Irritant Contact Dermatitis With Topical Povidone-Iodine Ointment Post Ear Surgery

A 15-year-old male patient, with bilateral squamous, uncomplicated chronic suppurative otitis media underwent right modified radical mastoidectomy under general anesthesia at our institution. The procedure went uneventfully, and the patient was discharged after 2 days of inpatient observation. Ten days after discharge, the patient presented back with erythema and slight purulent discharge from the postauricular suture line. An oral amoxicillin–clavulanate combination was prescribed along with topical application of povidone-iodine 5% ointment. The patient came back after days with slightly painful lesions with severe itching and burning sensation. There were no neurotological or systemic features. On examination, there were skin-colored, tense, vesicobullous lesions filled with turbid fluids varying in size from 2 mm to 2 cm in size, present anterior and inferior to the pinna, corresponding to the region of topical ointment application (Figure 1A). On review of the ointment preparation being used, it was found to be comprised of a 10% povidone-iodine aqueous soluble preparation. A dermatology consultation was sought, and in view of the patient’s symptoms, lesion morphology, and the distribution of the lesions to the area of ointment application, a diagnosis of irritant contact dermatitis (ICD) to povidone-iodine ointment was made. Oral levocetirizine (5 mg daily) and a combination of fluticasone propionate (0.005% wt/wt) and mupirocin (2.0% wt/wt) for topical application twice daily were prescribed. The patient’s symptoms abated after 3 days, and after a week, the lesion had subsided with scaling and crusting (Figure 1B).

Figure 1.

A, Multiple, skin-colored, tense, vesicobullous lesions involving the concha and the region anterior and inferior to the pinna corresponding to the area of povidone-iodine ointment application. The lesions were pruritic and associated with burning sensation. B, The appearance after 1 week of application of steroid-antibiotic ointment topically showing the healing of the lesions with slight crusting and scaling.

Iodine preparations have been used for many years as antiseptic and microbicidal agent. The shortcomings of short lasting action and irritant potential are well known. To reduce the irritant potential, iodophor preparations (conjugation of elemental iodine with large weight organic molecules) have been formulated. Povidone-iodine (polyvinylpyrrolidone-iodine) is one such iodophor in which the free elemental iodine is present at a lower equilibrium concentration with the bound form, the latter acting as a reservoir for the elemental iodine for sustained release. The complex form of iodine has been shown to have substantially reduced irritant and corrosive potential, without compromising the antiseptic efficacy. ¹

The 10% aqueous-based preparation of povidone-iodine contains 1% of available iodine, corresponding to the free iodine concentration of 1 ppm (parts per million) or 0.0001%. ² Sensitization to povidone-iodine has been reported to occur at a rate of 0.73%. ³ Most of the cases of povidone-iodine ICD have been described with prolonged exposure of dependent body surface to high concentration of betadine solution (10%) used to prepare the surgical sites for disinfection. ⁴ For surgical preparations, it is advisable not to rub the skin excessively at the site of application, to allow the solution to dry before draping, to avoid pooling of the solution, and to check the expiration date. ⁵

The possibility of viral etiology (herpes zoster) in our patient was ruled out based on patient symptomatology and chronology of the events, along with lesion distribution congruent with the application of the ointment. The treatment for an established ICD case involves topical application of steroid–antibiotic ointment. Steroid ointment should be avoided in cases with severe thinning or necrosis of the skin. Draining the large bullae with a sterile needle puncture may be attempted. However, deroofing of the bulla should be avoided. Antibiotics usually are not needed unless there is evidence of superimposed bacterial infection.