Surgical plume in dermatology: an insidious and often overlooked hazard

Generalized bullous fixed drug eruption after Oxford–AstraZeneca (ChAdOx1 nCoV‐19) vaccination

“…Our previous case report showed that intramatricial injection of low-dose secukinumab, an anti-interleukin (IL)-17A monoclonal antibody, could markedly improve the condition of NP. 1 However, the difference in efficacy between the nail matrix (pitting, leuconychia, nail plate crumbling and red lunula) and nail bed (oil-drop sign, onycholysis, subungual hyperkeratosis and splinter haemorrhages) was unclear. This protocol was approved by the local ethics committee, and all patients provided written informed consent.…”

“…During the study treatment, each patient received local anaesthesia into the proximal nail fold with 5% lidocaine cream and 1% tetracaine hydrochloride under occlusion. 1 This was left for 1 h to take effect, then three relatively severe nails on the left hand were injected into the nail matrix with secukinumab at different concentrations (7.5, 15 and 30 mg/mL, respectively). These were prepared by diluting the original secukinumab preparation (150 mg/mL) with sterile water for injection and the dilutions were then kept at 4°C.…”

Mitigating the risks of surgical smoke: positive pressure rooms and particulate air filters

“…Given the clinical and histological features, a diagnosis of generalized BFDE (GBFDE) was made. Fixed drug eruption (FDE) (not bullous or generalized) typically presents within 1-2 weeks after the initial exposure, and in < 2 days for subsequent episodes, whereas GBFDE occurs with more sudden onset and typically within 24 h. 1 Based on the temporal relationship, the ChAdOx1 nCoV-19 vaccine was considered as the eruption trigger, with a score of 5 (probable) on the Naranjo Adverse Drug Reaction Probability Scale.…”

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We thank Dr Brady for his response 1 to our article on surgical plume in dermatology, 2 and note his interest in investigating the difference between positive room air pressure compared with a normal pressure room. 1 In a positive air pressure room, the room is sealed and the air pressure in the room is greater than that outside, potentially pushing infectious particles such as those found in the surgical plume away from the patient and operator. 3 In our paper, we discussed the use of high-efficiency particulate air (HEPA) and ultra-low particulate air (ULPA) filters.

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“…[2][3][4][5] Whereas FDE is usually selflimiting and has a favourable prognosis, GBFDE is considered a severe cutaneous adverse reaction (SCAR) with a high mortality rate among elderly patients. 1 Despite the wide use of the COVID-19 vaccinations, only eight cases of SCAR associated with these vaccines have been documented (Table 1).…”