Systemic Poisoning In Adults Following Skin Absorption of Pharmaceutical Agents

Introduction: Human skin provides a protective physical barrier via the stratum corneum "brick and mortar" structure, effectively managing skin permeability in most instances. Many factors may perturb this barrier effect, including age, environmental conditions and physical trauma. Furthermore, chemical absorption is notably influenced by concentration, contact duration, frequency of application, and exposed surface area. Systemic poisoning by pharmaceuticals through childhood skin has previously been comprehensively reviewed and reported. However, systemic poisoning by pharmaceuticals through adult skin has not been well reported. Often, poisoning through skin may be undetected and emergent in nature, supporting the need for a comprehensive review and report to the dermatology community. The aim of this project was to comprehensively review the literature for evidence of trancutaneous systemic poisoning in adults. Methods: An evidence-based review of relevant literature through search of PubMed (January 1966 to August 2016) for systemic symptoms/poisoning/skin exposure was performed by use of descriptors that included: skin, cutaneous, percutaneous, absorption, penetration, exposure, systemic, symptoms, poisoning, toxicity, accidental, and drug. A total of 67 publications were included for analysis. Results: The level of evidence (LoE) for these publications is limited. Of 67 publications, 40 (59.7%) were individual case reports (LoE IV), 9 (13.4%) were case series (LoE IV) and 18 (26.9%) were anecdotal (LoE IV). Although unintended skin absorption and systemic poisoning is well-reported following exposure to chemicals used in the workplace and in agriculture, poisoning related to topical pharmaceuticals and cosmetics is often unanticipated by the consumer as well as the physician. Sixty-one studies report systemic poisoning after use of 25 different topical drugs while six studies are on 4 distinct cosmetic agents. Conclusion: Poisoning may occur via several routes including the skin. Because of its accessibility and continuous exposure to a myriad of chemicals, accidentally, professionally, and therapeutically applied, the skin represents a common target. Although many believe topical to be safer than systemic route, significant toxicity may still occur. Incorrect dosage of the correct medication or application of the incorrect medication is the main cause, although occasionally the appropriate medication in the right dose can result in toxicity. Therefore, it is helpful to provide precise application instructions for therapeutic agents. An in-depth knowledge of the possible systemic side effects due to topically applied products may increase physician awareness and prompt recognition of any systemic symptoms as a probable sign of percutaneous absorption.