HPI: The patient had a ganglionectomy on her right wrist on April 4, 2013. When she was taken from the operating room she noticed a whitish rectangular indurated plaque on her right triceps. Over the next couple of days bullae appeared which eventually ruptured and become erosions. There was moderate pain. At no point was she febrile.
Surgical procedure: Ganglionectomy performed under regional block anesthesia. The hand was painted with ChloraPrep (
chlorhexidine gluconate (CHG) 2% w/v and isopropyl alcohol
(IPA) 70% v/v). The wrist was attached to a tower and the area of the erosion was in contact with an arm-rest. A tourniquet was employed but was not over the affected area. Tourniquet time was 44 minutes.
O/E: A 5 x 2 cm erosion with some purulent material was noted when the patient was seen on 4/11/13. The areas of purulence corresponded to the bullae. On the forearm there was a linear dark erythematous macule with no erosion.Clinical Pictures:
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| Cell phone photo taken by patient on day after surgery |
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| Taken at doctor's office on day 7 p surgery |
Diagnosis: Chenical burn (irritant contact dermatitis, ICD) secondary to Chloroprep. It is postulated that some of the prep dripped down the elevated hand to the affected area which then pressed against the arm rest for at least 45 minutes.
Discussion: This type of injury is not reported, but makes sense. A recent article in the Archives of Dermatology reports ICD in newborns exposed to chlorhexidine impregnated catheter dressing. We speculate that erosive ICD is more common that the paucity of reports, probably because the surgeons who opperated on these patients are loath to report these cases. Our patient was treated with Dome-Boro wet compresses and silver-sulfadiazione cream. Penicillin G 250 mg qid was prescribed when culture was reported.
Reference:
Chlorhexidine gluconate–impregnated central access catheterdressings as a cause of erosive contact dermatitis: a report of 7 cases. Weitz NA, et. al. JAMA Dermatol. 2013 Feb;149(2):195-9. CONCLUSIONS: Erosive contact dermatitis is an under-recognized complication of chlorhexidine gluconate-impregnated dressings. Health care providers should be aware of this risk, particularly in young children and immunosuppressed and/or critically ill patients, who may be more susceptible to the irritant effects of these dressings. When the dressings are used, patients should be monitored closely for skin breakdown.
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The last case of this I saw was similar: from inadvertent exposure to full-strength 4% chlorhexidine for the length of time of a surgery. Chlorhexidine was never intended to be used as a prep that stays on the skin, poured on liberally as surgeons frequently do with betadine solution or other preps, leading to the chance of pooling to most dependent skin. Chlorhexidine is a great disinfectant. It is the technique of application that needs to be performed with care, as with all disinfectants.
ReplyDeletefrom Shardul Poudyal: Very Interesting Case. Never seen it before. I have 2 questions though,
ReplyDelete1. If " The hand was painted with ChloraPrep" , why did it only develop on that part of forearm? If chlora-prep is irritant, should it not cause irritation to the entire arm/hand?
2. What about the regional block? Did they scrub that area with iodine/alcohol or was that area also scrubbed by chlora prep? If chlora prep was used, why did that area not develop this?
from Robert Shapiro: I would use mipirocin. I am not sure group B strep needs to be treated if it is colonized but not infected. It looks like it may scar.
ReplyDelete