ABSTRACT
Chlorhexidine is a commonly used disinfectant throughout Australian hospitals. It is responsible for a number of iatrogenic complications. We describe a case of 27-yearold female who sustained a severe, blistering reaction at the site of chlorhexidine application, associated with significant pain. This reaction was initially managed with wet dressings and topical corticosteroids, but there was no improvement in pain or rash. Management was then changed to silver-coated polyethylene mesh dressings, with resolution of pain and rash after four days. No debridement was required, and area healed without scarring. Chlorhexidine is associated with a number of hypersensitivity reactions, ranging from anaphylaxis to irritant and allergic contact dermatitis. However, physical or chemical burns remain an underrecognised complication of chlorhexidine use. Intra-operatively, there is a risk of physical burn secondary to pooled chlorhexidine catching alight after cautery is applied, and this has been described in ten cases in the literature. Chemical burns from exposure to chlorhexidine can occur in neonatal patients, and in adult patients where a tourniquet has been used. It can be difficult to differentiate between chlorhexidine hypersentivity and burns clinically. When evaluating these patients, a differential diagnosis of burns should be considered, particularly if patients are not responsive to first line therapies. Surgeons and anaesthetists should consider the risk of burns when in theatres, and prevent any pooling of chlorhexidine - particularly when cautery is being used. Using chlorhexidine without alcohol, and allowing at least three minutes for the solution to dry can further reduce the risk of surgical fires.
ABSTRACT
BACKGROUND: Cyclosporine is a useful immunosuppressive agent for achieving disease control in moderate to severe atopic dermatitis in children and adults. However, it carries the potential for nephrotoxicity. Monitoring of drug levels is performed in other patient groups, such as transplant recipients, but is not commonplace in the management of atopic dermatitis. OBJECTIVES: To investigate levels of nephrotoxicity associated with cyclosporine use in atopic dermatitis and assess potential correlation with trough levels of cyclosporine. METHODS: An electronic search was conducted on MEDLINE, EMBASE, and Cochrane databases for randomized controlled trials and cohort studies assessing the safety profile of cyclosporine compared to placebo or other atopic dermatitis treatments, in adult and pediatric atopic dermatitis patients from 1966 to May 2019. Studies that did not assess renal toxicity were excluded from analysis. RESULTS: Thirty-eight trials were included for analysis, excluding 11 that did not assess renal toxicity. Descriptive statistical analysis only was performed, due to the high heterogeneity between study methodologies. Significant renal toxicity was seen in 0%-9% of pediatric participants. Monitoring of trough cyclosporine levels was performed in only 10 of the studies, and their correlation to toxicity or disease activity was not explored. CONCLUSION: There is limited evidence in atopic dermatitis regarding trough level monitoring of cyclosporine. Currently, the practice is not commonplace, particularly in pediatrics, and this is reflected in trial methodology. Monitoring may be useful in specific pediatric groups, such as those on multiple concurrent medications, patients with hepatic or renal dysfunction and non-responders to therapy.
