origin of their sensitization and the role of the excipients in their dermatosis.


We performed patch tests (PT) with chlorhexidine digluconate 0.5%, benzalkonium chloride 0.1%, benzyl alcohol 10%, 5% and 1% in ten children (1-16.5-year-old, including six children with a personal history of atopy) with severe contact reactions to chlorhexidine-based antiseptics (Biseptine®) and cosmetics. We also performed PT with sodium benzoate 5% in four of the children. Results were measured according to criteria recommended by the International Contact Dermatitis Research Group (ICDRG). Patch test reactions revealed that most children were sensitized to at least two components of CCA (chlorhexidine, benzyl alcohol and/or benzalkonium chloride).


To explore the origin of the sensitization, we searched for umbilical cord care (UCC) with CCA and the use of cosmetics and drugs containing chlorhexidine and excipients of CCA. Most parents reported prior disinfection of umbilical cord with CCA, but this was not always the case.


Allergic contact dermatosis to chlorhexidine, benzyl alcohol and benzalkonium chloride should be considered in infants and children with severe eczema and concomitant allergies. The regular use of cosmetics and drugs containing chlorhexidine, benzyl alcohol, benzalkonium chloride or sodium benzoate should probably be cautioned or avoided in children with severe eczema or pre-existing allergies.


Early suspicion and allergology exploration of ACD to CCA and their excipients is of paramount importance to help prevent severe allergic reactions to topical antiseptics and numerous cosmetics.

Article Details

How to Cite
KEFALA, Kalomoira; PONVERT, Claude. Allergic Contact Dermatitis to Chlorhexidine-Containing Antiseptics in Infants and Children: The Origin of Sensitization and The Role of The Excipients in This Sensitization (A Series of Ten Cases).. Medical Research Archives, [S.l.], v. 11, n. 6, july 2023. ISSN 2375-1924. Available at: <https://esmed.org/MRA/mra/article/view/4006>. Date accessed: 07 dec. 2024. doi: https://doi.org/10.18103/mra.v11i6.4006.
Section
Research Articles

References

1. Opstrup MS, Johansen JD, Zachariae C, Garvey LH. Contact allergy to chlorhexidine in a tertiary dermatology clinic in Denmark. Contact Dermatitis. Jan 2016;74(1):29-36. doi:10.1111/cod.12487
2. Darrigade AS, Leaute-Labreze C, Boralevi F, Taieb A, Milpied B. Allergic contact reaction to antiseptics in very young children. J Eur Acad Dermatol Venereol. Dec 2018;32(12):2284-2287. doi:10.1111/jdv.15140
3. Magdaleno-Tapial J, Martinez-Domenech A, Valenzuela-Onate C, Ferrer-Guillen B, Esteve-Martinez A, Zaragoza-Ninet V. Allergic contact dermatitis to chlorhexidine in pediatric patients. Pediatr Dermatol. Jul 2019;36(4):540-541. doi:10.1111/pde.13808
4. Galadari A, Darrigade AS, Boralevi F, Milpied B. A child polysensitized to all constituents of Biseptine. Contact Dermatitis. Jan 2020;82(1):65-66. doi:10.1111/cod.13393
5. Beaumont C, Darrigade AS, Barbaud A, et al. Multiple cases of sensitization to an antiseptic containing chlorhexidine digluconate/ benzalkonium chloride/benzyl alcohol with different profiles of sensitization in adults and children. Contact Dermatitis. Jul 2022;87(1):62-70. doi:10.1111/cod.14085
6. Kefala K, Ponvert C. Un cas pédiatrique de dermite de contact allergique à la Biseptine. Case Report. Rev Fr Allergol. 2020;60:614-618. doi:10.1016/j.reval.2020.08.003
7. Kefala K, Ponvert C. Allergic contact dermatitis to chlorhexidine-containing antiseptics and their excipients in children: A series of six cases. Pediatr Dermatol. Jan 2023;40(1):151-153. doi:10.1111/pde.15127
8. Lazzarini R, Duarte I, Ferreira AL. Patch tests. An Bras Dermatol. Nov-Dec 2013;88(6):879-88. doi:10.1590/abd1806-4841.20132323
9. Fregert S. Patch Testing. In: Publishers YBM, ed. Manual of Contact Dermatitis. Munksgaard; 1981:71-81:chap 10.
10. Johansen JD, Aalto-Korte K, Agner T, et al. European Society of Contact Dermatitis guideline for diagnostic patch testing - recommendations on best practice. Contact Dermatitis. Oct 2015;73(4):195-221. doi:10.1111/cod.12432
11. Deza G, Gimenez-Arnau AM. Allergic contact dermatitis in preservatives: current standing and future options. Curr Opin Allergy Clin Immunol. Aug 2017;17(4):263-268. doi:10.1097/ACI.0000000000000373
12. Sasseville D. Hypersensitivity to preservatives. Dermatol Ther. 2004;17(3):251-63. doi:10.1111/j.1396-0296.2004.04028.x
13. Atwater AR, Petty AJ, Liu B, et al. Contact dermatitis associated with preservatives: Retrospective analysis of North American Contact Dermatitis Group data, 1994 through 2016. J Am Acad Dermatol. Apr 2021;84(4):965-976. doi:10.1016/j.jaad.2020.07.059
14. Schnuch A, Lessmann H, Geier J, Uter W. Contact allergy to preservatives. Analysis of IVDK data 1996-2009. Br J Dermatol. Jun 2011;164(6):1316-25. doi:10.1111/j.1365-2133.2011.10253.x
15. Suresh R, Murase JE. The role of expanded series patch testing in identifying causality of residual facial dermatitis following initiation of dupilumab therapy. JAAD Case Rep. Oct 2018;4(9):899-904. doi:10.1016/j.jdcr.2018.08.027
16. Schalock PC, Dunnick CA, Nedorost S, et al. American Contact Dermatitis Society Core Allergen Series: 2020 Update. Dermatitis. Sep-Oct 2020;31(5):279-282. doi:10.1097/DER.0000000000000621
17. Nair B. Final report on the safety assessment of Benzyl Alcohol, Benzoic Acid, and Sodium Benzoate. Int J Toxicol. 2001;20 Suppl 3:23-50. doi:10.1080/10915810152630729
18. Nair B. Final report on the safety assessment of Mentha Piperita (Peppermint) Oil, Mentha Piperita (Peppermint) Leaf Extract, Mentha Piperita (Peppermint) Leaf, and Mentha Piperita (Peppermint) Leaf Water. Int J Toxicol. 2001;20 Suppl 3:61-73.
19. Chen H, Zhong Q. Antibacterial activity of acidified sodium benzoate against Escherichia coli O157:H7, Salmonella enterica, and Listeria monocytogenes in tryptic soy broth and on cherry tomatoes. Int J Food Microbiol. Jun 2 2018;274:38-44. doi:10.1016/j.ijfoodmicro.2018.03.017
20. Reynolds J, Gilmour N, Baltazar MT, Reynolds G, Windebank S, Maxwell G. Decision making in next generation risk assessment for skin allergy: Using historical clinical experience to benchmark risk. Regul Toxicol Pharmacol. Oct 2022;134:105219. doi:10.1016/j.yrtph.2022.105219
21. Safety SCoC. OPINION on Fragrance allergens in cosmetic products. SCCS/1459/11. European Commission; 2012. 27 June 2012. doi:10.2772/77628 https://ec.europa.eu/health/scientific_committees/consumer_safety/docs/sccs_o_102.pdf
22. Sutton T, Nixon R. Allergic contact dermatitis to sodium benzoate chloroacetamide in a sorbolene lotion. Australas J Dermatol. Aug 2006;47(3):209-10. doi:10.1111/j.1440-0960.2006.00276.x
23. Lax SJ, Harvey J, Axon E, et al. Strategies for using topical corticosteroids in children and adults with eczema. Cochrane Database Syst Rev. Mar 11 2022;3(3):CD013356. doi:10.1002/14651858.CD013356.pub2
24. Aljebab F, Choonara I, Conroy S. Systematic review of the toxicity of short-course oral corticosteroids in children. Arch Dis Child. Apr 2016;101(4):365-70. doi:10.1136/archdischild-2015-309522
25. Waljee AK, Rogers MA, Lin P, et al. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ. Apr 12 2017;357:j1415. doi:10.1136/bmj.j1415
26. Agency EM. Aerius, INN-desloratadine Summary of Product Characteristics. https://www.ema.europa.eu/en/documents/product-information/aerius-epar-product-information_en.pdf
27. Mezger E, Wendler O, Mayr S, Bozzato A. Anaphylactic reaction following administration of nose drops containing benzalkonium chloride. Head Face Med. Oct 18 2012;8:29. doi:10.1186/1746-160X-8-29
28. Kim SH, Ahn Y. Anaphylaxis caused by benzalkonium in a nebulizer solution. J Korean Med Sci. Apr 2004;19(2):289-90. doi:10.3346/jkms.2004.19.2.289