In newborns and infants, especially those born prematurely, the risk of percutaneous absorption and toxicity of topical medications is increased. Which of the following option(s) correctly lists the topical medication and its associated toxicity? (hint: more than one answer may be correct)
A. Calcipotriol, hypocalcemia
B. Povidone-iodine, hypothyroidism
C. Salicylic acid, metabolic acidosis
D. Lidocaine, deafness
E. Benzocaine, methemoglobinemia
Rationale: Neonates have an increased body surface area-to-weight ratio compared to older children or adults. Neonates, particularly those born prematurely, have a thinner stratum corneum and thus topical medications may be absorbed more readily. It is important to know commonly used topical medications and their risks and to caution liberal use of topical agents in newborns and infants.
Correct answers: B, C, E
Excessive absorption of povidone-iodine decreases thyroid function leading to hypothyroidism. Salicylic acid absorption can lead to metabolic acidosis; this has been reported in children with ichthyosis and in the author's experience, occurred in a patient with dystrophic epidermolysis bullosa who was using a topical medication compounded overseas containing salicylic acid. Benzocaine is available over the counter as a teething agent and has been reported to cause methemoglobinemia.
Incorrect answers:
A. Calcipotriol increases gastrointestinal absorption of calcium and can lead to hypercalcemia, not hypocalcemia.
D. Lidocaine toxicity includes petechiae and seizures. Neomycin is a commonly available topical antibiotic that when absorbed at high levels can cause deafness.
Additional reading at Chapter 104: Pediatric and Adolescent Dermatology
Table 104-7 Topical Medications Reported to Cause Systemic Toxicity in Children
| TOPICAL MEDICATION | COMPLICATION | REFERENCE |
|---|---|---|
| Tacrolimus 1% ointment | Three children with Netherton syndrome found to have blood levels of tacrolimus in the range of organ transplantation requirements | 35 |
| Hydrocortisone 1% ointment | Cushing syndrome developed in an 11-year-old boy with Netherton syndrome who received topical application to extensive areas for longer than 1 year | 36 |
| Benzocaine, 3% (Lanacane) | Methemoglobinemia in a 2-year-old child | 50 |
| Iodoquinol, clioquinol (Vioform) | Neurotoxicity when used as treatment for diaper dermatitis | 51, 52 |
| Lindane | Neurologic toxicity in children with disrupted epidermal barrier and/or excessive topical application or ingestion | 53, 54 |
| N,N-diethyl-m-toluamide (DEET) | Slurred speech, tremors, seizures, and death in children after repeated and extensive application of high concentrations of DEET | 55 |
| Povidone-iodine (Betadine) | Hypothyroidism in infants with spina bifida | 56 |
| Povidone-iodine (Betadine) | Decreased free thyroxine and elevated iodine levels in infants treated with diluted povidone-iodine during Staphylococcus aureus epidemic | 57 |
| Salicylic acid | A 7-year-old boy with ichthyosis vulgaris developed life-threatening salicylism with neurologic sequelae lasting 6 months | 58 |
| Saline, sodium chloride | Fatalities in infants and children following ancient Turkish custom of “salting” | 59 |
| Viscous lidocaine, 2% | Lidocaine overdose following frequent application to oral lesions | 60 |
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