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Quiz Page September 2012
QUIZ PAGE SEPTEMBER 2012 Erythematous Rash Around Peritoneal Dialysis Catheter Exit Site CLINICAL PRESENTATION A 69-year-old peritoneal dialysis (PD) patient with end-stage renal disease due to hypertensive nephropathy presented for a routine visit. He had been treated with PD without complications for 3 years. On physical examination, a small area of redness was noted at the catheter exit site (Fig 1A). The patient denied pain, discharge, pruritus, or cloudy peritoneal fluid. Anal-
ysis of a dialysate sample showed no cells. Cultures of the pericatheter skin were obtained, and the patient was reminded to conduct a daily exit-site care routine, including application of a standard antiseptic solution. Three days later, the patient presented with an expanding erythematous rash in the pericatheter area (Fig 1B). Physical examination otherwise was unre-
markable, including a nontender abdomen with intact bowel sounds. An ultrasound of the PD catheter tunnel showed no signs of inflammation. Because culture results of the pericatheter skin were negative for bacteria and fungi, empiric antibiotic therapy was started. Despite this treatment, signs of exit-site inflammation progressively worsened (Fig 1C).
What causes exit-site reactions? What evaluation is indicated? How might this patient be managed?
Figure 1. Peritoneal dialysis catheter exit site with (A) local irritation and (B, C) progressive expansion of erythema in the pericatheter area.
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QUIZ PAGE SEPTEMBER 2012 ANSWERS DISCUSSION f What causes exit-site reactions? Many processes can cause exitsite erythema in PD patients. Although erythema is often an early sign of infection at the catheterepidermal interface, it also occurs in noninfectious skin conditions.1 Evidence of infectious peritonitis (abdominal pain, cloudy effluent, and fever) or tunnel infection (tenderness over the subcutaneous pathway and hypoechogenic area surrounding the catheter wall by sonography) was absent in our patient. Purulent drainage, which is the most reliable indicator of infection, was not found, and no bacteria or fungi were isolated from repeated cultures of the catheter exit site. Noninfectious pericatheter erythema might be a skin reaction to trauma, such as thermal burns and friction, or it can be caused by chemical irritants. Our patient had not experienced trauma and had not been knowingly exposed to heat
Figure 2. Evaluation and follow-up. (A, B) Skin test patch site containing Octenisept. (C) Peritoneal dialysis catheter exit site 1 week after eliminating the antiseptic.
or chemical irritants. Rarely, exit-site erythema also can be an allergic reaction to the PD catheter itself or to exit-site care products (Table 1).2,3 Although the patient had treated the exit site exclusively with a hypoallergenic antiseptic solution, we considered allergic contact dermatitis. f What evaluation is indicated? Octenisept (Schülke & Mayer, www.schuelke-mayr.com), the major antiseptic used for exitsite care in our center, is known for its broad antimicrobiological effects. It contains 0.1% octenidine and 2% phenoxyetha-
QUIZ PAGE
Table 1. Synopsis of Topical Antiseptic and Antimicrobial Agents Used in Exit-Site Care Topical Antiseptic/Antimicrobial Agent
Use by Geographic Area
Allergic Dermatologic Reaction
Chlorhexidine Hydrogen peroxide Sodium hypochlorite Isopropyl alcohol Octenidine Povidone iodine Mupirocin Soap (antimicrobial or pure)
US, Canada, Europe US Europe US, Europe, Asia Europe, Australia US, Canada, Europe, Australia UK, Canada, Australia, India Worldwide
Rare Rare Rare Occasional Occasional Occasional Frequent Frequent
xxx
nol and is considered to have a very low allergenic potential. However, a recent study of wound care patients found a 3% rate of potential contact dermatitis after using Octenisept.4 In order to test for allergic dermatitis, epicutaneous patch testing was performed using a standard series of potential allergens, including Octenisept. Our patient showed a pronounced skin reaction to Octenisept (Fig 2A and B), with no reaction to other tested substances. f How might this patient be managed? The key treatment strategy for allergic contact dermatitis is avoiding the responsible allergen. After eliminating Octenisept from the patient’s exit-site care routine, the skin reaction cleared up within 1 week (Fig 2C). The initial local pericatheter redness that was present before antiseptic treatment most likely was a harmless physical irritation. We conclude that although it might be rare that allergic contact dermatitis in PD exit-site care is caused by antiseptics, it should be considered in the differential diagnosis. Am J Kidney Dis. 2012;60(3):xxix-xxxi
FINAL DIAGNOSIS Allergic dermatitis due to use of antiseptic solution.
ACKNOWLEDGMENTS We thank Dr K. Ehrich for epicutaneous patch testing in our patient.
REFERENCES 1. Gonthier D, Bernardini J, Holley JL, Piraino B. Erythema: does it indicate infection in a peritoneal catheter exit site? Adv Perit Dial. 1992;8: 230-233. 2. Yavascan O, Kara OD, Sozen G, Aksu N. Allergic dermatitis caused by povidone iodine: an uncommon complication of chronic peritoneal di-
CASE PROVIDED AND AUTHORED BY Roland Schmitt, MD, Hermann Haller, MD, and Marcus Hiss,
MD, Department of Nephrology and Hypertension, Medical School Hannover, Hannover, Germany. Address correspondence to Roland Schmitt, MD, Department of Nephrology and Hypertension, Medical School Hannover, Carl-Neubergstrasse 1, 30625 Hannover, Germany. E-mail: schmitt. [email protected] © 2012 by the National Kidney Foundation, Inc. http://dx.doi.org/10.1053/j.ajkd. 2012.04.030 SUPPORT: None. FINANCIAL DISCLOSURE: The authors declare that they have no relevant financial interests.
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alysis treatment. Adv Perit Dial. 2005;21:131-133. 3. Yavascan O, Anil M, Kara OD, et al. The comparison of exit-site care with normal saline and povidoneiodine in preventing exit-site infection and peritonitis in children on chronic peritoneal dialysis treatment. Saudi J Kidney Dis Transpl. 2011; 22(5):931-934. 4. Calow T, Oberle K, BrucknerTuderman L, Jakob T, Schumann H. Contact dermatitis due to use of Octenisept in wound care. J Dtsch Dermatol Ges. 2009;7(9):759-765.
ysis of a dialysate sample showed no cells. Cultures of the pericatheter skin were obtained, and the patient was reminded to conduct a daily exit-site care routine, including application of a standard antiseptic solution. Three days later, the patient presented with an expanding erythematous rash in the pericatheter area (Fig 1B). Physical examination otherwise was unre-
markable, including a nontender abdomen with intact bowel sounds. An ultrasound of the PD catheter tunnel showed no signs of inflammation. Because culture results of the pericatheter skin were negative for bacteria and fungi, empiric antibiotic therapy was started. Despite this treatment, signs of exit-site inflammation progressively worsened (Fig 1C).
What causes exit-site reactions? What evaluation is indicated? How might this patient be managed?
Figure 1. Peritoneal dialysis catheter exit site with (A) local irritation and (B, C) progressive expansion of erythema in the pericatheter area.
xxix
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Am J Kidney Dis. 2012;60(3):xxix-xxxi
QUIZ PAGE SEPTEMBER 2012 ANSWERS DISCUSSION f What causes exit-site reactions? Many processes can cause exitsite erythema in PD patients. Although erythema is often an early sign of infection at the catheterepidermal interface, it also occurs in noninfectious skin conditions.1 Evidence of infectious peritonitis (abdominal pain, cloudy effluent, and fever) or tunnel infection (tenderness over the subcutaneous pathway and hypoechogenic area surrounding the catheter wall by sonography) was absent in our patient. Purulent drainage, which is the most reliable indicator of infection, was not found, and no bacteria or fungi were isolated from repeated cultures of the catheter exit site. Noninfectious pericatheter erythema might be a skin reaction to trauma, such as thermal burns and friction, or it can be caused by chemical irritants. Our patient had not experienced trauma and had not been knowingly exposed to heat
Figure 2. Evaluation and follow-up. (A, B) Skin test patch site containing Octenisept. (C) Peritoneal dialysis catheter exit site 1 week after eliminating the antiseptic.
or chemical irritants. Rarely, exit-site erythema also can be an allergic reaction to the PD catheter itself or to exit-site care products (Table 1).2,3 Although the patient had treated the exit site exclusively with a hypoallergenic antiseptic solution, we considered allergic contact dermatitis. f What evaluation is indicated? Octenisept (Schülke & Mayer, www.schuelke-mayr.com), the major antiseptic used for exitsite care in our center, is known for its broad antimicrobiological effects. It contains 0.1% octenidine and 2% phenoxyetha-
QUIZ PAGE
Table 1. Synopsis of Topical Antiseptic and Antimicrobial Agents Used in Exit-Site Care Topical Antiseptic/Antimicrobial Agent
Use by Geographic Area
Allergic Dermatologic Reaction
Chlorhexidine Hydrogen peroxide Sodium hypochlorite Isopropyl alcohol Octenidine Povidone iodine Mupirocin Soap (antimicrobial or pure)
US, Canada, Europe US Europe US, Europe, Asia Europe, Australia US, Canada, Europe, Australia UK, Canada, Australia, India Worldwide
Rare Rare Rare Occasional Occasional Occasional Frequent Frequent
xxx
nol and is considered to have a very low allergenic potential. However, a recent study of wound care patients found a 3% rate of potential contact dermatitis after using Octenisept.4 In order to test for allergic dermatitis, epicutaneous patch testing was performed using a standard series of potential allergens, including Octenisept. Our patient showed a pronounced skin reaction to Octenisept (Fig 2A and B), with no reaction to other tested substances. f How might this patient be managed? The key treatment strategy for allergic contact dermatitis is avoiding the responsible allergen. After eliminating Octenisept from the patient’s exit-site care routine, the skin reaction cleared up within 1 week (Fig 2C). The initial local pericatheter redness that was present before antiseptic treatment most likely was a harmless physical irritation. We conclude that although it might be rare that allergic contact dermatitis in PD exit-site care is caused by antiseptics, it should be considered in the differential diagnosis. Am J Kidney Dis. 2012;60(3):xxix-xxxi
FINAL DIAGNOSIS Allergic dermatitis due to use of antiseptic solution.
ACKNOWLEDGMENTS We thank Dr K. Ehrich for epicutaneous patch testing in our patient.
REFERENCES 1. Gonthier D, Bernardini J, Holley JL, Piraino B. Erythema: does it indicate infection in a peritoneal catheter exit site? Adv Perit Dial. 1992;8: 230-233. 2. Yavascan O, Kara OD, Sozen G, Aksu N. Allergic dermatitis caused by povidone iodine: an uncommon complication of chronic peritoneal di-
CASE PROVIDED AND AUTHORED BY Roland Schmitt, MD, Hermann Haller, MD, and Marcus Hiss,
MD, Department of Nephrology and Hypertension, Medical School Hannover, Hannover, Germany. Address correspondence to Roland Schmitt, MD, Department of Nephrology and Hypertension, Medical School Hannover, Carl-Neubergstrasse 1, 30625 Hannover, Germany. E-mail: schmitt. [email protected] © 2012 by the National Kidney Foundation, Inc. http://dx.doi.org/10.1053/j.ajkd. 2012.04.030 SUPPORT: None. FINANCIAL DISCLOSURE: The authors declare that they have no relevant financial interests.
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Am J Kidney Dis. 2012;60(3):xxix-xxxi
alysis treatment. Adv Perit Dial. 2005;21:131-133. 3. Yavascan O, Anil M, Kara OD, et al. The comparison of exit-site care with normal saline and povidoneiodine in preventing exit-site infection and peritonitis in children on chronic peritoneal dialysis treatment. Saudi J Kidney Dis Transpl. 2011; 22(5):931-934. 4. Calow T, Oberle K, BrucknerTuderman L, Jakob T, Schumann H. Contact dermatitis due to use of Octenisept in wound care. J Dtsch Dermatol Ges. 2009;7(9):759-765.