Contact allergy and allergic contact dermatitis from benzalkonium chloride in a tertiary dermatology center in Melbourne, Australia

Systemic contact dermatitis in a family: Case report

BACKGROUND

Systemic contact dermatitis (SCD) is an allergic inflammatory skin disease. We report that 3 family members developed SCD after exposing to laundry detergent containing benzalkonium chloride, which is rare. SCD caused by benzalkonium chloride has been reported. However, Similar symptoms in the whole family caused by it have not been reported yet. In our case, a 36-year-old man was diagnosed as SCD, and his symptoms had not controlled after 7 days treatment, until he stopped dressing the clothes washed by the laundry detergent containing benzalkonium chloride. It was interesting that both his wife and the daughter developed SCD successively, and they have not exposed to any haptens besides the benzalkonium chloride in the laundry detergent.

METHODS

Dermoscopic examination showed bright-red background, focal branching vessels and white scales. HE staining from the lesion revealed hyperkeratosis and parakeratosis, focal subcorneal microabscess, ocal hyperkeratosis, koilocyte in the epidermis, and erythrocyte extravasation, fibroplasia, hyaline degeneration and scattered aggregates of lymphocytes in the dermis. Then path test was performed 1 month after recovery with benzalkonium chloride 0.05% and 0.1% in petrolatum.

RESULTS

Stop the laundry detergent containing benzalkonium chloride. The symptoms had controlled after they stopped the laundry detergent containing benzalkonium chloride.

CONCLUSION

The case highlights that benzalkonium chloride with very low concentration and repeated exposure may be an active agent of SCD. It is of the utmost importance to pay close attention to patients presenting with similar symptoms within the family. A thorough examination of the medical history is essential to determine the underlying cause.

Is it time to re-evaluate exposure risks to quaternary ammonium compounds as disinfectants?

•The use of quaternary ammonium compounds (QACs) as disinfectants has increased exponentially due to the COVID-19 pandemic.•There is, thus, a corresponding increase in human exposure to these compounds.•New studies reveal important human health concerns.•A re-evaluation of the use of these compounds is in order.•A change over to newer and safer products may bode well for the future.

Risks of benzalkonium chlorides as emerging contaminants in the environment and possible control strategies from the perspective of ecopharmacovigilance

An unprecedented increase in the use of disinfection products triggered by the coronavirus disease 2019 (COVID-19) pandemic is resulting in aggravating environmental loads of disinfectants as emerging contaminants, which has been considered a cause for worldwide secondary disasters. This review analyzed the literature published in the last decade about occurrence, bioaccumulation, and possible environmental risks of benzalkonium chlorides (BKCs) as emerging contaminants. Results indicated that BKCs globally occurred in municipal wastewater, surface water, groundwater, reclaimed water, sludge, sediment, soil, roof runoff, and residential dust samples across 13 countries. The maximum residual levels of 30 mg/L and 421 μg/g were reported in water and solid environmental samples, respectively. Emerging evidences suggested possible bioaccumulation of BKCs in plants, even perhaps humans. Environmentally relevant concentrations of BKCs exert potential adverse impacts on aquatic and terrestrial species, including genotoxicity, respiratory toxicity, behavioural effects and neurotoxicity, endocrine disruption and reproductive impairment, phytotoxicity, etc. Given the intrinsic biocidal and preservative properties of disinfectants, the inductive effects of residual BKCs in environment in terms of resistance and imbalance of microorganisms have been paid special attention. Considering the similarities of disinfectants to pharmaceuticals, from the perspective of ecopharmacovigilance (EPV), a well-established strategy for pharmaceutical emerging contaminants, we use the control of BKC pollution as a case, and provide some recommendations for employing the EPV measures to manage environmental risks posed by disinfectant emerging contaminants.

Contact Dermatitis to Ophthalmic Solutions: An Update

Eyelid and periorbital dermatitis remains a distressing and recalcitrant disease. Contact dermatitis remains the most common cause of eyelid and periorbital dermatitis. Ophthalmic solutions used in the treatment of ophthalmic conditions can often be the cause. This article is an update of our previous study, summarizing the contact allergens involved and the new test concentrations reported to investigate through patch testing. New insights found during the review are also documented.

Contact dermatitis caused by prevention measures during the COVID-19 pandemic: a narrative review

Introduction

During the outbreak of Coronavirus disease 2019 (COVID-19), health care workers wore personal protective equipment including masks, gloves and goggles for a long time. In order to reduce the transmission routes of the virus, public places were sprayed with disinfectant. Moreover, the body, hands and clothing were frequently disinfected and washed for hygiene purposes. Studies have shown that these practices could easily irritate the skin and damage the skin barrier. Long-term irritation or exposure to allergens may lead to the occurrence of contact dermatitis (CD).

Methods

Subject headings were searched via the National Library of Medicine (PubMed) and web of science databases: COVID-19; contact dermatitis; adverse skin reaction; PPE; dermatitis; mask; glory; hand hygiene, disinfection; face shield; goggle; protect cloth. A total of 246 and 646 articles were retrieved from the two databases, respectively. 402 articles remained after removing duplicates. Reviews, non-English articles, articles that could not be accessed to read or did not conform to our topic were excluded. Finally, a total of 32 cross-sectional studies, 9 case reports and 2 randomized controlled trials were included.

Discussion

This article reviews reports of CD caused by various prevention and hygiene measures during the COVID-19 pandemic. The amount of skin damage caused by COVID-19 prevention measures could be decreased by improved education about skin management.

Quaternary Ammonium Compounds and Contact Dermatitis: A Review and Considerations During the COVID-19 Pandemic

The recent global pandemic has resulted in increased use of quaternary ammonium compounds (QACs). Currently, QACs are active ingredients in 292 disinfectants recommended by the US EPA for use against SARS-CoV-2. Among QACs, benzalkonium chloride (BAK), cetrimonium bromide (CTAB), cetrimonium chloride (CTAC), didecyldimethylammonium chloride (DDAC), cetrimide, quaternium-15, cetylpyridinium chloride (CPC), and benzethonium chloride (BEC) were all identified as potential culprits of skin sensitivity. Given their widespread utilization, additional research is needed to better classify their dermal effects and identify other cross-reactors. In this review, we aimed to expand our knowledge about these QACs to further dissect its potential allergic and irritant dermal effects on healthcare workers during COVID-19.

Occupational Hand Dermatitis

PURPOSE OF REVIEW

Occupational hand dermatitis is a common work-related disorder of the skin. Prevention and management of this disease is critical to improving workers' quality of life and for occupation-specific retention.

RECENT FINDINGS

This is a critical review of the current literature on occupational hand dermatitis. Occupational dermatitis continues to have a high prevalence among workers although the overall incidence may be slowly decreasing. Irritant contact dermatitis due to wet work exposure is the most common cause of occupational hand dermatitis. Healthcare workers, hairdressers, and metal workers are at particularly high risk for this disease. While some prevention programs have been ineffective in mitigating occupational hand dermatitis, other more resource-intensive initiatives may have benefit. Continued research is needed on ways to manage wet work exposures and on scalable, effective prevention programs for occupational hand dermatitis. The spectrum of culprit contact allergens continues to evolve, and vigilance for potential occupation-specific allergens remains important.

Quaternary ammonium compounds in hypersensitivity reactions

Quaternary ammonium compounds (QAC) are commonly used disinfectants, antiseptics, preservatives, and detergents due to their antibacterial property and represent the first used biocides before phenolic or nitrogen products. Their common structure consists of one or more quaternary ammonium bound with four lateral substituents. Their amphiphilic structure allows them to intercalate into microorganism surfaces which induces an unstable and porous membrane that explains their antimicrobial activity towards bacteria, fungi, and viruses. QAC are thus found in many areas, such as household products, medicines, hygiene products, cosmetics, agriculture, or industrial products but are also used in medical practice as disinfectants and antiseptics and in health care facilities where they are used for cleaning floors and walls. QAC exposure has already been involved in occupational asthma in healthcare workers or professional cleaners by many authors. They also have been suggested to play a role in contact dermatitis (CD) and urticaria in workers using cosmetics such as hairdressers or healthcare workers, inciting reglementary agencies to make recommendations regarding those products. However, distinguishing the irritant or sensitizing properties of chemicals is complex and as a result, the sensitizing property of QAC is still controverted. Moreover, the precise mechanisms underlying the possible sensitization effect are still under investigation, and to date, only a few studies have documented an immunological mechanism. Besides, QAC have been suggested to be responsible for neuromuscular blocking agents (NMBA) sensitization by cross-reactivity. This hypothesis is supported by a higher prevalence of quaternary ammonium (QA)-specific IgE in the professionally exposed populations, such as hairdressers, cleaners, or healthcare workers, suggesting that the sensitization happens with structurally similar compounds present in the environment. This review summarizes the newest knowledge about QAC and their role in hypersensitivities. After describing the different QAC, their structure and use, the most relevant studies about the effects of QAC on the immune system will be reviewed and discussed.