presence of two features either at the time of presentation
or in the past should be considered diagnostic.
No specific treatment exists for YNS. The control of
lymphedema,respiratorymanifestations,orboth,leadsto
improvement of the nail changes (1,5). Several treatment
modalities have been tried with varying degree of success,
including high dose vitamin E, 1200 IU daily, itraconazole,
400 mg daily for 1 week, monthly, fluconazole,
300 mg weekly for 18 months, intralesional corticosteroids,
topical vitaminE, and zinc supplements (1,2,5). Our
patient demonstrated mild improvement on the combination
therapywith fluconazole and vitamin E. Given the
long-standing history before treatment initiation, it is
unlikely that improvement was coincidental; therefore, it
may beworth trying this combination in similar cases.
REFERENCES
1. Maldonado F, Ryu JH. Yellow nail syndrome. Curr Opin
Pulm Med 2009;15:371–375.
Dermatol Online J 2008;14:17.
3. Cebeci F, Celebi M, Onsun N. Nonclassical yellow nail
syndrome in six-year-old girl: a case report. Cases J
2009;24:165.
4. Hoque SR, Monsour S, Mortimer PS. Yellow nail syndrome:
not a genetic disorder? Eleven new cases and review
of the literature. Br J Dermatol 2007;156:1230–1234.
5. Maldonado F, Tazelaar HD, Wang CW et al. Yellow nail
syndrome: analysis of 41 consecutive patients. Chest 2008;
134:375–381.
KHALID AL HAWSAWI, M.D.
ELENA POPE, M.D., M.SC., F.R.C.P.C.
Section of Dermatology, Hospital for Sick Children,
Toronto, Ontario, Canada
CHLORHEXIDINE-METHANOL BURNS IN
TWO EXTREME PRETERM NEWBORNS
Abstract: Safe and effective antiseptic use in neonatal
intensive care units is mandatory. High efficacy
and a low number of side-effects from chlorhexidine
have permitted avoidance of the use of mercurials and
iodine derivatives, but methanol use can be unsafe in
extreme preterm newborns. We report two cases of
chemical burn after skin cleansing, due to alcoholic
chlorhexidine (0.5%) use in extremely premature infants
used for umbilical catheter insertion. Although this
formulation is less concerning for use in full-term
newborns, nonalcoholic preparations are preferable for
use in preterm newborns.
Figure 1. Fingernail changes, before and after treatment.
Figure 2. Toenail changes, before and after treatment.
Address correspondence to Elena Pope, M.D., M.Sc., FRCPC,
Section of Dermatology, Hospital for Sick Children, 555 University
Ave, Toronto, Ontario, M5G 1X8, Canada, or e-mail: elena.
pope@sickkids.ca.
676 Pediatric Dermatology Vol. 27 No. 6 November ⁄ December 2010
CASE REPORT
We report the case of two twin siblings with a gestational
age of 26 weeks. In preparation for the insertion
of an umbilical catheter, local antisepsis with chlorhexidine
0.5% in 70% methanol was undertaken.
Within minutes, an erythematous zone in periumbilical
region appeared. In spite of immediately washing with
saline solution, first- and second-degree chemical burns
developed (Fig. 1). Local treatment with mupirocine
was started, with progressive resolution occurring in
10 days leaving minimal scarring (Fig. 2). Both patients
remained stable during the recovery period,
without systemic complications.
DISCUSSION
Effective and reliable topical antiseptics are necessary
before invasive procedures. Chlorhexidine is a topical
antiseptic agent with well-known activity against grampositive
bacteria, viruses, and fungi (1). Its favorable
activity, is associated with few adverse effects compared
with other antiseptics such as mercury or iodine
derivatives, and have made it a first-line choice for
antisepsis in most neonatal units. Chlorhexidine 0.5%
in 70% methanol is generally used in older children
and adults, because it has more residual effects with
similar antiseptic properties compared to chlorhexidine
aqueous solution (2). Several reports (3–8) have emphasized
that, alcoholic formulations are not safe in
preterm babies under 28 weeks of gestational age, as
the skin at this gestational age is more fragile and
susceptible to injury. No reports of burns resulting
from chlorexidine alone have been found in the literature,
which leads us to conclude that the alcoholic
component of the solution is responsible for the burns
in these cases. Chemical burns due to alcoholic solutions
in preterm babies may cause important local
sequelae and impairment of neurodevelopmental outcome
(8,9). Therapy for chlorhexidine-related burns is
empirical may include such treatments as, analgesia,
topical mupirocin, sulfadiazine, and hydrocolloid
dressings. Other treatments such as nanocrystalline
silver dressing can be used with good results (10). In
cases with evidence of bacterial infection (not simply
colonization) an antibiotic with good activity against
Staphylococcus epidermidis must be used, because
these bacteria are most often responsible for infection
in these patients, although other microorganisms such
as Streptococcus agalactiae or Escherichia coli can also
be found.
We conclude that in extremely premature infants
(
of chlorhexidine should be avoided, because of its
risk of causing skin damage and that the aqueous preparation
is preferable.
REFERENCES
1. Garland JS, Buck RK, Maloney P et al. Comparison of
10% povidone-iodine and 0.5% chlorhexidine gluconate
for the prevention of peripheral intravenous catheter colonization
in neonates: a prospective trial. Pediatr Infect Dis
J 1995;14:510–516.
2. Hibbard JS, Mulberry KG, Brady AR. A clinical study
comparing the skin antisepsis and safety of ChloraPrep,
70% isopropyl alcohol, and 2% aqueous chlorhexidine.
J Infus Nurs 2002;4:244–249.
3. Reynolds PR, Barnajee S, Meek JH. Alcohol burns in
extremely low birthweight infants: still occurring. Arch Dis
Child Fetal Neonatal Ed 2005;90:F10.
4. Upadhyayula S, Kambalapalli M, Harrison J. Safety of
anti-infective agents for skin preparation in premature infants.
Arch Dis Child 2007;92:646–647.
5. Schick JB, Milstein JM. Burn hazard of isopropyl alcohol
in the neonate. Pediatrics 1981;68:587–588.
6. Watkins AM, Keogh EJ. Alcohol burns in the neonate.
J Paediatr Child Health 1992;28:306–308.
Figure 2. Resultant scar.
Figure 1. Abdominal burns.
Brief Reports 677
7. Brayer C, Michean P, Bony C et al. Neonatal accidental
burn by isopropyl alcohol. Arch Pediatr 2004;11:932–
935.
8. MannanK, Chow P, Lissauer T et al.Mistaken identity of
skin cleansing solution leading to extensive chemical burns
in an extremely preterm infant. Acta Paediatr 2007;96:
1536–1537.
9. Bhutta AT, Anand KJ. Vulnerability of the developing
brain. Neuronal mechanisms. Clin Perinatol 2002;29:357–
372.
10. Rustogi R, Mill J, FraserRMet al.The use of acticoattm in
neonatal burns. Burns 2005;31:878–882.
XAVIER BRINGUE´ ESPUNY,M.D.
XAVIER SORIA, M.D.
EDUARD SOLE´ ,M.D., PH.D.
JORDI GARCIA, M.D.
JUAN JOSE MARCO, M.D.
JOSEP ORTEGA,M.D.
MIERIA ORTIZ,M.D.
ALFREDO PUEYO, M.D.
Neonatal Unit, Dermatology Service, Hospital
Universitari Arnau de Vilanova, Lleida, Spain
Address correspondence to Xavier Bringue´ Espuny, M.D.,
Servei de Pediatria, Unitat Neonatal. H. Universitari Arnau de
Vilanova. Avda Rovira Roure, 80. Lleida 25198 Lleida Spain, or
e-mail: xbringue@comll.cat.
678 Pediatric Dermatology Vol. 27 No. 6 November ⁄ December 2010
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