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Chlorhexidine Hypersensitivity: A Case Report Of Delayed Reactions To Epidermal Preparations
Priya Bhardwaj, MS, Jenna C. Bekeny, BA, Elizabeth G. Zolper, BS, Manas Nigam, MD, Sarah R. Sher, MD.
MedStar Georgetown University Hospital, Washington, DC, USA.

PURPOSE
Chlorhexidine is a topical antiseptic that is generally well tolerated in patients, making it a common preparation substance in surgical settings. As its use increases, several case reports of adverse reactions have come to light. Adverse reactions to chlorhexidine have been related to the method of applicationómucosal, epidermal, or via impregnated devices. Epidermal chlorhexidine preparations, in particular, have produced adverse reactions that occur in a gradient of mild, delayed hypersensitivity to severe, acute anaphylaxis. This case report serves to add to the body of knowledge about delayed hypersensitivity reactions to topical chlorhexidine, raise awareness of unique clinical presentations, and provide an algorithm for treatment.
METHODS
A retrospective chart review of patients from a single center between December 2018 and January 2019 identified three breast surgery patients who had adverse delayed reactions to chlorhexidine.
RESULTS
We identified three cases in which female patients ages 19-54 developed a delayed hypersensitivity reaction to an epidermal chlorhexidine surgical preparation, ChloraPrepTM, following breast procedures. Each patient developed an erythematous, pruritic maculopapular rash in the distribution of the chlorhexidine prep application. This occurred beyond the immediate postoperative periodóranging from postoperative day 5 to postoperative day 35. Initial treatment included hydrocortisone 1% along with a systemic antihistamine. If there was no improvement in symptoms after three days, we transitioned patients to triamcinolone 0.5% ointment. If there was no improvement after five days on triamcinolone, patient was re-examined and systemic steroids were prescribed. In each of our cases, all skin changes had resolved within seven to ten days of initial symptoms with no evidence of prolonged skin changes or ulceration following treatment.
CONCLUSIONS
Our findings highlight the possibility of a delayed adverse reaction developing to epidermal chlorhexidine beyond the intraoperative and immediate postoperative period. Thus, this case report serves to recognize a unique presentation pattern of delayed hypersensitivity reactions to chlorhexidine. Recognition of these cases is important to ensure that patients are accurately diagnosed and promptly treated.


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