Skin necrosis due to cetrimide application in a neonate
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《美国医学杂志》
Department of Pediatrics, Pt. B.D.S PGIMS Rohtak, India
Cetrimide is a quaternary ammonium antiseptic. Very dilute solutions of concentrations up to 1% are used for topical application. Reports of skin necrosis caused by cetrimide in children are rare. We report a three day neonate who developed skin necrosis on topical application of cetrimide powder.
A three-day-old, full term 2.5 Kg. male baby born at home to a primigravida mother was brought to the pediatric casualty services of PGIMS, Rohtak with complaints of decreased acceptance, increased crying and blackening of skin in the inguinoscrotal and axillary regions for the last four hours. There was history of pustular lesions in the inguinoscrotal and axillary regions. As advised by local dai, parents had applied 100% concentrated cetrimide powder on the affected area which initially led to froth formation and was followed by redness of the area. Baby started crying incessantly on application of the cetrimide powder and developed decreased acceptance of feeds. Two hours later blackening of the area of application of cetrimide powder was observed. On physical examination child was irritable and had an ill-sustained suck. The areas of cetrimide application - axillary & inguinoscrotal areas revealed black necrosis of the skin with associated redness Figure1. Rest of the examination was unremarkable. On investigation the initial CRP was negative but when repeated 24 hours later it was positive. The absolute neutrophil count was normal and blood culture was reported sterile. The blood sugar, blood urea and serum electrolytes were within normal limits. On USG of inguinoscrotal region bilateral testes appeared normal with gross thickening and edema of the scrotal sac and there were bilateral multiple enlarged inguinal lymph nodes. Daily dressing with sofratulle was done on the affected areas and injectable augmentin and amikacin were given for seven days. The baby made uneventful recovery and the skin lesions had healed completely by day seven.
Cetrimide (Alkyl trimethylammonium bromide) , a halogenated quaternary ammonium compound is an antiseptic with detergent properties that has a wide spectrum of activity against bacteria and fungi. Concentrations exceeding 1% may be irritant to skin. Concentrated solutions of quaternary ammonium compounds are corrosive and can cause burns to skin and mucous membrane which is due to caustic nature of these compounds.[1] Adverse reactions after topical use have been reported earlier.[2],[3] Mercer reported a three-month- old baby who sustained burns in the nappy area due to application of 17% cetrimide solution.[4] Daily dressings with neat, pure cetrimide powder for secondary infection in a seventy-seven year old woman with eczema resulted in cutaneous necrosis.[5] In the index case a single application of pure cetrimide powder (100%) for pustules resulted in skin necrosis of the areas. This was due to the local irritant necrotic effect of cetrimide. No systemic side effects or toxicity was observed. This is because dermal absorption has been documented to be very low.
To the best of our knowledge, skin necrosis of this nature by cetrimide has not been reported in a neonate. Cetrimide is available over the counter at any chemist shop in powder form. Its toxic effects need to be appreciated. Also emphatic warning about application using the appropriate concentration must be made on the product.
References
1. Arena JM, Durham NC. Poisonings and other heath hazards with use of detergents. JAMA 1964; 190 : 168-170.
2. Haider Z. An adverse reaction to a topical antiseptic (Cetrimide) British Journal of Oral Surgery 1977; 5 : 86.
3. Sharpvill D. Reaction to Chlorhexidine and cetrimide. Lancet 1965; 1 : 771.
4. Mercer DM. Cetrimide burn in an infant. Post Graduate Medical Journal 1983; 59 : 472-473.
5. August PJ. Cutaneous necrosis due to cetrimide application. British Medical Journal 1975; 1 : 70.(Gathwala Geeta, Agarwal N)
Cetrimide is a quaternary ammonium antiseptic. Very dilute solutions of concentrations up to 1% are used for topical application. Reports of skin necrosis caused by cetrimide in children are rare. We report a three day neonate who developed skin necrosis on topical application of cetrimide powder.
A three-day-old, full term 2.5 Kg. male baby born at home to a primigravida mother was brought to the pediatric casualty services of PGIMS, Rohtak with complaints of decreased acceptance, increased crying and blackening of skin in the inguinoscrotal and axillary regions for the last four hours. There was history of pustular lesions in the inguinoscrotal and axillary regions. As advised by local dai, parents had applied 100% concentrated cetrimide powder on the affected area which initially led to froth formation and was followed by redness of the area. Baby started crying incessantly on application of the cetrimide powder and developed decreased acceptance of feeds. Two hours later blackening of the area of application of cetrimide powder was observed. On physical examination child was irritable and had an ill-sustained suck. The areas of cetrimide application - axillary & inguinoscrotal areas revealed black necrosis of the skin with associated redness Figure1. Rest of the examination was unremarkable. On investigation the initial CRP was negative but when repeated 24 hours later it was positive. The absolute neutrophil count was normal and blood culture was reported sterile. The blood sugar, blood urea and serum electrolytes were within normal limits. On USG of inguinoscrotal region bilateral testes appeared normal with gross thickening and edema of the scrotal sac and there were bilateral multiple enlarged inguinal lymph nodes. Daily dressing with sofratulle was done on the affected areas and injectable augmentin and amikacin were given for seven days. The baby made uneventful recovery and the skin lesions had healed completely by day seven.
Cetrimide (Alkyl trimethylammonium bromide) , a halogenated quaternary ammonium compound is an antiseptic with detergent properties that has a wide spectrum of activity against bacteria and fungi. Concentrations exceeding 1% may be irritant to skin. Concentrated solutions of quaternary ammonium compounds are corrosive and can cause burns to skin and mucous membrane which is due to caustic nature of these compounds.[1] Adverse reactions after topical use have been reported earlier.[2],[3] Mercer reported a three-month- old baby who sustained burns in the nappy area due to application of 17% cetrimide solution.[4] Daily dressings with neat, pure cetrimide powder for secondary infection in a seventy-seven year old woman with eczema resulted in cutaneous necrosis.[5] In the index case a single application of pure cetrimide powder (100%) for pustules resulted in skin necrosis of the areas. This was due to the local irritant necrotic effect of cetrimide. No systemic side effects or toxicity was observed. This is because dermal absorption has been documented to be very low.
To the best of our knowledge, skin necrosis of this nature by cetrimide has not been reported in a neonate. Cetrimide is available over the counter at any chemist shop in powder form. Its toxic effects need to be appreciated. Also emphatic warning about application using the appropriate concentration must be made on the product.
References
1. Arena JM, Durham NC. Poisonings and other heath hazards with use of detergents. JAMA 1964; 190 : 168-170.
2. Haider Z. An adverse reaction to a topical antiseptic (Cetrimide) British Journal of Oral Surgery 1977; 5 : 86.
3. Sharpvill D. Reaction to Chlorhexidine and cetrimide. Lancet 1965; 1 : 771.
4. Mercer DM. Cetrimide burn in an infant. Post Graduate Medical Journal 1983; 59 : 472-473.
5. August PJ. Cutaneous necrosis due to cetrimide application. British Medical Journal 1975; 1 : 70.(Gathwala Geeta, Agarwal N)