Visual and confocal microscopic interpretation of patch tests to benzethonium chloride and benzalkonium chloride.

Quaternary ammonium compounds (Quats), such as benzalkonium chloride (BAC) and benzethonium chloride (BEC), are widely used as antibacterial active ingredients and preservatives in personal care products, disinfectants, and ophthalmic preparations. BAC is known to be a marginal irritant when patch tested at 0.15% aq. Data on BEC are limited. To differentiate irritant from allergic patch test reactions to quaternary ammonium compounds. Eight subjects who were considered likely to react based on history of rash after exposure to disinfectants or a history of prior positive patch test to BAC were recruited, as well as two patients undergoing routine patch testing. BAC (0.15% aq), BAC (0.15% pet), BEC (0.05% aq), BEC (0.15% pet), BEC (0.15% aq), BEC (0.5% aq), sodium lauryl sulfate (2.0%), and deionized water were applied under Finn chambers for 48 h. Four days and 7 days after application, the sites were examined visually and then by in vivo reflectance confocal microscopy (RCM) which was interpreted by blinded experts. Two patients with definite allergic reactions according to visual patch test reads and RCM were clinically relevant. Cross-reaction between BEC and BAC was demonstrated in one patient. RCM imaging correlated well with clinical scoring and interpretation of patch test reactions in terms of irritancy vs. allergy for BEC and BAC. Relevant allergic reactions to quats occur in humans. Possible cross-reaction was noted to occur between BAC and BEC. RCM appears to be a useful tool in distinguishing between irritancy and sensitization during patch testing to BAC and BEC. Further study of prevalence and best test concentration and vehicle is needed.