X-Ray Microanalysis of the Fingernails in Term and Preterm Infants

The element content of the fingernails of 10 term and 14 preterm infants, clipped for the first time after delivery, was determined by x-ray microanalysis. The results showed a decrease in sulfur and aluminum, and a higher chlorine content in term infants in comparison with preterm ones, the difference being statistically significant. Sodium, potassium, calcium, and zinc content did not differ in the two groups. Copper, iron, magnesium, aluminum, and phosphorus were detected in trace amounts only. Cobalt was not detected in the fingernails of newborns in either group. The elevated content of aluminum in the fingernails of preterm infants may be a clue to the osteopenia observed in these infants.     

Allergic Urticaria: A Case Report of Rare Skin Allergy with a Common Mouthwash

Chlorhexidine is a widely used antiseptic and disinfectant in medical and non-medical environments. Compared to its ubiquitous use, allergic contact dermatitis from chlorhexidine has rarely been reported and so its sensitization rate seems to be low. Chlorhexidine has been used for more than 50 years but it was only in the last two decades, that reports of immediate- type reactions to chlorhexidine were seen. Reactions ranging from localized urticaria to anaphylactic shock and hypersensitivity reactions, including delayed hypersensitivity reactions such as contact dermatitis, fixed drug eruptions, and photosensitivity reactions, began to appear more frequently. However the prevalence of contact urticaria and anaphylaxis due to chlorhexidine remains to be unknown. In this case report we have reported a case of urticaria due to oral use of chlorhexidine. The adverse reaction was confirmed by a skin prick test.     

Evidence‐based skin care in preterm infants

Most guidelines on neonatal skin care emphasize issues pertaining to healthy, term infants. Few address the complex task of skin barrier maintenance in preterm, very preterm, and extremely preterm infants. Here, we provide an evidence‐based review of the literature on skin care of preterm neonates. Interestingly, the stratum corneum does not fully develop until late in the third trimester, and as such, the barrier function of preterm skin is significantly compromised. Numerous interventions are available to augment the weak skin barrier of neonates. Plastic wraps reduce the incidence of hypothermia while semipermeable and transparent adhesive dressings improve skin quality and decrease the incidence of electrolyte abnormalities. Tub bathing causes less body temperature variability than sponge bathing and can be performed as infrequently as once every four days without increasing bacterial colonization of the skin. Topical emollients, particularly sunflower seed oil, appear to reduce the incidence of skin infections in premature neonates—but only in developing countries. In developed countries, studies indicate that topical petrolatum ointment increases the risk of candidemia and coagulase‐negative Staphylococcus infection in the preterm population, perhaps by creating a milieu similar to occlusive dressings. For preterm infants with catheters, povidone‐iodine and chlorhexidine are comparably effective at preventing catheter colonization. Further studies are necessary to examine the safety and efficacy of various skin care interventions in premature infants with an emphasis placed on subclassifying the patient population. In the interim, it may be beneficial to develop guidelines based on the current body of evidence.     

Chlorhexidine anaphylaxis: case report and review of the literature

Chlorhexidine is a widely used antiseptic and disinfectant. Compared to its ubiquitous use in medical and non-medical environments, the sensitization rate seems to be low. Multivarious hypersensitivity reactions to the agent have been reported, including delayed hypersensitivity reactions such as contact dermatitis, fixed drug eruptions and photosensitivity reactions. An increasing number of immediate-type allergies such as contact urticaria, occupational asthma and anaphylactic shock have been reported. In the case report, we describe anaphylaxis due to topical skin application of chlorhexidine, confirmed by skin testing and sulfidoleukotriene stimulation test (CAST(R): cellular antigen stimulation test). The potential risk of anaphylactic reactions due to the application of chlorhexidine is well known, especially that application to mucous membranes can cause anaphylactic reactions and was therefore discouraged. The use of chlorhexidine at a 0.05% concentration on wounds and intact skin was so far thought to be safe. Besides our patient, only one other case of severe anaphylactic reaction due to application of chlorhexidine on skin has been reported. Hypersensitivity to chlorhexidine is rare, but its potential to cause anaphylactic shock is probably underestimated. This review should remind all clinicians of an important potential risk of this widely used antiseptic.     

Anaphylactic symptoms due to chlorhexidine gluconate

Six patients who developed urticaria, dyspnea, and anaphylactic shock due to topical application of chlorhexidine gluconate solution are described. Chlorhexidine gluconate was confirmed as the causative agent of type I hypersensitivity by intradermal, scratch, and epicutaneous tests. To prevent life-threatening adverse reactions, it seems important to use chlorhexidine gluconate on wound surfaces at a concentration of 0.05%, as recommended by the manufacturer; chlorhexidine gluconate may not be suitable for application to mucous membranes.     

Chlorhexidine gluconate and acetate in patch testing

Patch testing to chlorhexidine is usually performed with chlorhexidine gluconate aq. We report the results of 297 patients, almost all with leg ulcers, concomitantly tested with chlorhexidine acetate 1% aq. and chlorhexidine gluconate 1% aq. 39 patients had positive reactions to one of these compounds or to both. 36 positive reactions to the acetate were found, in contrast to 18 reactions to the gluconate. The reactions were considered relevant in 22 of 39 patients, since these patients had developed an eczema in an area where a chlorhexidine compound was used, and discontinuing the chlorhexidine compound resulted in improvement of the condition. In 10 of these 22 patients, the diagnosis would have been missed if the gluconate only had been used for testing, while the acetate failed to diagnose 2 patients. In 109 patients without leg ulcers, inconclusive patch test readings (i.e., irritant reactions or weak positive reactions) were found in 17% with chlorhexidine acetate 1% aq., compared to 5% with chlorhexidine gluconate 1% aq., indicating a high degree of irritant potential of the acetate 1% aq. We consider that some positive reactions are lost if chlorhexidine gluconate 1% aq. only is used for patch testing, but that chlorhexidine acetate 1% aq., on the other hand, is an unacceptably strong irritant. We therefore suggest that further testing with chlorhexidine acetate 1 and 0.5% aq. should be performed, in parallel with chlorhexidine gluconate 1% aq., in order to establish appropriate test concentrations. We find that up to 13% of the leg ulcer patients in this study may be sensitized to chlorhexidine, and we recommend that the indications for the drug in leg ulcer patients should be reconsidered.     

Allergic contact dermatitis to chlorhexidine

Chlorhexidine is a commonly used antiseptic agent in the health‐care setting. Although exposure to chlorhexidine is very common, allergic contact dermatitis (ACD) is rarely reported. We report a case series of ACD to chlorhexidine in health‐care workers and discuss our rates of allergy to chlorhexidine, from patch‐testing performed at the Skin and Cancer Foundation, Melbourne, Australia. Of 7890 patients patch‐tested, 840 patients were tested to 0.5% chlorhexidine diacetate with 28 (3%) positive reactions, 13 (2%) of which relevant to their presenting dermatitis. Altogether 1565 patients were tested to 0.5% chlorhexidine digluconate, with 47 (3%) positive reactions, 16 (1%) of which were relevant. We estimate our rate of relevant chlorhexidine ACD from our total clinic patients, non‐occupational and occupational, to be at least 19/7890 (0.24%). Our rate of relevant chlorhexidine ACD in health‐care workers is 10/541 (2%). Interestingly, our rates of chlorhexidine allergy are slightly higher than documented elsewhere. This raises the possibility that chlorhexidine is underestimated as an allergen worldwide, and should be tested for in health‐care workers where there is a history of exposure.     

Studies on purity and stability of photopatch test substances

19 photo substances were studied by thin-layer chromatography (TLC) as fresh solutions, and during storage under various conditions. Chlorhexidine was excluded as it is sparingly soluble and only used in commercial products as a derivative. Trichlorocarbanilide was the only substance shown to be impure from the start. Only benzocaine, buclosamide, chlorhexidine acetate and chlorhexidine gluconate remained unchanged to the naked eye, and in TLC. The other substances were changed in colour and/or in their TLC-pattern. An extraction method is described which makes it possible to use TLC for the examination of substances in petrolatum preparations. UV-absorption spectra have also been examined for all the substances.     

Surgical antiseptics

The skin cannot be sterilized because approximately 20% of the resident flora are beyond the reach of surgical scrubs and antiseptics. The goal of surgical preparation of the skin with antiseptics is to remove transient and pathogenic microorganisms on the skin surface and to reduce the resident flora to a low level. Four antiseptics which have been popular over the past two decades are discussed. Benzalkonium chloride is somewhat unstable on the skin and is too prone to contamination to be in general use. Hexachlorophene is not recommended due to narrow spectrum and risks secondary to percutaneous absorption. The iodophors are excellent antiseptics, but recent studies raise questions about effectiveness and contamination. Chlorhexidine is a very safe and effective antiseptic. Comparison studies with chlorhexidine, hexachlorophene, and iodophors show chlorhexidine to be the most effective agent. Chlorhexidine can be toxic to the middle ear and irritating to the eyes with direct contact. Caution should be used in these areas with chlorhexidine and other antiseptics.     

The relevance of chlorhexidine contact allergy

Background. Chlorhexidine is used for disinfection of skin and mucosae in medicine and dentistry. Prolonged exposure may lead to contact sensitization and allergic contact dermatitis or stomatitis. Objectives. The purpose of this study was to analyse the sources of chlorhexidine exposure and sensitization, and to obtain data on the prevalence of sensitization and chlorhexidine‐related contact allergy. Patients and methods. From 1999, patch testing was performed with chlorhexidine digluconate (0.5% aq.) on 7610 general dermatology patients with suspected contact allergy at the Turku University Hospital Dermatology Department. The medical records were reviewed concerning the patients' exposure to chlorhexidine. Results. A positive patch reaction to chlorhexidine was seen in 36 patients (0.47%). Current dermatitis or stomatitis caused by chlorhexidine‐containing topical medicaments was seen in 5 patients. Chlorhexidine sensitization contributed to the current dermatitis in 11 patients. A history of earlier exposure to chlorhexidine‐containing products was recalled by only 16 sensitized patients, whereas no exposure was revealed in 4 cases. Conclusions. Chlorhexidine‐containing corticosteroid creams, skin disinfectants and oral hygiene products are principal sources of chlorhexidine contact sensitization. Exposure to chlorhexidine in cosmetics may lead to delayed improvement of eczema in sensitized patients, emphasizing the importance of identifying the potential cosmetic sources.     

Skin care practices for newborns and infants: review of the clinical evidence for best practices

In recent years, there have been continuing efforts to understand the effects of baby skin care routines and products on the healthy development of baby skin. Such efforts aim ultimately to determine the best infant skin care practices. The pediatric and dermatologic communities have not reached consensus on what constitutes an appropriate cleansing practice. In the United States, guidelines for neonatal skin care have been developed, propagated, and implemented. The accumulated knowledge has promoted evidence-based clinical practices and, therefore, may help to improve clinical outcomes, although these guidelines primarily cover the care of preterm newborns and the treatment of those with other health problems. High-level, long-term clinical evidence of the effective and safe cleansing of healthy, full-term newborns and infants is scarce. This review presents a comprehensive analysis of the scientific literature on baby skin development, cleansing practices, and related products (for healthy newborns and babies) since 1970. The evidence drawn from the reviewed literature can be summarized as follows: Bathing immersed in water seems generally superior to washing alone. Bathing or washing with synthetic detergents (syndets) or mild liquid baby cleansers seems comparable with or even superior to water alone. Nevertheless, larger randomized clinical trials with age-defined cohorts of babies as well as more-defined parameters are required to identify optimal practices and products for skin cleansing of healthy infants. These parameters may include standardized skin function parameters such as transepidermal water loss, stratum corneum hydration, skin surface pH, and sebum production. Clinical skin scores such as the Neonatal Skin Condition Score may be employed as outcome measures.     

Contact dermatitis caused by cetrimide in antiseptics *

Cetrimide and chlorhexidine are widely used antiseptics. Irritant contact dermatitis from cetrimide has been reported, but only rarely and without pathologic study. We report the clinical and pathologic findings from a series of 18 cases of contact dermatitis caused by antiseptic solutions containing 3% cetrimide and 0.3% chlorhexidine. The patients consisted of 10 males and 8 females, aged from 2 to 62 years. Most patients developed pruritic, burning or painful rashes over the flexors and genitalia after 1 to 4 weeks of daily use of undiluted antiseptics for an underlying pruritic dermatosis. The lesions varied from slight scaling with minimal erythema to fiery or dusky red patches with a glazed surface. The rashes resolved in 2 to 4 weeks after discontinuing the antiseptics. Concentric annular lesions were noted in some patients. Patch testing revealed negative reaction to chlorhexidine 0.5% aq. but irritant reaction to cetrimide 0.5. 1 or 2% aq. and Savlon at 1:3 or 1:6 dilution Light microscopy showed compact orthokeratosis and confluent parakeratosis without spongiosis. Our study suggests that the dermatitis was an irritant reaction to cetrimide after improper self-application of the antiseptic liquids for underlying pruritic rashes or personal hygiene. Recognition of the characteristic xerosis- or chemical-burn-like features primarily involving the flexors or genital area is essential to the diagnosis.     

Allergic contact dermatitis to chlorhexidine in a very young child

Allergic contact dermatitis to chlorhexidine is an unusual condition, with sensitization in childhood rarely reported. We report the observation of allergic contact dermatitis to chlorhexidine in a 23-month-old boy.     

Debridement via collagenase application in two neonates

Slow-healing wounds contain insufficient amounts of intrinsic collagenases to provide sufficient wound debridement, so that the use of products containing synergistic collagenases and proteases may be helpful. We report the successful use of collagenase clostridipeptidase A in two newborns, a premature infant with 3rd degree burns, and a term neonate with an extravasation necrosis caused by calcium gluconate. Surgical excision of necrotic tissue is a serious intervention and prolongs the duration of hospitalization. Enzymatic eschar removal may have an advantage over surgery especially in newborns with a high risk for surgery, with its possible complications, need for anesthesia, and perhaps for blood transfusion.     

Effect of chlorhexidine on genital microflora, Neisseria gonorrhoeae, and Trichomonas vaginalis in vitro

BACKGROUND: Chlorhexidine is a disinfectant that has been used in skin and mouth washes and as a preservative in some vaginal lubricants. A gel containing 0.25% chlorhexidine gluconate has been found to be effective against Chlamydia trachomatis in vitro and in animal models. Applied vaginally, 5 g of this gel could achieve vaginal fluid concentrations of < or = 1250 microg/ml. GOAL: To test the in vitro activity of chlorhexidine in a gel over a pH range of 4 to 8 in the presence or absence of blood. STUDY DESIGN: Organisms were exposed to chlorhexidine for 30 minutes to 2 hours, and the minimum cidal concentration (MCC) was calculated. RESULTS: The MCC for Neisseria gonorrhoeae was 25 microg/ml at 30 minutes and 12.5 microg/ml at 1 to 2 hours of exposure, whereas the MCC for Trichomonas vaginalis was 1250 microg/ml. Chlorhexidine was more active at pH 8 than pH 4, and less active in the presence of blood. The MCC for Lactobacillus crispatus was 1250 microg/ml at pH 4 and only 125 microg/ml at pH 8. CONCLUSIONS: Based on its in vitro activity, chlorhexidine may be an appropriate topical microbicide for prevention of gonorrhea, but not for prevention of trichomoniasis. This study suggests that the presence of blood and pH affect the activity of chlorhexidine against genital pathogens and commensals.     

Conjunctivitis due to soft lens solutions

In cases of conjunctivitis associated with the use of soft lenses, delayed hypersensitivity to disinfecting components of the used soft lens liquids has to be considered. In 7/15 patients, positive patch test reactions to merthiolate, chlorhexidine or the soaking solutions were observed. The significance of these findings is discussed.     

Immediate hypersensitivity to chlorhexidine

Chlorhexidine is a widely used and effective antiseptic agent. Although skin contact is usually well tolerated, it may cause both immediate and delayed hypersensitivity reactions. We report a case of immediate hypersensitivity to chlorhexidine causing both skin and respiratory symptoms following occupational exposure to chlorhexidine in a health‐care worker.     

Contact dermatitis to chlorhexidine

In a 3-year period, 551 patients were patch tested with chlorhexidine gluconate 1% in water. 14 patients showed a strong and obviously relevant reaction. A severe dermatitis developed daring treatment with a chlorhexidine preparation in 10 patients with venous or traumatic ulcers of the leg, and in 4 patients with skin infection on the face and/or scalp. So far the sensitizing potential of chlorhexidine has probably been underestimated.     

Functional skin adaptation in infancy – almost complete but not fully competent

Please cite this paper as: Functional skin adaptation in infancy – almost complete but not fully competent. Experimental Dermatology 2010; 19: 483–492. Abstract: Early postnatal life is a period of active functional reorganization and cutaneous physiological adaptation to the extrauterine environment. Skin as the outermost organ of mammalians is endowed of multiple functions such as protection, secretion, absorption and thermoregulation. Birth stimulates the epidermal barrier maturation and the skin surface acidification especially in premature infants. In full‐term infants the developed stratum corneum accomplishes competent barrier function, in contrast to prematures. Complete barrier maturation in preterm infants is fulfilled by 2–4 weeks of the postnatal life. However, in preterms with 23–25 weeks gestational age this process takes longer. Versatile regulatory mechanisms, namely skin surface acidity, calcium ion gradient and nuclear hormone receptors/ligands are interrelated in the complex postnatal newborn adaptation. The skin of newborns is adjusting quickly to the challenging environmental conditions of the postpartum. However, certain functions, for example, microcirculation, continue to develop even beyond the neonatal period, that is, up to the age of 14–17 weeks. Different environmental factors (for instance, dry and cold climate, diapers and cosmetic care procedures) influence the postnatal development of skin functional parameters such as stratum corneum hydration and the permeability barrier especially in premature infants. The aim of this article is to summarize the current knowledge on skin physiology in newborn and infants with a practical approach and to discuss the possible clinical consequences. This review offers the readership a critical and practical overview of skin physiology in newborns and infants. It emphasizes possible new research fields in neonatal and infantile skin physiology.     

Symptoms of immediate chlorhexidine hypersensitivity in patients with a positive prick test

There are numerous reports of anaphylaxis from chlorhexidine in surgical operations and other medical procedures, usually due to its application to wounds or mucous membranes. We wanted to analyse the clinical data of patients with a positive chlorhexidine prick test and perform some additional testing. We studied the case records of the patients with a positive chlorhexidine prick test and performed an open application test and tests for specific IgE. We found 33 patients with a positive prick test. 10 of them had had severe symptoms from chlorhexidine, and 11 had had only mild local symptoms. The size of the prick test reaction was mainly in line with the strength of the severest symptoms. Small 3- to 4-mm reactions were usually without obvious clinical relevance. Specific IgE could be demonstrated in 6 patients out of 14 tested by the ImmunoCAP method. Besides severe attacks, patients with a positive prick test often have milder local symptoms, such as exacerbation of dermatitis. Local symptoms from chlorhexidine-containing products may precede severe attacks. We recommend a prick test to be performed routinely when symptoms during medical interventional procedures, e.g. local and general anaesthesia, are investigated.