Benzalkonium chloride contact dermatitis

Authors: Dr Claire Felmingham, Research Fellow, Occupational Dermatology Research and Education Centre, Skin and Cancer Foundation Inc., Melbourne, VIC, Australia; A/Prof Rosemary Nixon, Dermatologist and Occupational Physician, Occupational Dermatology Research and Education Centre, Skin and Cancer Foundation Inc., Melbourne, VIC, Australia. DermNet NZ Editor in Chief: Adjunct A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. August 2019.


What is benzalkonium chloride?

Benzalkonium chloride is a quaternary ammonium cationic detergent. It can be used as an antiseptic and preservative in personal care, health care, household, pharmaceutical, and industrial products [1,2].

What is benzalkonium chloride contact dermatitis?

When benzalkonium chloride comes into contact with the skin, it can cause irritant contact dermatitis or allergic contact dermatitis in some individuals.

Benzalkonium chloride is a well-known irritant [1]. Irritant contact dermatitis to benzalkonium chloride is more common than allergic contact dermatitis.

Who gets benzalkonium chloride contact dermatitis?

Irritant contact dermatitis to benzalkonium chloride can affect anyone. Allergic contact dermatitis can affect any individual who becomes sensitised or allergic to benzalkonium chloride.

Both irritant and allergic contact dermatitis to benzalkonium chloride are more likely to occur in people with a compromised skin barrier, such as in people with atopic dermatitis (eczema).

Healthcare workers are also at a greater risk of developing contact dermatitis to benzalkonium chloride, given the use of benzalkonium chloride use in sterilisation solutions and antiseptics and disinfectants in healthcare settings [2,3].

Where is benzalkonium chloride found?

Benzalkonium chloride can be found in:

  • Household cleaning products, such as laundry rinses/detergents [4]
  • Personal care products [5]
  • Wet wipes
  • Antiseptics [6]
  • Eye drops and ophthalmic solutions [7]
    • Glaucoma treatments
    • Antibacterial eye drops
    • Corticosteroid eye drops
    • Antihistamine eye drops
    • Lubricating eye drops/artificial tears
    • Contact lens solutions
  • Nasal sprays
  • Dental products
  • Plaster of Paris [8,9]
  • Sterilisation solutions for medical instruments [2]
  • Industries, including:

How does benzalkonium chloride contact dermatitis present?

Both allergic and irritant contact dermatitis start at the site of contact with benzalkonium chloride. In prolonged or severe cases, dermatitis may spread to other sites [10,11]. The affected skin may be red, itchy, dry, or scaly, and may also blister or peel.

Symptoms may start to occur hours or days after contact with benzalkonium chloride. Some people may develop periorbital or eye dermatitis or conjunctivitis (red and itchy eyes) after the use of ophthalmic solutions containing benzalkonium chloride [1].

A small subset of people exposed to benzalkonium chloride may develop a rash called granular parakeratosis [4]. Granular parakeratosis is a red or brown patchy and scaly rash that most commonly affects skin folds such as the armpits and groin. As the skin heals, it might peel [12].

It is thought that, in addition to being provoked by occlusion, friction, and sweating, granular parakeratosis can also be provoked by contact with benzalkonium chloride. People with atopic dermatitis are predisposed to this condition [4,12].

Granular parakeratosis due to contact with benzalkonium chloride

How is benzalkonium chloride contact dermatitis diagnosed?

Patch testing is used to diagnose allergic contact dermatitis (type IV/delayed hypersensitivity) to benzalkonium chloride. Benzalkonium chloride is included in the Australian Baseline series for patch testing (tested as benzalkonium chloride 0.1% aqueous) [13].

Doubtful or weakly positive patch test reactions to benzalkonium chloride should be interpreted cautiously. These may represent irritant reactions, rather than allergic reactions [5,14].

The open application test may also be useful to confirm reactions [14].

Doubtful patch test reaction to benzalkonium chloride

What is the treatment for benzalkonium chloride contact dermatitis?

Once the diagnosis of contact dermatitis is confirmed, it is important to avoid contact with any product containing benzalkonium chloride.

The affected individual should be aware of the types of products that can contain benzalkonium chloride and should carefully read product ingredient labels.

The avoidance of benzalkonium chloride along with treatment of acute dermatitis usually results in resolution of the rash over weeks.

In cases of contact allergy, it is likely that the individual will remain allergic to benzalkonium chloride indefinitely, or at least for many years.

Potential cross-reactors

Benzalkonium chloride can cross-react with other quaternary ammonium compounds (preservatives), such as behentrimonium methosulfate, cetrimonium (cetrimide) chloride, and benzethonium chloride [5]. If someone is found to have allergic contact dermatitis to benzalkonium chloride, they should avoid these ingredients as well.

  • Alkyl dimethyl benzyl ammonium chloride
  • Alkyl dimethyl ethyl benzyl ammonium chloride
  • Behentrimonium methosulfate
  • Benzethonium chloride
  • Cetrimonium (cetrimide) chloride
  • Cetylpyridinium chloride
  • Distearoylethyl dimonium chloride
  • Guar hydroxypropyltrimonium chloride [5].

Active dermatitis can be treated as any acute eczema/dermatitis, with:

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Related information

 

References

  1. Wentworth AB, Yiannias JA, Davis MD, Killian JM. Benzalkonium Chloride: A Known Irritant and Novel Allergen. Dermatitis 2016; 27: 14–20. doi: 10.1097/DER.0000000000000160. PubMed
  2. Rietschel RL, Fowler JF, Jr. Preservatives and vehicles in cosmetics and toiletries. In: Fisher’s Contact Dermatitis. 1. 6 ed. Hamilton, Ontario, Canada; BC Decker, 2008: 278–9.
  3. Suneja T, Belsito DV. Occupational dermatoses in health care workers evaluated for suspected allergic contact dermatitis. Contact Dermatitis 2008; 58: 285–90. doi: 10.1111/j.1600-0536.2007.01315.x. PubMed
  4. Robinson AJ, Foster RS, Halbert AR, King E, Orchard D. Granular parakeratosis induced by benzalkonium chloride exposure from laundry rinse aids. Australas J Dermatol 2017; 58: e138–40. doi: 10.1111/ajd.12551. PubMed
  5. Isaac J, Scheinman PL. Benzalkonium Chloride: An Irritant and Sensitizer. Dermatitis 2017; 28: 346–52. doi: 10.1097/DER.0000000000000316. PubMed
  6. Hann S, Hughes TM, Stone NM. Flexural allergic contact dermatitis to benzalkonium chloride in antiseptic bath oil. Br J Dermatol 2007; 157: 795–8. doi: 10.1111/j.1365-2133.2007.08134.x. PubMed
  7. Gilissen L, De Decker L, Hulshagen T, Goossens A. Allergic contact dermatitis caused by topical ophthalmic medications: Keep an eye on it! Contact Dermatitis 2019; 80: 291–7. DOI: 10.1111/cod.13209. PubMed
  8. Lovell CR, Staniforth P. Contact allergy to benzalkonium chloride in plaster of Paris. Contact Dermatitis 1981; 7: 343–4. PubMed
  9. Stanford D, Georgouras K. Allergic contact dermatitis from benzalkonium chloride in plaster of Paris. Contact Dermatitis 1996; 35: 371–2. PubMed
  10. Oakley A, Post R. Allergic contact dermatitis. DermNet NZ. 1997. Available at: www.dermnetnz.org/topics/allergic-contact-dermatitis/ (accessed 12 July 2019).
  11. Ngan V. Irritant contact dermatitis. DermNet NZ. 2003. Available at: www.dermnetnz.org/topics/irritant-contact-dermatitis/ (accessed 12 July 2019).
  12. Oakley A. Granular Parakeratosis. DermNet NZ. 2008. Available at: www.dermnetnz.org/topics/granular-parakeratosis/ (accessed 12 July 2019).
  13. Toholka R, Wang YS, Tate B, Tam M, Cahill J, Palmer A, et al. The first Australian Baseline Series: Recommendations for patch testing in suspected contact dermatitis. Australas J Dermatol 2015; 56: 107–15. DOI: 10.1111/ajd.12186. PubMed
  14. Klein GF, Sepp N, Fritsch P. Allergic reactions to benzalkonium chloride? Do the use test! Contact Dermatitis 1991; 25: 269–70. PubMed

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