Chlorhexidine anaphylaxis - check before you prep!
Chlorhexidine is well-known to dermatologists as a type IV contact sensitiser where it can produce eczema, particularly when chlorhexidine-containing creams and dressings have been repetitively applied to the skin.
A much more serious and increasingly recognised problem with chlorhexidine is type I allergy producing chlorhexidine anaphylaxis.
Acute angioedema of the face and lips after chlorhexidine exposure.
A positive prick test to chlorhexidine indicating type I hypersensitivity.
Chlorhexidine is used extensively both for preoperative skin preparation and also in mucosal products such as mouthwashes, and in combination with local anaesthetics for urethral lubrication prior to catheterisation. It is also in some alcohol skin preparation wipes and sprays that are used to clean intravenous access ports, and in lubricants like KY Jelly. Some indwelling venous access lines have chlorhexidine tips to prevent line infections.
Some 1.5 million patients are exposed to chlorhexidine during medical procedures in the UK annually, and 1 in 100,000 have severe type I sensitivity. There have been both near misses and fatalities.
It is becoming an increasingly recognised cause of perioperative anaphylaxis. Sufferers have often been sensitised from mucosal exposure. Afterwards, even with the application of chlorhexidine skin cleaner to small areas of skin, it can induce anaphylaxis.
It may present with the typical features of a rapid onset urticarial eruption and angioedema, but sometimes it can present just as collapse and severe perioperative hypotension.
So before applying the skin prep, it's prudent always to specifically ask if there are any previous reactions to any of the products that you're about to apply, either local anaesthetics, skin cleaners, or dressings.
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