Beldon_subbed.qxp 19/5/09 12:52 pm Page 77
Contact Sensitivities in Chronic Wounds and the Need for Hypoallergenic Dressings
Table 1: Common Sensitisers Included in Products Used in Wound Management
Common Skin Sensitiser/Allergen Possible Products Containing Sensitiser/Allergen
Antibiotics: neomycin, framycetin, bacitrain, fucidin
11
Some medicated paraffin gauze dressings
May be added to topical steroid creams/ointment
Quinoline
8
Used as antiseptic in creams. May be combined with a corticosteroid
Wool alcohols: lanolin
8,18
Present in some barrier creams,
8
body creams
18
and emollients
8,18
Rubber: thiuram/mercapto/carba mix Rubber gloves use during wound care
(accelerators used in manufacture of rubber)
3
Some compression bandages
Some compression hosiery
Emulsifiers: cetylstearyl alcohol, cetyl alcohol
16
Prevalent in creams, e.g. aqueous cream, Diprobase
®
, corticosteroid creams
Some paste bandages.
Preservatives: parabens/hydroxybenzoates Parabens or hydroxybenzoates are used as preservatives in some creams
to prolong the shelf-life
Chlocresol
8
Used in many corticosteroid creams
Fragrance mix
8
Contained in some body lotions, moisturisers and baby creams
Colophony
8
Found on some bordered wound dressings
Tapes for securing bandages/dressings
Some cohesive bandages used in compression therapy
Balsam of Peru
8
Some scented cosmetics, some spices and suppositories, e.g. Anusol™
Dyes
8
Used in compression hosiery
accelerators and topical corticosteroids (see Table 1). This study Contact allergic hypersensitivity to standard series allergens was
was substantiated by that of Saap et al.,
6
who patch-tested 54 demonstrated in 25 patients, with a total of 49 positive reactions
patients with venous leg ulcers, 63% of whom had positive patch and a mean of 1.6 reactions per patient. Positive reactions were
test results to one or more allergen. most commonly recorded to balsam of Peru, fragrance mix and
neomycin sulphate. Tmoljanovic Veselski et al.
11
concluded that
Lim et al.
10
noted that there were no published studies examining while study results did not confirm a statistically significant higher
the rate of contact sensitisation in Asian patients and determined to rate of sensitisation to particular topical agents commonly used in
investigate the rate of contact sensitisation in patients with chronic the treatment of patients with venous leg ulcers, patch testing to
venous leg ulcers in Singapore and the variation in the common standard series and special series allergens should be performed in
allergens based on local practices compared with western cases of prolonged leg ulceration.
countries. Forty-four patients were patch-tested against the
National Skin Centre standard series, steroid series, medicaments, In light of this information, which has been available for several
topical Chinese medicaments and modern wound dressings. The years in some instances, it seems pragmatic to include skin
overall rate of contact sensitisation was 61.4%. The common assessment and detailed questioning into the usual assessment
allergen groups were topical antibiotics (18.2%) and topical process of patients with venous leg ulcers. It also behoves the
traditional Chinese medicaments (TTCMs) (15.9%). Individually, practitioner to ensure that only those products that have none of
colophony (11.3%), Saw Hong Choon skin ointment (Kam Bo Med, the common sensitisers/allergens present should be utilised in the
Hong Kong) (11.3%), balsam of Peru (9.1%) and povidone iodine management of venous leg ulcers and that a hypoallergenic dressing
(9.1%) were among the most frequent allergens. The sensitisation is used as the primary wound contact layer.
12
Due to the high rate
rate among users of TTCM was notably high (41%). Lim et al.
10
of contact sensitivity in venous leg ulcer patients, it is advisable
concluded that a high rate of contact sensitisation was found, that the wound contact layer should be low-cost, non-adherent,
similar to previous reports from western studies, and also that TTCM hypoallergenic and acceptable to the patient.
13
Where the wound is
played a major role as possible allergens in Asian patients and so a producing large volumes of exudate, an absorbent dressing is
history of their usage should be elicited. They also concluded that required. Many are available; however, the fluid-handling capability of
patch testing should include commonly used TTCMs where possible. individual dressings should be stringently questioned in order to
ensure the patient is not at risk of maceration of peri-ulcer skin.
14
Tmoljanovic-Veselski et al.
11
performed a study to examine the
prevalence of contact sensitivity in patients with venous leg Table 1 details some of the many skin sensitisers that are known to
ulceration, specifically between the standard series of allergens practitioners and possible products in which they may be contained.
used in patch testing and to particular topical wound preparations Some of the simple equipment known to practitioners such as
used in the treatment of venous leg ulcers. Sixty subjects were latex/rubber gloves may cause an adverse reaction,
3
and should be
recruited, 30 of whom had suffered previous contact sensitivity and substituted with vinyl gloves. The treatment for varicose eczema or a
30 of whom had not. The two groups of patients underwent testing dermatitis commonly involves the use of a corticosteroid cream and
to standard series allergens and target series allergens including emollients, yet many of these preparations commonly include a
mupirocin, bepanthene, silver sulphadiazine, chloramphenicol plus known sensitising agent, most of which are included to prolong the
clostridiopeptidase, betamethasone dipropionate, hydrocortisone shelf-life of a product and thus make it more commercially
plus oxytetracycline, momethasone, alginate, hydrocolloid, lanolin, successful. Guidelines for the management of venous leg ulceration
pyrogallol, vaseline, permanganate, Rivanol, povidone–iodine and are clear in stating that practitioners must avoid the use of potential
gentamicin (i.e. local agents most frequently used by the patients). sensitising products in the treatment of patients.
13–17
EUROPEAN DERMATOLOGY 77
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99