Salicylism from topical salicylates: review of the literature

Update on Chemical Peels

Chemical peeling is a procedure used for cosmetic improvement of the skin or treatment of some medical skin disorders, by the application of chemical exfoliant. In spite of a long history of clinical use of chemical peels, understanding of the science behind the procedure is still evolving. In this article, we review new concepts, understandings, and publications in the field of chemical peels.

GC-MS and SPME-GC/MS Analysis and Bioactive Potential Evaluation of Essential Oils from Two Viola Species Belonging to the V. calcarata Complex

Viola calcarata L. and Viola dubyana Burnat ex Gremli belong to the V. calcarata complex in Viola section Melanium (Violaceae family). For the first time, the essential oils (EOS) obtained by hydrodistillation from dried flowers, were analyzed by GC/MS and SPME-GC/MS to describe their volatile chemical profile. Differences in the qualitative and quantitative composition between the two violets have been found. A total of 43 compounds were identified among which methyl salicylate was the most abundant (from 45.5 to 68.0%) both in the vapor and liquid phase. The performed bioactivity tests pointed out the greater effect of V. dubyana EO compared to that obtained from V. calcarata. Nevertheless, both EOs proved to be good scavengers, especially toward the ABTS⋅+ radical. They also showed a dose-dependent phytotoxic action against Sinapis alba and Lolium multiflorum. Their seed germination was inhibited up to 100% and 25%, respectively, in response to the highest used dose (100 μL) of each EO. Furthermore, a significant decrease in root and shoot length was observed. The resulting seedling vigor index was reduced by 15–100% and 8–82% for S. alba and by 11–91% and 4–91% for L. multiflorum by V. dubyana and V. calcarata EOS, respectively.

Risk of toxicity from pediatric topical salicylate ingestions

INTRODUCTION

Suspected pediatric ingestions of greater than or equal to one teaspoon topical salicylate analgesic are recommended by poison control centers to be managed at healthcare facilities. This cutoff is applied for both liquid and non-liquid (cream, ointment, gel) formulations.

METHODS

California poison control cases involving topical salicylate exposures in children less than 6-years-old who were evaluated at a health care facility between 2003 and 2018 were analyzed.

RESULTS

Of 599 patient cases, the majority described no or minor symptoms, with gastrointestinal distress being the most common. Signs of salicylate toxicity (metabolic acidosis, tachypnea) occurred in six cases. Seven patients were hospitalized, six of whom were exposed to liquid preparations.

DISCUSSION

In line with previous research, liquid salicylate preparations were more frequently associated with the signs of salicylate toxicity and hospitalization.

CONCLUSION

There was a low frequency of severe side effects and low hospitalization rates among those referred to a healthcare facility, especially for non-liquid topical salicylate ingestions.

A multicompartment vascular implant of electrospun wintergreen oil/ polycaprolactone fibers coated with poly(ethylene oxide)

Background

The aim of the present study was to fabricate double layered scaffolds of electrospun polycaprolactone (PCL) and poly(ethylene oxide) (PEO). The electrospun PCL fibers were functionalized with wintergreen oil (WO) as a novel approach to prevent vascular grafts failure due to thrombosis by adjusting biomaterial–blood interactions.

Methods

PCL tubular scaffolds were prepared by electrospinning approach and coated with PEO as a hydrophilic polymer. The single and double layered scaffolds were characterized in terms of their morphological, chemical properties -as well as-hemocompatibility assays (i.e. prothrombin time, hemolysis percentage and platelets adhesion). Moreover, the antioxidant potential of WO-PCL samples were measured by 2,2-diphenyl-1-picrylhydrazyl hydrate (DPPH) free radical assay.

Results

The results demonstrated that incorporation of WO during the electrospinning process decreased the PCL fiber diameter. In addition, the prothrombine time assay shows that WO could be used to lower the electrospun PCL fiber tendency to induce blood clotting. Moreover, SEM observations of platelets adhesion of both single and double layered PCL/PEO scaffolds fiber shows an increase of platelets number, compared with the scaffolds containing WO.

Conclusions

The antioxidant potential and blood compatibility measurements of WO-PCL/PEO samples highlight the approach made so far as an ideal synthetic small size vascular grafts to overcome autogenous grafts shortages and drawbacks.

Modern Intermittent Haemodialysis (IHD) is an Effective Method of Removing Salicylate in Chronic Topical Salicylate Toxicity

INTRODUCTION

There are limited data on modern intermittent hemodialysis (IHD) efficacy on salicylate elimination from topical poisoning.

CASE REPORT

A 54-year-old male sought treatment for dyspnea but was then diagnosed with salicylate toxicity from topical application of Dencorub Extra Strength Heat Gel® for 1 week. Each tube contained 100 g with 26 % methylsalicylate (26 g). Laboratory workup was remarkable for an elevated anion gap of 30 and salicylate concentration of 78.7 mg/dL [5.7 mmol/L (N < 0.4 mmol/L)]. Treatment with urinary alkalinization was followed by hemodialysis for 5 h. Extraction ratios were 0.44 with clearance rates of 78.5 mL/min. Salicylate concentrations fell rapidly following initiation of hemodialysis with no rebound observed.

DISCUSSION

Modern high flux IHD is an effective method of removing salicylates in the treatment of chronic topical poisoning.

Management of Acute Soft Tissue Injuries

Participation in sports-related activities increases the risk for acute injury to soft tissues. In adults, the sites most often affected include the ankle, knee, and wrist joint structures, along with the muscles of the back and extremities. The subsequent inflammatory response to tissue damage results in pain and swelling, which limits mobility. A thorough patient assessment is required for accurate diagnosis and provides a guide for appropriate treatment. Initial management is based on the principles of basic first aid: rest, ice, compression, and elevation. Pharmacological therapy can also be used to achieve pain relief and improve mobility. There are few well-controlled studies addressing the pharmacotherapy of acute soft tissue injury, but clinical experience with nonsteroidal anti-inflammatory drugs is extensive. Both traditional and nontraditional therapeutic approaches are discussed.

Salicylate Toxicity from Genital Exposure to a Methylsalicylate-Containing Rubefacient

Methylsalicylate-containing rubefacients have been reported to cause salicylate poisoning after ingestion, topical application to abnormal skin, and inappropriate topical application to normal skin. Many over-the-counter products contain methylsalicylate. Topical salicylates rarely produce systemic toxicity when used appropriately; however, methylsaliclyate can be absorbed through intact skin. Scrotal skin can have up to 40-fold greater absorption compared to other dermal regions. We report a unique case of salicylate poisoning resulting from the use of a methylsalicylate-containing rubefacient to facilitate masturbation in a male teenager. Saliclyate toxicity has not previously been reported from the genital exposure to methylsaliclyate.

Adverse effects of acne medications: recognition and management

Acne vulgaris is a very common chronic inflammatory disease of the skin. The clinical features of acne range from non-inflammatory comedones to inflammatory nodules. While often perceived as an adolescent disease, the prevalence remains high into adulthood, and the manifestations can have detrimental psychosocial effects. It is therefore not surprising that many patients are motivated to seek treatment. The existing treatment strategies for acne are complex due to the multifactorial pathogenesis of the disease. Although it is difficult to cure, four categories of medications have proved efficacious in reducing acne lesions: topical agents, systemic antibiotics, systemic retinoids, and hormonal agents. Unfortunately, these medications can cause adverse effects that may limit their use. Typically, these adverse effects are mild and transient and can be remedied by altering the dose or frequency of the offending agent. However, more serious adverse effects can occur that pose a significant health risk to the patient. Understanding how to recognize and manage the adverse effects of common acne therapies is imperative to providing the safest and most appropriate treatment for each patient. This article focuses on the recognition and management of adverse effects associated with current acne medications.

Salicylate toxicity from ingestion of traditional massage oil

A 16-month-old child developed a brief generalised tonic-clonic fitting episode and vomiting at home, after accidental ingestion of traditional massage oil. As the patient presented with clinical features of salicylate toxicity, appropriate management was instituted. He was admitted to the intensive care unit for multiorgan support. The child was discharged well 1&emsp14;week after the incident. Methyl-salicylate is a common component of massage oils which are used for topical treatment of joint and muscular pains. However, these massage oils may be toxic when taken orally. Early recognition of the salicylate toxicity is very important in producing a good patient outcome.

The 2010 nephrology quiz and questionnaire: part 1

Presentation of the Nephrology Quiz and Questionnaire (NQQ) has become an annual "tradition" at the meetings of the American Society of Nephrology. It is a very popular session judged by consistently large attendance. Members of the audience test their knowledge and judgment on a series of case-oriented questions prepared and discussed by experts. They can also compare their answers in real time, using audience response devices, to those of program directors of nephrology training programs in the United States, acquired through an Internet-based questionnaire. As in the past, the topics covered were transplantation, fluid and electrolyte disorders, end-stage renal disease and dialysis, and glomerular disorders. Two challenging cases representing each of these categories along with single best answer questions were prepared by a panel of experts (Drs. Hricik, Palmer, Bargman, and Fervenza, respectively). The "correct" and "incorrect" answers then were briefly discussed, after the audience responses and the results of the questionnaire were displayed. The 2010 version of the NQQ was exceptionally challenging, and the audience, for the first time, gained a better overall correct answer score than the program directors, but the margin was small. In this issue we present the transplantation and fluid and electrolyte cases; the remaining end-stage renal disease and dialysis, and glomerular disorder cases will be presented next month. These articles try to recapitulate the session and reproduce its educational value for a larger audience--the readers of the Clinical Journal of the American Society of Nephrology. Have fun.

A Volunteer Study on the Blood Salicylate Level of Excessive Use of Topical Methylsalicylate

Objective

The purpose of this study was to evaluate the serum level of salicylate after topical application of methylsalicylate (analgesic balm), and to determine the safety of its use in our population.

Methods

This was a human volunteer study involving six volunteers. Each of them applied 10 grams of analgesic balm (containing 5 grams of methylsalicylate) on the limbs, and serial serum salicylate levels were measured just before the trial, and 1, 2, 4 and 8 hours after application. The time required to reach the maximum blood level after application was recorded.

Results

The serum salicylate level ranged from non-detectable level up to near therapeutic level in different subjects. The maximum salicylate level measured was 130 mg/L in one of the volunteers 8 hours after application. The calculated systemic bioavailability of dermal methylsalicylate in our study was 19-45%, which was comparable to previous studies.

Conclusions

Dermal application of massive amount of analgesic balm may cause unpredictable absorption of methylsalicylate. Patients and physicians should be aware of its potential risk.

Salicylate intoxication: a clinical review

Salicylates are widely used and are easily available as over-the-counter medications; thus, they can be readily abused. Although acute toxicity can be readily diagnosed if an ingestion history is provided, both acute and chronic salicylate toxicity often goes unrecognized, with high mortality when the patient is not treated properly. Salicylates should be considered in the differential diagnosis of an adult patient with acid-base abnormalities of uncertain cause, especially when there are concurrent neurologic symptoms. Patients with salicylate toxicity are treated with alkaline diuresis and sometimes dialysis. The prognosis depends on prompt recognition and treatment. Delayed diagnosis results in increased morbidity and mortality, particularly in the elderly.

Comparison of oral aspirin versus topical applied methyl salicylate for platelet inhibition

BACKGROUND

Oral acetylsalicylic acid (aspirin) is the primary antiplatelet therapy in the treatment of acute myocardial infarction and acute coronary syndrome. Methyl salicylate (MS; oil of wintergreen) is compounded into many over-the-counter antiinflammatory muscle preparations and has been shown to inhibit platelet aggregation locally and to be absorbed systemically.

OBJECTIVE

To assess the ability of topically applied MS to inhibit systemic platelet aggregation for patients who are unable to tolerate oral drug therapy.

METHODS

A randomized, prospective, blinded, crossover study was conducted in 9 healthy men, aged 30-46 years. All subjects ingested 162 mg of aspirin or applied 5 g of 30% MS preparation to their anterior thighs. There was a minimum 2-week washout period between study arms. Blood and urine were collected at baseline and at 6 hours. An aggregometer measured platelet aggregation over time against 5 standard concentrations of epinephrine, and a mean area under the curve (AUC) was calculated. Urinary metabolites of thromboxane B(2) were measured by a standard enzyme immunoassay. Differences in and between groups at baseline and 6 hours were tested by the Wilcoxon signed-rank test.

RESULTS

Baseline platelet aggregation did not differ significantly between the 2 arms of the study (median AUC [% aggregation(*)min]; binominal confidence intervals): aspirin 183; 139 to 292 versus MS 197; 118 to 445 (p = 0.51). Both aspirin and MS produced statistically significant platelet inhibition; aspirin decreased the AUC from 183; 139 to 292 to 85; 48 to 128 (p = 0.008) and MS decreased the AUC from 197; 118 to 445 to 112; 88 to 306 (p = 0.011). No significant difference was detected between baseline and 6-hour thromboxane levels for either aspirin (p = 0.779) or MS (p = 0.327).

CONCLUSIONS

Topical MS and oral aspirin both significantly decrease platelet aggregation in healthy human volunteers.

Salicylate poisoning: an evidence-based consensus guideline for out-of-hospital management

A review of U.S. poison center data for 2004 showed over 40,000 exposures to salicylate-containing products. A guideline that determines the conditions for emergency department referral and pre-hospital care could potentially optimize patient outcome, avoid unnecessary emergency department visits, reduce health care costs, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create the guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the lead author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial out-of-hospital management of patients with a suspected exposure to salicylates by 1) describing the process by which a specialist in poison information should evaluate an exposure to salicylates, 2) identifying the key decision elements in managing cases of salicylate exposure, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. This guideline does not substitute for clinical judgment. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses: 1) Patients with stated or suspected self-harm or who are the victims of a potentially malicious administration of a salicylate, should be referred to an emergency department immediately. This referral should be guided by local poison center procedures. In general, this should occur regardless of the dose reported (Grade D). 2) The presence of typical symptoms of salicylate toxicity such as hematemesis, tachypnea, hyperpnea, dyspnea, tinnitus, deafness, lethargy, seizures, unexplained lethargy, or confusion warrants referral to an emergency department for evaluation (Grade C). 3) Patients who exhibit typical symptoms of salicylate toxicity or nonspecific symptoms such as unexplained lethargy, confusion, or dyspnea, which could indicate the development of chronic salicylate toxicity, should be referred to an emergency department (Grade C). 4) Patients without evidence of self-harm should have further evaluation, including determination of the dose, time of ingestion, presence of symptoms, history of other medical conditions, and the presence of co-ingestants. The acute ingestion of more than 150 mg/kg or 6.5 g of aspirin equivalent, whichever is less, warrants referral to an emergency department. Ingestion of greater than a lick or taste of oil of wintergreen (98% methyl salicylate) by children under 6 years of age and more than 4 mL of oil of wintergreen by patients 6 years of age and older could cause systemic salicylate toxicity and warrants referral to an emergency department (Grade C). 5) Do not induce emesis for ingestions of salicylates (Grade D). 6) Consider the out-of-hospital administration of activated charcoal for acute ingestions of a toxic dose if it is immediately available, no contraindications are present, the patient is not vomiting, and local guidelines for its out-of-hospital use are observed. However, do not delay transportation in order to administer activated charcoal (Grade D). 7) Women in the last trimester of pregnancy who ingest below the dose for emergency department referral and do not have other referral conditions should be directed to their primary care physician, obstetrician, or a non-emergent health care facility for evaluation of maternal and fetal risk. Routine referral to an emergency department for immediate care is not required (Grade C). 8) For asymptomatic patients with dermal exposures to methyl salicylate or salicylic acid, the skin should be thoroughly washed with soap and water and the patient can be observed at home for development of symptoms (Grade C). 9) For patients with an ocular exposure of methyl salicylate or salicylic acid, the eye(s) should be irrigated with room-temperature tap water for 15 minutes. If after irrigation the patient is having pain, decreased visual acuity, or persistent irritation, referral for an ophthalmological examination is indicated (Grade D). 10) Poison centers should monitor the onset of symptoms whenever possible by conducting follow-up calls at periodic intervals for approximately 12 hours after ingestion of non-enteric-coated salicylate products, and for approximately 24 hours after the ingestion of enteric-coated aspirin (Grade C).

Are one or two dangerous? Methyl salicylate exposure in toddlers

Serious toxicity can result from exposure to small amounts of methyl salicylate. Methyl salicylate is widely available as a component in many over-the-counter brands of creams, ointments, lotions, liniments and medicated oils intended for topical application to relieve musculoskeletal aches and pains. Among the most potent forms of methyl salicylate is oil of wintergreen (98% methyl salicylate). Other products with varying concentrations of methyl salicylate are ubiquitous throughout many parts of the world, including a number of products marketed as Asian herbal remedies. The toxic potential of all of these formulations is often underestimated by health care providers and the general public. A comprehensive review of the existing medical literature on methyl salicylate poisoning was performed, and data compiled over the past two decades by the American Association of Poison Control Centers (AAPCC) was examined. Methyl salicylate continues to be a relatively common source of pediatric exposures. Persistent reports of life-threatening and fatal toxicity were found. In children less than 6 years of age, a teaspoon (5 mL) or less of oil of wintergreen has been implicated in several well-documented deaths. More needs to be done to educate both health care providers and the general public regarding the dangers of these widely available formulations.

Astonishing diversity of natural surfactants: 5. Biologically active glycosides of aromatic metabolites

This review article presents 342 aromatic glycosides, isolated from and identified in plants and microorganisms, that demonstrate different biological activities. They are of great interest, especially for the medicinal and/or pharmaceutical industries. These biologically active natural surfactants are good prospects for the future chemical preparation of compounds useful as antioxidant, anticancer, antimicrobial, and antibacterial agents. These glycosidic compounds have been classified into several groups, including simple aromatic compounds, stilbenes, phenylethanoids, phenylpropanoids, naphthalene derivatives, and anthracene derivatives.

Acute methyl salicylate toxicity complicating herbal skin treatment for psoriasis

We present an interesting case of salicylism arising from the use of methyl salicylate as part of a herbal skin cream for the treatment of psoriasis. A 40-year-old man became quite suddenly and acutely unwell after receiving treatment from an unregistered naturopath. Methyl salicylate (Oil of Wintergreen) is widely available in many over the counter topical analgesic preparations and Chinese medicated oils. Transcutaneous absorption of the methyl salicylate was enhanced in this case due to the abnormal areas of skin and use of an occlusive dressing. The presence of tinnitus, vomiting, tachypnoea and typical acid/base disturbance allowed a diagnosis of salicylate toxicity to be made. Our patient had decontaminated his skin prior to presentation, limiting the extent of toxicity and was successfully treated with rehydration and establishment of good urine flow.

An evidence based flowchart to guide the management of acute salicylate (aspirin) overdose

OBJECTIVE

To develop a flowchart to be used as a tool to guide clinicians step by step through the management of salicylate poisoning.

METHODS

A comprehensive literature search was carried out.

RESULTS

The evidence base was used to develop a management flowchart that guides the clinician through the three main steps in caring for the patient with salicylate poisoning: preventing further absorption, assessing the severity of poisoning and, where appropriate, increasing elimination.

CONCLUSIONS

Salicylate poisoning can result in severe morbidity and mortality and this flowchart provides an evidence based guideline that will guide clinicians through the management of patients presenting to the emergency department with salicylate poisoning.

Salicylate toxicity masquerading as malignant hyperthermia

We report a case of hyperpyrexia presumed due to topical salicylate toxicity occurring immediately following general anaesthesia for appendicectomy in an eleven year old boy. Some of the features strongly suggested the diagnosis of malignant hyperpyrexia.