Deodorant Spray: A Newly Identified Cause of Cold Burn Ulrich May, Karl-Heinz Stirner, Roger Lauener, Johannes Ring and Matthias Möhrenschlager Pediatrics 2010;126;e716; originally published online August 2, 2010; DOI: 10.1542/peds.2009-2936 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/126/3/e716.full.html PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from pediatrics.aappublications.org by guest on August 22, 2014 Deodorant Spray: A Newly Identiﬁed Cause of Cold Burn abstract Two patients encountered a ﬁrst-degree cold burn after use of a deodorant spray. The spray-nozzle to skin-surface distance was ⬃5 cm, and the spraying lasted ⬃15 seconds. Under laboratory conditions, the deodorant in use was able to induce a decline in temperature of ⬎60°C. These 2 cases highlight a little-known potential for skin damage by deodorant sprays if used improperly. Pediatrics 2010;126:e716–e718 AUTHORS: Ulrich May, MD,a Karl-Heinz Stirner, MD,b Roger Lauener, MD,b Johannes Ring, MD, PhD,c and Matthias Möhrenschlager, MDa Departments of aDermatology and Allergology and bPediatrics, Allergieklinik, Hochgebirgsklinik/Christine Kühne-Center for Allergy Research and Education, Davos, Switzerland; and cDepartment of Dermatology and Allergy Biederstein, Technical University of Munich, Munich, Germany KEY WORDS frostbite, deodorant, propellant www.pediatrics.org/cgi/doi/10.1542/peds.2009-2936 doi:10.1542/peds.2009-2936 Accepted for publication May 6, 2010 Address correspondence to Matthias Möhrenschlager, MD, Department of Dermatology and Allergology, Allergieklinik, Hochgebirgsklinik/Christine Kühne-Center for Allergy Research and Education, Herman-Burchard-Strasse 1, CH-7265 Davos, Switzerland. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2010 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no ﬁnancial relationships relevant to this article to disclose. e716 MAY et al Downloaded from pediatrics.aappublications.org by guest on August 22, 2014 CASE REPORT Although deodorant sprays are applied many million times per day, cold burns after use of these devices have been rarely mentioned in the medical literature.1– 4 Here, we report a cluster of frostbite injuries caused by the improper use of an aerosol spray. CASE REPORTS A 14-year-old mixed-race (black/white) girl (patient 1) complained of localized pain and dark discoloration on her right hand 1 day after use of a deodorant spray (Rexona Girl Dance Energy [Unilever, Thayngen, Switzerland]) (Fig 1) within a distance of ⬃5 cm for ⬃15 FIGURE 2 First-degree frostbite on the dorsum of the hand after low-distance spraying of a deodorant for ⬃15 seconds (patient 1). FIGURE 3 Temperature recorded by a contact thermometer (Fluke 51 II) according to time of exposure to the aerosol spray in use. The distance from the spray nozzle to the measuring point of the thermometer was 5 cm. seconds. The reason for this kind of exposure was, according to the patient, “a test of courage.” Except for atopic eczema and allergic asthma, her general medical history was uneventful. A healthy 45-year-old white friend of patient 1 (patient 2), who did not believe the report given by patient 1, reapplied the deodorant spray at a similar distance and for a similar amount of time. FIGURE 1 Aerosol deodorant that was used within a few centimeters of the cutaneous surface. PEDIATRICS Volume 126, Number 3, September 2010 Macroscopically, patients 1 and 2 showed on the right dorsum of their hands a 4- ⫻ 3-cm and a 3- ⫻ 2-cm, respectively, erythematous macula with sharply conﬁned margins representing ﬁrst-degree frostbite (Fig 2). The lesions were treated with nonadhesive dressings and topical corticosteroids at night and ultraviolet-ray protection during the day. As a sequela, a postinﬂammatory hypopigmentation (patient 1) and a hyperpigmentation (patient 2) became evident after several weeks of treatment. The patients were encouraged to continue with ultraviolet-ray protection for the next months. Figure 3 (created with Excel 2003 [Microsoft Corp, Redmond, WA]) depicts the obtained temperature/ exposure-time curve of the deodor- Downloaded from pediatrics.aappublications.org by guest on August 22, 2014 e717 ant aerosol sprayed on a contact thermometer (Fluke 51 II [Fluke Corp, Everett, WA]) within a distance of 5 cm and recorded for 15 seconds starting at a room temperature of 22.1°C. A decline in temperature of ⬎60°C was demonstrated. DISCUSSION Frostbite is a disorder caused by the actual freezing of tissue beginning at temperatures of ⫺2°C to ⫺10°C.1 Similar to burns caused by heat, the duration of exposure, affected region, immobility, and other factors may inﬂuence the amount of skin damage encountered.5,6 Low temperature-related effects can be induced, for example, by direct injury to the cell with intracellular ice formation, hypoxia caused by vessel constriction, and damage from inﬂammatory mediators.7 According to Amonton’s law,8 the pressure (P) of a gas is proportional to the absolute temperature (T) for a ﬁxed quantity of gas in a ﬁxed volume: P1/T1 ⫽ P2/T2. Therefore, a decline in the pressure of a gas (eg, by spraying the content of an aerosol can) results in a decline of temperature. Cooling effects may also arise from the low boiling points of propellants (eg, ⫺42.2°C for propane, ⫺11.7°C for isobutane, and ⫺0.6°C for butane). Another possible cause for cutaneous affection may arise from hypertonic damage by the aerosol.7 In contrast to protein denaturation caused by heat burns, preserved dermal collagen prevents signiﬁcant scarring after cold burns unless the freezing contact is particularly prolonged.9 In the literature, several reports deal with frostbite injuries after improper use of an aerosol spray by young persons. Lacour and Le Coultre2 discussed an 8-year-old boy who sustained a cold burn after spraying his forearm with a toilet air-freshener aerosol at close range for an unknown period of time. The aerosol in question used butane and propane as propellants. As in our case, the authors demonstrated that such a spray could induce a substantial decrease in temperature (⫺40°C) when sprayed onto a toluene thermometer at close range. Elliott3 described a young boy who experienced a second-degree frostbite injury to his oral cavity, including the lower lip, hard palate, tongue, and buccal mucosa. This unusual injury occurred as a result of substance abuse via inhalation of an aerosolized propane propellant as a means of achieving euphoria. with a deodorant by holding the nozzle ⬃1 cm from the skin surface for a period of 20 to 30 seconds, which resulted in ﬁrst- and second-degree frostbite injuries, respectively. The spray used by the girls contained butane and propane as propellants. In an experiment for which the same type of deodorant was used, Camp et al sprayed the contents onto the bulb of an alcohol thermometer from a distance of 1 cm and recorded the temperature reached. After spraying for 5 seconds, the starting temperature (21°C) decreased to 0°C and declined further to ⫺8°C, ⫺13°C, and ⫺15°C after 10, 15, and 20 seconds of spraying, respectively.3 The spray in our case contained propane, isobutane, and butane as propellants. The producer informed us on a written warning on the spraying device that the product must be used from a minimum distance of 15 cm and that prolonged spraying should be avoided (Karin Zimmermann, Unilever, written communication Ref 13069903, 2009). CONCLUSIONS As an act “out of curiosity,” Camp et al4 reported the cases of 2 teenaged girls who sprayed their forearms and ankle These cases highlight a little-known potential for skin damage from deodorant sprays when used improperly. However, in a majority of cases, the patients were obviously aware that such improper use would cause skin damage. 4. Camp DF, Ateaque A, Dickson WA. Cryogenic burns from aerosol sprays: a report of two cases and review of the literature. Br J Plast Surg. 2003;56(8): 815– 817 5. Möhrenschlager M, Ring J, Henkel V. Iatrogenic neonatal burns: more causes. Pediatr Dermatol. 2008;25(2):285–286 6. Möhrenschlager M, Weigl LB, Haug S, et al. Iatrogenic burns by warming bottles in the neonatal period. J Burn Care Rehabil. 2003; 24(1):52–55; discussion 49 7. Dawber R. Cold kills! Clin Exp Dermatol. 1988; 13(3):137–150 8. Lide DR. CRC Handbook of Chemistry and Physics. 90th ed. Boca Raton, FL: Taylor & Francis; 2009 9. Shepherd JP, Dawber RP. Wound healing and scarring after cryosurgery. Cryobiology. 1984;21(2):157–169 REFERENCES 1. Petrone P, Kuncir EJ, Asensio JA. Surgical management and strategies in the treatment of hypothermia and cold injury. Emerg Med Clin North Am. 2003;21(4):1165–1178 2. Lacour M, Le Coultre C. Spray-induced frostbite in a child: a new hazard with novel aerosol propellants. Pediatr Dermatol. 1991;8(3): 207–209 3. Elliott DC. Frostbite of the mouth: a case report. Mil Med. 1991;156(1):18 –19 e718 MAY et al Downloaded from pediatrics.aappublications.org by guest on August 22, 2014 Deodorant Spray: A Newly Identified Cause of Cold Burn Ulrich May, Karl-Heinz Stirner, Roger Lauener, Johannes Ring and Matthias Möhrenschlager Pediatrics 2010;126;e716; originally published online August 2, 2010; DOI: 10.1542/peds.2009-2936 Updated Information & Services including high resolution figures, can be found at: http://pediatrics.aappublications.org/content/126/3/e716.full.h tml Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Dermatology http://pediatrics.aappublications.org/cgi/collection/dermatolo gy_sub Pharmacology http://pediatrics.aappublications.org/cgi/collection/pharmacol ogy_sub Toxicology http://pediatrics.aappublications.org/cgi/collection/toxicology _sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pediatrics.aappublications.org/site/misc/Permissions.xht ml Reprints Information about ordering reprints can be found online: http://pediatrics.aappublications.org/site/misc/reprints.xhtml PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from pediatrics.aappublications.org by guest on August 22, 2014