| |
|
|
| Year : 2009 | Volume
: 20
| Issue : 3 | Page : 377-379 |
|
| Chlorhexidine urticaria: A rare occurrence with a common mouthwash |
|
|
Anamika Sharma, Harneet Chopra
Department of Periodontics, Subharti Dental College, Meerut (U.P), India
Click here for correspondence address and email
| Date of Submission | 19-Jul-2008 |
| Date of Decision | 17-Dec-2008 |
| Date of Acceptance | 01-Apr-2009 |
| Date of Web Publication | 30-Oct-2009 |
|
|
 |
|
 Abstract | | |
Chlorhexidine is a widely used antiseptic and disinfectant in medical and nonmedical environments. Compared to its ubiquitous use, allergic contact dermatitis from chlorhexidine has rarely been reported and so its sensitization rate seems to be low. The prevalence of contact urticaria and anaphylaxis due to chlorhexidine remains to be unknown. This case report presents a case of urticaria due to oral use of chlorhexidine. The adverse reaction was confirmed by skin prick test. Keywords: Allergic contact dermatitis, chlorhexidine, delayed hypersensitivity, urticaria
How to cite this article:
Sharma A, Chopra H. Chlorhexidine urticaria: A rare occurrence with a common mouthwash. Indian J Dent Res 2009;20:377-9 |
How to cite this URL:
Sharma A, Chopra H. Chlorhexidine urticaria: A rare occurrence with a common mouthwash. Indian J Dent Res [serial online] 2009 [cited 2020 Jan 23];20:377-9. Available from: http://www.ijdr.in/text.asp?2009/20/3/377/57368 |
Chlorhexidine gluconate is a cationic bis-biguanide, with a very broad antimicrobial spectrum. Chlorhexidine's antimicrobial effects are associated with the attractions between chlorhexidine (cation) and negatively charged bacterial cells. After chlorhexidine is absorbed onto the organism's cell wall, it disrupts the integrity of the cell membrane and causes the leakage of intracellular components of the organisms. The first report of its antiplaque activity was by Loe and Schiott. [1]
The major advantage of chlorhexidine over most of the other compounds lies in its substantivity. It binds to hard and soft tissues in the mouth enabling it to act over a long period after use. Bacterial counts in saliva consistently drop to between 10 and 20% of baseline after single rinses and remain at this level for at least 7 h [2] and probably more than 12 h. [3]
This paper presents a case report of immediate hypersensitivity reaction to chlorhexidine due to oral rinsing (topical application) of chlorhexidine gluconate mouthwash (Rexidin mouthwash).
| Case Report | |  |
A 19-year-old female patient with the chief complaint of bleeding from the gums reported to the Department of Periodontics at Subharti Dental College, Meerut. After thorough oral examination, she was advised oral prophylaxis and was prescribed chlorhexidine mouth rinse (Rexidin), twice daily for a period of three weeks. Next day, patient presented with urticaria on her forehead and face, the front of the elbow and forearms, side and upper back region of the neck and on the lower abdomen. No oral changes were observed.
On questioning, the patient reported using chlorhexidine mouthwash (Rexidin) formulation in a 1:1 concentration and rinsed with it for at least 1 min. On rinsing with it for the first time she noticed reddening on her forehead, face and side of the neck (after about 12 h of using it) [Figure 1] and [Figure 2]. On waking up the next morning, she felt some burning sensation on the red spots, which she had noticed the previous night. Upon using the formulation again, after a couple of hours she observed marked redness on her upper back [Figure 3] neck region, lower abdomen, and on the front of the elbow and forearms [Figure 4]. This was accompanied with irritation. History of any previous such allergic reactions were also recorded.
To confirm the allergic reaction to chlorhexidine, skin prick test was performed in the following was:
- The inner forearm of the patient was cleaned with soap and water and was coded with a skin marker pen. A drop of allergen (chlorhexidine) was then placed besides the mark.
- A small prick through the drop was made to the skin using a sterile prick lancet.
- The excess allergen solution was dabbed off with a tissue.
A reaction was seen within 30 min of performing the test. The skin under the drop of the chlorhexidine solution had become red and itchy and this was surrounded by a white raised wheal.
| Discussion | | |
The result of the skin prick test confirmed that the urticaria with which the patient reported was caused by the topical use of the chlorhexidine mouthwash in a 1:1 concentration. Though rare chlorhexidine can cause immediate hypersensitivity, sometimes taking the form of acute urticaria that may result in anaphylactic shock which is even rarer. [4],[5]
Urticaria was suspected to be caused by the mouthwash, and a skin test was conducted. Intradermal test was positive with the mouthwash and its component chlorhexidine gluconate. Scratch test showed positive result with chlorhexidine gluconate and chlorhexidine hydrochloride.
The various tests which can be used to confirm the allergic reactions to chlorhexidine are as follows:
- Prick tests.
- Intradermal reactions.
- Sulfidoleukotriene stimulation test (CAST: Cellular antigen stimulation test).
- Patch test.
Similar reactions [6],[7] have also been reported after the use of chlorhexidine as a spray or as pre and postoperative antiseptic solutions. Goon et al. [8] reported five cases of allergic contact dermatitis from chlorhexidine, out of which three had positive patch test reactions to chlorhexidine.
A literature review of 66 case reports was done by Heinemann et al. [9] Twenty reactions occurred when chlorhexidine was applied to damaged skin surfaces and 27 patients showed an immediate type reaction when chlorhexidine was applied to mucous membranes. Similarly, two cases of mucosal sensitivity to contact with chlorhexidine were reported by Yusof and Khoo. [10]
Kenrad [11] also reported major changes in the oral mucosa after an overdose of mouth rinsing with chlorhexidine gluconate, which included a thickening of the mucosa resembling leukoplakia but disappeared when the dose was reduced.
In a case report similar to the present one, anaphylaxis due to topical skin application of chlorhexidine was reported. This was confirmed by skin testing and CAST. Thus, the application of chlorhexidine especially to mucous membranes was discouraged as it could cause anaphylaxis. [12]
Hypersensitivity and other adverse reactions to chlorhexidine are rare, but its potential to cause anaphylactic shock is probably underestimated.
| Conclusion | | |
Chlorhexidine is the most effective and widely used antiplaque agent to date. Nevertheless, the present case report would remind the clinicians of an important potential risk of this widely used antiseptic and make them cautious before prescribing any chlorhexidine formulation as it may lead to local symptoms or even severe attacks.
| References | | |
| 1. | Loe H, Schiott CR. The effect of mouthrinses and topical application of chlorhexidine on the development of dental plaque and gingivitis in man. J Periodontol Res 1970;5:79-83.  |
| 2. | Addy M, Wright R. Comparison of the in vivo and in vitro antibacterial properties of povidone iodine and chlorhexidine gluconate mouthrinses. J Clin Periodontol 1978;5:198-205. [PUBMED] [FULLTEXT] |
| 3. | Schiott CR, Loe H, Jensen SB, Killian M, Davies RM, Glavind K. The effect of chlorhexidine mouthrinses on the human oral flora. J Periodont Res 1970;5:84-9. |
| 4. | Flotra L, Gijermo P, Rolla G, Waerhaug J. Side effects of chlorhexidine mouthwashes. Scand J Dent Res 1971;79:119-25. |
| 5. | Beaudouin E, Kanny G, Morisset M, Renaudin JM, Mertes M, Laxenaire MC, et al. Immediate Hypersensitivity to Chlorhexidine: Literature review. Eur Ann Allergy Clin Immunol 2004;36:123-6. [PUBMED] |
| 6. | Okano M, Nomura M, Hata S, Okada N, Sato K, Kitano Y, et al. Anaphylactic symptoms due to Chlorhexidine gluconate. Arch Dermatol 1989;125:50-2. [PUBMED] [FULLTEXT] |
| 7. | Yoneyama K, Hatamochi A, Murata K, Shinkai H. A case of urticaria due to the gurgle containing chlorhexidine gluconate. Japanese Journal of Clinical Dermatology 2002;56:106-8. |
| 8. | Goon AT, White IR, Rycroft RJ, McFadden JP. Allergic contact dermatitis from chlorhexidine. Dermatitis 2004;15:45-7. [PUBMED] [FULLTEXT] |
| 9. | Heinemann C, Sinaiko R, Maibach HI. Immunological contact urticaria and anaphylaxis to chlorhexidine: Overview. Exogenous Dermatology 2002;1:186-94. |
| 10. | Yusof WZ, Khoo SP. Mucosal sensitivity to chlorhexidine mouthwashes. Singapore Dent J 1988;13:39-40. [PUBMED] |
| 11. | Kenrad B. Toxic effects from chlorhexidine gluconate. Case report. Tandlaegebladet 1990;94:489-91. |
| 12. | Krautheim AB, Jermann TH, Bircher AJ. Chlorhexidine anaphylaxis: Case report and review of the literature. Contact Dermatitis 2004;50:113-6. [PUBMED] [FULLTEXT] |
Correspondence Address:
Harneet Chopra
Department of Periodontics, Subharti Dental College, Meerut (U.P)
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-9290.57368
[Figure 1], [Figure 2], [Figure 3], [Figure 4] |
|
| This article has been cited by | | 1 |
Fixed Drug Eruption Due to Chlorhexidine Mouthwash Confirmed by Lesional Patch Testing |
|
| Timothy J. Watts,David Thursfield,Rubaiyat Haque | | The Journal of Allergy and Clinical Immunology: In Practice. 2019; 7(2): 651 | | [Pubmed] | [DOI] | | | 2 |
The rash that presents as a red swollen face |
|
| Mariana Batista,Margarida Gonçalo | | Clinics in Dermatology. 2019; | | [Pubmed] | [DOI] | | | 3 |
Fixed Drug Eruption Due to Chlorhexidine Mouthwash Confirmed by Lesional Patch Testing |
|
| Timothy J. Watts,David Thursfield,Rubaiyat Haque | | The Journal of Allergy and Clinical Immunology: In Practice. 2019; 7(2): 651 | | [Pubmed] | [DOI] | | | 4 |
Immediate hypersensitivity to chlorhexidine |
|
| Mi Vu,Harini Rajgopal Bala,Jennifer Cahill,Ryan Toholka,Rosemary Nixon | | Australasian Journal of Dermatology. 2018; 59(1): 55 | | [Pubmed] | [DOI] | | | 5 |
Immediate hypersensitivity to chlorhexidine |
|
| Mi Vu,Harini Rajgopal Bala,Jennifer Cahill,Ryan Toholka,Rosemary Nixon | | Australasian Journal of Dermatology. 2018; 59(1): 55 | | [Pubmed] | [DOI] | | | 6 |
Cosmetic components causing contact urticaria: a review and update |
|
| Lien Verhulst,An Goossens | | Contact Dermatitis. 2016; 75(6): 333 | | [Pubmed] | [DOI] | | | 7 |
Allergy to chlorhexidine |
|
| Michael N Pemberton | | Dental Update. 2016; 43(3): 272 | | [Pubmed] | [DOI] | | | 8 |
Allergy to chlorhexidine |
|
| Michael N Pemberton | | Dental Update. 2016; 43(3): 272 | | [Pubmed] | [DOI] | | | 9 |
Cosmetic components causing contact urticaria: a review and update |
|
| Lien Verhulst,An Goossens | | Contact Dermatitis. 2016; 75(6): 333 | | [Pubmed] | [DOI] | | | 10 |
Acute allergic reaction after intravenous saline injection: an unusual presentation of chlorhexidine allergy |
|
| Usman Mushtaq,Aaron Tan,Ju Ann Tan,William B Smith | | Medical Journal of Australia. 2014; 200(10): 599 | | [Pubmed] | [DOI] | | | 11 |
Acute allergic reaction after intravenous saline injection: an unusual presentation of chlorhexidine allergy |
|
| Usman Mushtaq,Aaron Tan,Ju Ann Tan,William B Smith | | Medical Journal of Australia. 2014; 200(10): 599 | | [Pubmed] | [DOI] | | | 12 |
Chlorhexidine |
|
| Dianne L. Silvestri,Melissa McEnery-Stonelake | | Dermatitis. 2013; 24(3): 112 | | [Pubmed] | [DOI] | | | 13 |
Chlorhexidine and hypersensitivity reactions in dentistry |
|
| M. N. Pemberton,J. Gibson | | BDJ. 2012; 213(11): 547 | | [Pubmed] | [DOI] | | | 14 |
Local interventions for the management of alveolar osteitis (dry socket) |
|
| Blánaid Daly,Mohammad O Sharif,Tim Newton,Kate Jones,Helen V Worthington | | Cochrane Database of Systematic Reviews. 2012; | | [Pubmed] | [DOI] | | | 15 |
Local interventions for the management of alveolar osteitis (dry socket) |
|
| Blánaid Daly,Mohammad O Sharif,Tim Newton,Kate Jones,Helen V Worthington | | Cochrane Database of Systematic Reviews. 2012; | | [Pubmed] | [DOI] | | | 16 |
Chlorhexidine and hypersensitivity reactions in dentistry |
|
| Pemberton, M.N. and Gibson, J. | | British Dental Journal. 2012; 213(11): 547-550 | | [Pubmed] | | | 17 |
Chlorhexidine allergy due to topical application |
|
| Keni, N.N. and Aras, M.A. and Chitre, V. | | Indian Journal of Dental Research. 2012; 23(5): 674-676 | | [Pubmed] | | | 18 |
Mastocytosis: Oral implications of a rare disease |
|
| Rama, T.A. and Côrte-Real, I. and Gomes, P.S. and Escribano, L. and Fernandes, M.H. | | Journal of Oral Pathology and Medicine. 2011; 40(6): 441-450 | | [Pubmed] | | | 19 |
Skin cleansers: The risks of chlorhexidine |
|
| Sivathasan, N., Goodfellow, P.B. | | Journal of Clinical Pharmacology. 2011; 51(5): 785-786 | | [Pubmed] | | | 20 |
Quantitative analysis of skeletal symmetric chlorhexidine in rat plasma using doubly charged molecular ions in LC-MS/MS detection |
|
| Pan, J., Fair, S.J., Mao, D. | | Bioanalysis. 2011; 3(12): 1357-1368 | | [Pubmed] | | | 21 |
Skin Cleansers: The Risks of Chlorhexidine |
|
| Niroshan Sivathasan,Peter Bryan Goodfellow | | The Journal of Clinical Pharmacology. 2011; 51(5): 785 | | [Pubmed] | [DOI] | | | 22 |
Quantitative analysis of skeletal symmetric chlorhexidine in rat plasma using doubly charged molecular ions in LC–MS/MS detection |
|
| Jiongwei Pan,Sarah J Fair,Dunmin Mao | | Bioanalysis. 2011; 3(12): 1357 | | [Pubmed] | [DOI] | | | 23 |
Mastocytosis: oral implications of a rare disease : Oral implications of mastocytosis |
|
| T. A. Rama, I. Côrte-Real, P. S. Gomes, L. Escribano, M. H. Fernandes | | Journal of Oral Pathology and Medicine. 2010; : no | | [VIEW] | [DOI] | |
|
|
|
|
|
|
|
|
|
|
|
|
| Article Access Statistics | | | Viewed | 5838 | | | Printed | 258 | | | Emailed | 5 | | | PDF Downloaded | 428 | | | Comments | [Add] | | | Cited by others | 23 | | |
|
|
Users online: 1012
