key: cord-0950074-b5mpluwg
authors: Chan, Ming Yan Lydia; Cheng, Harriet; Oakley, Amanda M. M.
title: Sensitisation to antiseptics in Waikato, New Zealand, prior to the coronavirus disease 2019 pandemic
date: 2021-05-10
journal: Australas J Dermatol
DOI: 10.1111/ajd.13621
sha: 055cf26876d26ba74b6ebe160f30fd8105ff3a02
doc_id: 950074
cord_uid: b5mpluwg

nan

We retrospectively reviewed records between 1 January 2009 and 31 December 2019 at the Waikato Hospital Department of Dermatology to identify patients who had been patch tested to the baseline series (the European and a local baseline series) and the antiseptic series (see Table 3 ) and/or benzalkonium chloride.

Patch test readings were performed on day two and day four. Readings were graded as per international guidelines 2 : À denoting a negative reaction, +/À a doubtful reaction and positive reactions were defined as a + (palpable erythema), ++ (oedematous or vesicular) or +++ (bullous or ulcerative).

The clinician performing the day four read categorised positive reactions as of historical, unknown, possible or current relevance to the patient (where the allergen was causally linked to the presenting dermatosis).

Patient demographics, clinical data and patch testing results were extracted from the clinical record. It was anonymised and entered in a tailored REDCap database 3 hosted at the University of Auckland. Data analysis was performed with Microsoft Excel.

Ethics approval was obtained from the Northern B Health and Disability Ethics Committee.

Over this period, 483 patients underwent patch testing, of which 233 had been tested to the antiseptic series and/or benzalkonium chloride. Their baseline characteristics are summarised in Table 1 .

The median duration of symptoms prior to patch testing was 365 days (standard deviation 2207 days). Positive reactions were seen in 142 patients (60.9%) to one or more allergens overall. The most frequent of these are summarised in the Figures S1-S3.

At day four, 24 patients (10.3%) had a positive patch test result to one or more allergens in the antiseptic series ( Table 2) . Of the three patients with weak/irritant reactions to benzalkonium at day two, all became negative at day four. Five patients had allergic contact dermatitis to allergens in the antiseptic series; three reacted to Funding source: No external funding was obtained for this study. Conflict of interest: We declare we have no conflict of interest in this research. antiseptic allergens and two to formalin releasing preservatives (Table 3 ).

We have found no cases of contact sensitisation to benzalkonium chloride in our patch testing population and a low rate of relevant contact allergy to allergens in the antiseptic series (5/233, 2.1%). None were health-care workers, a key risk group for contact dermatitis to antiseptic allergens, especially benzalkonium 4 ; however, two of the five had sensitisation in health-care settings around wounds. In addition to the use of benzalkonium chloride and other quaternary ammonium disinfectants in COVID decontamination settings 5 , rising presentations of hyperkeratotic flexural erythema have been seen. This was attributed to benzalkonium chloride, used as a rinse aid in laundry and in antibacterial bath preparations. Patch testing of patients in published case series has not been reported. 6 Publications on contact dermatitis in the current pandemic era document symptoms of irritant dermatitis in health-care workers 7 and case reports of contact allergy to face mask components. 8 Whether there is any relationship between the use of environmental antiseptics and allergic contact dermatitis remains to be seen. To pre-empt this, the American Contact Dermatitis Society's guidelines on hand dermatitis in the COVID era highlight potential allergens (e.g. benzalkonium chloride impregnated dressings) to avoid and recommend hand washing before and after use of antiseptics with antiviral activity. 9 Our population had a high rate of patch test positivity (60.9%), with under-representation of M aori (12.0%) compared to the national (15.7%) and background Waikato Health Board population (22.8%). 10 This reflects the local public health system where limited access to dermatological (and by extension, patch testing) services results in more severe presentations; future research may identify whether these limitations have a particular ethnic bias.

Our study is limited by inter-observer variation: several dermatologists determined patch test results in the department over the study period. We used retrospective data from a single tertiary referral centre; this may not be representative of the rest of New Zealand. Some relevant records may be missing as there is no centralised database to store patch records.

In summary, we show an important low baseline rate of sensitisation to antiseptics which can be used as a comparator in years to come, especially as regular surface sanitisation becomes standard during the global pandemic. 

The following allergens in the antiseptic series had no positive results over the study period: p-chloro-m-cresol, 2-bromo-2-nitropropane-1,3-diol (bronopol), phenyl mercuric acetate, sorbic acid, 2,6-ditert-butyl-4-cresol (BHT), 2-tert-butyl-4-methoxyphenol (BHA), chloroacetamide, 2-phenylphenol, triclosan and sodium-2pyridinethiol-1-oxide. 

Additional Supporting Information may be found online in Supporting Information: Figure S1 . Graph showing the other 30 allergen series available in the department that the patients in the study were tested to and the frequencies of testing thereof. Figure S2 . Most frequent positive reactions were to nickel (53 patients), fragrance mix I (24), cobalt (21), with fragrance mix II, methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) and colophonium affecting 11 patients each. Figure S3 . The most frequent reactions of current relevance were to thiuram mix (12 patients), fragrance mix 1 (11), nickel (10), p-phenylenediamine (8), with MCI/MI, MI and cobalt affecting seven patients each.

Increased indoor exposure to commonly used disinfectants during the COVID-19 pandemic

Terminology of contact dermatitis

Research electronic data capture (REDCap) -A metadata-driven methodology and workflow process for providing translational research informatics support

Occupational dermatitis in health care workers evaluated for suspected allergic contact dermatitis

Appropriate use of disinfectants: Information for consumers, health professionals and healthcare facilities

Granular parakeratosis in an adult female secondary to exposure to benzalkonium chloride laundry rinse

Onset of occupational hand eczema among healthcare workers during the SARS-CoV-2 pandemic: comparing a single surgical site with a COVID-19 intensive care unit

Mask-induced contact dermatitis in handling COVID-19 outbreak

Hand hygiene during COVID-19: recommendations from the American Contact Dermatitis Society

Population of Waikato DHB. Ministry of Health

We thank Associate Professor Rosemary Nixon AM for her peer review of the study protocol. We thank Mr Graham Kean, Faculty of Medical and Health Sciences, University of Auckland, for his assistance in the development of the research database.

Ethics approval was obtained from the Northern B Health and Disability Ethics Committee, New Zealand.Ming Yan Lydia Chan 1 | Harriet Cheng 2,3 |