Multiple Oozing Facial Eruption in a Child Caused by Antiseptics

The diagnosis of allergic contact dermatitis to antiseptics remains poorly know. We report the case of a very young child who suffered six episodes before the diagnosis of allergic contact dermatitis to antiseptics was considered.

A 2-year-old boy was hospitalised in the paediatric department for a new episode of a superinfected erythematopapular and blistering eruption on the face (Figure 1). This was his sixth episode. The initial clinical hypothesis was immune deficiency or infection. However, treatment with antibiotics proved ineffective and an extensive immune workup returned normal results (full blood count (FBC), quantitative serum immunoglobulin tests, serum complement levels, lymphocyte immunophenotyping, respiratory burst assays, post-vaccine antibody titers and viral PCR testing). The only relevant medical history reported by his mother was persistent oozing of the umbilical cord with a surrounding eczematous eruption (Figure 2).

Dermatological advice led to the diagnosis of allergic contact dermatitis, as the eruption occurred 2 days after a traumatic wound, following systematic application of topical antiseptic. Biseptine, an antiseptic containing chlorhexidine digluconate, benzalkonium chloride and benzyl alcohol, was used throughout.

Patch tests were performed with the European baseline series, antiseptic series (Chemotechnique Diagnostics, Vellinge, Sweden) and Biseptine as is with IQ ultra-chambers.

On Day 2 and 3, positive reactions were respectively observed to Biseptine (+/+), chlorhexidine (+/+), benzyl alcohol (?/+), linalool (?/+) and polyaminopropyl biguanide (+/+) (Figure 3). Also to Myroxylon pereirae (+/+) which contains benzyl alcohol.

The polyaminopropyl biguanide had apparently never been used before.

Allergic contact dermatitis to Biseptine contchlorhexidine and benzyl alcohol was diagnosed.

Allergic contact dermatitis to antiseptics in children has been well documented with Biseptine in France [1, 2]. Despite several published cases, the diagnosis is often delayed, and eczema is frequently misdiagnosed as cellulitis or impetigo [2]. In our case, the initial hypothesis was an immune deficiency, which led to delayed management. However, this diagnosis was excluded due to the absence of severe and/or recurrent infections, as well as normal immune investigations. The diagnosis was ultimately confirmed only after the sixth episode.

Allergen profiles from antiseptics differ according to age, with benzyl alcohol being the primary allergen in adults and chlorhexidine digluconate in children [1].

However, sensitization to multiple components is possible, as seen in our case [1, 2].

Benzyl alcohol, although a rare allergen, has been implicated in contact dermatitis due to its presence in various products [3]. Chlorhexidine, one of the most widely used biocides in Europe, is also commonly employed as a preservative in cosmetics [4, 5].

The initial sensitization is particularly notable given the patient's young age. In fact, his mother had been using antiseptics, as recommended by medical professionals for umbilical cord care, which may explain the periumbilical eczematous eruption (Figure 2) and the subsequent development of allergic contact dermatitis to antiseptics.

In a French retrospective study of 31 children with contact dermatitis to Biseptine, 92% had received umbilical cord care with Biseptine and exhibited delayed umbilical cord separation [1].

Antiseptics are not recommended for umbilical cord care in newborns. The World Health Organisation (WHO) recommends the use of only soap and water for umbilical cord care [6]. This case underscores the importance of adhering to the WHO's current guidelines for postnatal umbilical cord care, which no longer advocate the use of antiseptics for infants in healthcare facilities.

Therefore, it is essential to provide therapeutic education to all healthcare providers to prevent allergic contact dermatitis due to antiseptics.

Chlorhexidine can also induce immediate anaphylactic reactions [7]. In November 2023, the French National Agency for Medicines and Healthcare (ANSM) issued a warning regarding the risk of serious allergic reactions associated with chlorhexidine. Antiseptics should not be used to clean superficial wounds [8].

In conclusion, our case report highlights that allergic contact dermatitis to antiseptics should be considered a cause of acute facial eruptions in children following traumatic wounds.

Magalie Coco-Viloin: conceptualization, investigation, writing – review and editing, writing – original draft. Maella Severino-Freire: investigation, supervision. Françoise Giordano: validation, supervision.

The patient's parents' consent was obtained.

The authors declare no conflicts of interest.