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SELENIUM SHAMPOOS

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Selenium sulfide, the primary ingredient of selenium shampoos, is a topical antiseborrheic agent.

Specific Substances

    1) Selenii Disulfidum
    2) Selenium Disulphide
    3) Selenium Sulphide

Available Forms Sources

    A) FORMS
    1) Selenium shampoos may contain additional products such as bentonite, glycerol, citric acid, and perfume. All of these substances should have concentrations too low to influence the clinical presentation or to be a hazard.
    2) FORMULATIONS: 1% selenium sulfide shampoos are available over the counter and 2.5% prescription formulations are available (Gilbertson et al, 2012; Abdel-Rahman & Nahata, 1997).
    B) USES
    1) Selenium sulfide shampoos are used to treat seborrheic dermatitis and tinea versicolor (Gilbertson et al, 2012). Selenium shampoo is also used in combination with an oral antimycotic therapy (ie, griseofulvin) to treat tinea capitis (Abdel-Rahman & Nahata, 1997). It has also been used to treat scalp psoriasis, Pityrosporoum folliculitis, and transient acantholytic dermatosis.

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) USES: Selenium sulfide shampoos are used to treat seborrheic dermatitis and tinea versicolor. It has also been used for tinea capitis, scalp psoriasis, Pityrosporoum folliculitis, and transient acantholytic dermatosis.
    B) PHARMACOLOGY: Selenium sulfide has fungicidal activity to Pityrosporum ovale in vitro and also has cytostatic effects on hyperproliferative keratinocytes and keratolytic effects via hydrogen sulfide formation. During normal use, selenium shampoos do not significantly promote an increase in total body burden of selenium.
    C) TOXICOLOGY: These shampoos have generally low toxicity. Ten mL of a typical shampoo would represent about 100 to 250 mg of selenium. Systemic absorption appears limited with topical application of selenium.
    D) EPIDEMIOLOGY: Overdose is uncommon.
    E) WITH THERAPEUTIC USE
    1) Irritation and pruritus or a burning of the scalp are common. Mucous membranes and genitalia may be especially sensitive to irritation. Discoloration of the skin has occurred and resolves with discontinuation of therapy. Allergic contact dermatitis has been reported in some individuals. Eye exposures may cause momentary irritation and blurring without permanent damage.
    F) WITH POISONING/EXPOSURE
    1) OVERDOSE: Severe toxicity is not anticipated with topical application.
    2) MILD TO MODERATE TOXICITY: Clinical events are anticipated to be similar to adverse events and include local skin irritation and pruritus. Allergic contact dermatitis may develop.
    3) SEVERE TOXICITY: Severe toxicity is rare.
    0.2.8) GASTROINTESTINAL
    A) Both the nonionic and anionic detergents as well as the selenium salts may cause nausea, vomiting and diarrhea. There may also be a burning sensation in the mouth and a garlic-like taste and smell to the breath.
    B) Because these substances are so irritating, it is unlikely that the selenium will be retained for absorption. If large amounts are retained, then care should be taken to observe for systemic neurologic effects. These substances are not caustic.

Laboratory Monitoring

    A) Laboratory studies are not routinely necessary following exposure.
    B) Serum electrolytes may be necessary in cases of prolonged vomiting and/or diarrhea.
    C) No blood or urine concentrations exist for detergents. Serum selenium concentrations are generally not indicated as absorption is minimal after topical exposure.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) MILD TO MODERATE TOXICITY
    1) Treatment is symptomatic and supportive. In most cases, patients can likely be managed at home. Vomiting may develop if ingested; monitor fluid status and electrolytes, if symptoms persist. Flush the eyes and skin with copious amounts of water following exposure; if irritation or pain persist further evaluation may be necessary.
    B) SEVERE TOXICITY
    1) Treatment is symptomatic and supportive. A specific treatment is not available. In most cases, severe toxicity is not anticipated with these products.
    C) DECONTAMINATION
    1) INGESTION: Significant toxicity is unlikely unless very large amounts have been ingested. Gastrointestinal decontamination is generally NOT necessary. Dilution with a small amount of water may relieve oral irritation.
    2) DERMAL: Topical exposure may cause itching or irritation of the skin in some individuals; mucous membranes may be particularly sensitive. Rinse thoroughly with water. If irritation or pain persists after washing, further evaluation may be necessary.
    3) OCULAR: Irrigate exposed eyes with copious amounts of room temperature water for a few minutes. If irritation, pain, swelling, lacrimation, or photophobia persist, the patient requires further evaluation and possible treatment.
    D) ANTIDOTE
    1) None.
    E) PATIENT DISPOSITION
    1) HOME CRITERIA: Patients experiencing mild mucosal, eye or skin irritation or self-limited GI symptoms following inadvertent ingestion can be managed at home.
    2) OBSERVATION CRITERIA: Patients with persistent GI, dermal or eye irritation or if a self-harm ingestion should be referred to a healthcare facility for evaluation and treatment.
    3) ADMISSION CRITERIA: Patients with persistent GI symptoms (ie, vomiting, diarrhea) may need to be admitted for further treatment.
    4) CONSULT CRITERIA: Consult a medical toxicologist if there is a question or evidence of systemic toxicity. Consult an ophthalmologist for a patient with persistent pain or evidence of corneal injury.
    0.4.4) EYE EXPOSURE
    A) DECONTAMINATION: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, the patient should be seen in a healthcare facility.
    0.4.5) DERMAL EXPOSURE
    A) OVERVIEW
    1) DECONTAMINATION: Remove contaminated clothing and jewelry and place them in plastic bags. Wash exposed areas with soap and water for 10 to 15 minutes with gentle sponging to avoid skin breakdown. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).

Range Of Toxicity

    A) TOXICITY: Selenium sulfide is a non-soluble salt and is less toxic than the soluble selenites, selenates, and organic selenium compounds. Significant toxicity due to inadvertent exposures to anionic and nonionic detergents alone is not anticipated.

Clinical Effects

Summary Of Exposure

    A) USES: Selenium sulfide shampoos are used to treat seborrheic dermatitis and tinea versicolor. It has also been used for tinea capitis, scalp psoriasis, Pityrosporoum folliculitis, and transient acantholytic dermatosis.
    B) PHARMACOLOGY: Selenium sulfide has fungicidal activity to Pityrosporum ovale in vitro and also has cytostatic effects on hyperproliferative keratinocytes and keratolytic effects via hydrogen sulfide formation. During normal use, selenium shampoos do not significantly promote an increase in total body burden of selenium.
    C) TOXICOLOGY: These shampoos have generally low toxicity. Ten mL of a typical shampoo would represent about 100 to 250 mg of selenium. Systemic absorption appears limited with topical application of selenium.
    D) EPIDEMIOLOGY: Overdose is uncommon.
    E) WITH THERAPEUTIC USE
    1) Irritation and pruritus or a burning of the scalp are common. Mucous membranes and genitalia may be especially sensitive to irritation. Discoloration of the skin has occurred and resolves with discontinuation of therapy. Allergic contact dermatitis has been reported in some individuals. Eye exposures may cause momentary irritation and blurring without permanent damage.
    F) WITH POISONING/EXPOSURE
    1) OVERDOSE: Severe toxicity is not anticipated with topical application.
    2) MILD TO MODERATE TOXICITY: Clinical events are anticipated to be similar to adverse events and include local skin irritation and pruritus. Allergic contact dermatitis may develop.
    3) SEVERE TOXICITY: Severe toxicity is rare.

Heent

    3.4.3) EYES
    A) Eye exposure to these products may cause momentary irritation and blurring without permanent damage (Gilbertson et al, 2012).

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) HYPOTENSIVE EPISODE
    1) Although decreased peripheral pulse and blood pressure has been noted with selenium poisoning, it is unlikely that such symptoms would occur from ingesting selenium sulfide shampoos.

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) COMA
    1) The CNS symptoms of dizziness, depression, decreased pupillary response and coma should not be a problem unless large amounts of the shampoo are ingested and retained for absorption.
    B) TREMOR
    1) CASE REPORT: Approximately 1 hour after using a selenium sulfide-containing shampoo, a 46-year-old woman developed a tremor of the arms and hands that progressed in severity to a generalized tremor that lasted for 8 hours. The patient had been using the shampoo 2 to 3 times a week for 8 months for treatment of a scalp eruption (Ransone et al, 1961).

Gastrointestinal

    3.8.1) SUMMARY
    A) Both the nonionic and anionic detergents as well as the selenium salts may cause nausea, vomiting and diarrhea. There may also be a burning sensation in the mouth and a garlic-like taste and smell to the breath.
    B) Because these substances are so irritating, it is unlikely that the selenium will be retained for absorption. If large amounts are retained, then care should be taken to observe for systemic neurologic effects. These substances are not caustic.
    3.8.2) CLINICAL EFFECTS
    A) NAUSEA, VOMITING AND DIARRHEA
    1) Both the nonionic and anionic detergents, as well as the selenium salts may cause nausea, vomiting and diarrhea.
    2) CASE REPORT: Vomiting, weakness, anorexia, and abdominal pain occurred following topical application of a selenium sulfide-containing shampoo 2 to 3 times a week for 8 months for treatment of scalp eruptions. The patient completely recovered 10 days after discontinuing use of the shampoo (Ransone et al, 1961).
    B) GARLIC BREATH
    1) There may also be a burning sensation in the mouth and a garlic-like taste and smell to the breath. Because these substances are so irritating, it is unlikely that the selenium will be retained for absorption.
    2) CASE REPORT: A woman experienced a metallic taste in her mouth and a garlic-like breath after using a selenium sulfide-containing shampoo 2 to 3 times a week for 8 months for treatment of excoriated eruptions on her scalp. The symptoms disappeared within 10 days after cessation of the shampoo (Ransone et al, 1961).
    3) If large amounts are retained, then care should be taken to observe for systemic effects. These substances are not caustic.

Hepatic

    3.9.2) CLINICAL EFFECTS
    A) CIRRHOSIS OF LIVER
    1) Although cirrhosis is possible with other selenium salts it is unlikely after ingestions of these products.

Genitourinary

    3.10.2) CLINICAL EFFECTS
    A) RENAL TUBULAR DISORDER
    1) Mild tubular degeneration of the kidneys is an unlikely symptom.

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) DERMATITIS
    1) These materials may be irritating to the skin, especially broken skin and can cause pruritus or burning sensation of the scalp (Gilbertson et al, 2012).
    B) DISCOLORATION OF SKIN
    1) WITH THERAPEUTIC USE
    a) CASE SERIES: Six children (ranging in age from 10-months to 8-years) developed asymptomatic reddish-brown to orange-red discoloration of the scalp after using a selenium shampoo for seborrheic dermatitis. In all cases, the discoloration resolved within a few weeks of discontinuing the shampoo without recurrence. In a few cases, the discoloration was removed with an isopropyl alcohol swab which avoided any further testing or biopsy (Gilbertson et al, 2012).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Laboratory studies are not routinely necessary following exposure.
    B) Serum electrolytes may be necessary in cases of prolonged vomiting and/or diarrhea.
    C) No blood or urine concentrations exist for detergents. Serum selenium concentrations are generally not indicated as absorption is minimal after topical exposure.
    4.1.2) SERUM/BLOOD
    A) BLOOD/SERUM CHEMISTRY
    1) Laboratory studies are not routinely necessary following exposure.
    2) No blood or urine concentrations exist for detergents. Serum selenium concentrations are generally not indicated as absorption is minimal after topical exposure (Noisel et al, 2010).
    3) Serum electrolytes may be necessary in cases of prolonged vomiting and/or diarrhea.
    4.1.3) URINE
    A) URINARY LEVELS
    1) Selenium urine concentrations range from 10 to 150 mcg/L in patients chronically exposed to selenium, yet without symptoms.

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.1) DISPOSITION/ORAL EXPOSURE
    6.3.1.1) ADMISSION CRITERIA/ORAL
    A) Patients with persistent GI symptoms (ie, vomiting, diarrhea) may need to be admitted for further treatment.
    6.3.1.2) HOME CRITERIA/ORAL
    A) Patients experiencing mild mucosal, eye or skin irritation or self-limited GI symptoms following inadvertent ingestion can be managed at home.
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) Consult a medical toxicologist if there is a question or evidence of systemic toxicity. Consult an ophthalmologist for a patient with persistent pain or evidence of corneal injury.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Patients with persistent GI, dermal or eye irritation or if a self-harm ingestion should be referred to a healthcare facility for evaluation and treatment.

Monitoring

    A) Laboratory studies are not routinely necessary following exposure.
    B) Serum electrolytes may be necessary in cases of prolonged vomiting and/or diarrhea.
    C) No blood or urine concentrations exist for detergents. Serum selenium concentrations are generally not indicated as absorption is minimal after topical exposure.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) SUMMARY
    1) Significant toxicity is unlikely unless very large amounts have been ingested. Gastrointestinal decontamination is generally NOT necessary.
    B) DILUTION
    1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    6.5.2) PREVENTION OF ABSORPTION
    A) SUMMARY
    1) Significant toxicity is unlikely unless very large amounts have been ingested. Gastrointestinal decontamination is generally NOT necessary. Dilution with a small amount of water may relieve oral irritation.
    B) DILUTION
    1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    6.5.3) TREATMENT
    A) SUPPORT
    1) Treatment is symptomatic and supportive. In most cases, patients can likely be managed at home. Vomiting may develop if ingested; monitor fluid status and electrolytes, if symptoms persist. Flush the eyes and skin with copious amounts of water following exposure; if irritation or pain persist further evaluation may be necessary. In most cases, severe toxicity is not anticipated with these products.
    B) MONITORING OF PATIENT
    1) Monitor electrolytes if the patient has protracted vomiting or prolonged diarrhea.

Eye Exposure

    6.8.1) DECONTAMINATION
    A) EYE IRRIGATION, ROUTINE: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, an ophthalmologic examination should be performed (Peate, 2007; Naradzay & Barish, 2006).

Dermal Exposure

    6.9.1) DECONTAMINATION
    A) DERMAL DECONTAMINATION
    1) DECONTAMINATION: Remove contaminated clothing and wash exposed area thoroughly with soap and water for 10 to 15 minutes. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).

Abstracts

Case Reports

    A) ADULT
    1) A 46-year-old woman was admitted to the hospital with complaints of weakness and anorexia for 48 hours. She had been using a selenium sulfide shampoo 2 to 3 times/week for 8 months. Forty-eight hours prior to admission the patient had developed progressive tremor of the arms and hands and severe perspiration one hour after the last exposure to the shampoo. Two hours postexposure the patient noticed a metallic taste in her mouth and a garlic breath odor. The tremor lasted 8 hours and was followed by lower abdominal pain. Weakness, lethargy, and anorexia lasted for 3 days. Liver function studies were normal. Laboratory studies showed elevated urinary porphyrins, 24-hour urine selenium level of 28 mcg/mL. Symptoms resolved within 10 days postexposure (Ransone et al, 1961).

Range Of Toxicity

Summary

    A) TOXICITY: Selenium sulfide is a non-soluble salt and is less toxic than the soluble selenites, selenates, and organic selenium compounds. Significant toxicity due to inadvertent exposures to anionic and nonionic detergents alone is not anticipated.

Therapeutic Dose

    7.2.1) ADULT
    A) Apply 1% or 2.5% selenium sulfide shampoo (approximately 30 mL) to a wet scalp. Wait 2 to 3 minutes and then rinse thoroughly. Frequency of application is variable, but 2 to 3 times per week has been suggested to maintain control (Noisel et al, 2010).
    7.2.2) PEDIATRIC
    A) SEBORRHEIC DERMATITIS: Infants and children with seborrheic dermatitis have been treated with 1% selenium sulfide shampoo, and in some cases 2.5% selenium sulfide shampoo has been used to treat a variety of scalp conditions (ie, tinea capitis, atopic dermatitis) (Gilbertson et al, 2012; Chen et al, 2010).

Maximum Tolerated Exposure

    A) SUMMARY
    1) Selenium sulfide is a non-soluble salt and is less toxic than the soluble selenites, selenates, and organic selenium compounds (Henschler & Kirschner, 1969).
    2) Significant toxicity due to inadvertent exposures to anionic and nonionic detergents alone is not anticipated. The amount which produces systemic effects varies considerably with substance and patient.
    B) CASE REPORT
    1) A 46-year-old woman was admitted to the hospital with complaints of weakness and anorexia for 48 hours. She had been using a selenium sulfide shampoo 2 to 3 times/week for 8 months. Forty-eight hours prior to admission the patient had developed progressive tremor of the arms and hands and severe perspiration one hour after the last exposure to the shampoo. Two hours postexposure the patient noticed a metallic taste in her mouth and a garlic breath odor. The tremor lasted 8 hours and was followed by lower abdominal pain. Weakness, lethargy, and anorexia lasted for 3 days. Liver function studies were normal. Laboratory studies showed elevated urinary porphyrins, 24-hour urine selenium level of 28 mcg/mL. Symptoms resolved within 10 days postexposure (Ransone et al, 1961).

Serum Plasma Blood Concentrations

    7.5.1) THERAPEUTIC CONCENTRATIONS
    A) THERAPEUTIC CONCENTRATION LEVELS
    1) In a study of 10 healthy volunteers using selenium shampoo 3 times a week over a month, blood (range: 127 to 233 mg/L) and urine (range: 11.9 to 150 mcg/d) concentrations of selenium remained at baseline range for the general population during the 18-month study period (Noisel et al, 2010).

Toxicity Information

    7.7.1) TOXICITY VALUES
    A) LD50- (ORAL)RAT:
    1) 138 mg/kg (Budavari, 1996)

Pharmacology Toxicology

Pharmacologic Mechanism

    A) Selenium sulfide appears to react with dermatophytic enzymes in vitro forming complexes that can lead to protein precipitation and denaturation(Chen et al, 2010). The cytostatic effect on hyperproliferative keratinocytes and keratolytic effects appear via hydrogen sulfide formation upon interaction with keratinocytes (Gilbertson et al, 2012).

Physicochemical

Physical Characteristics

    1) No information found at the time of this review.

Molecular Weight

    A) Not applicable

References

General Bibliography

    1) Abdel-Rahman SM & Nahata MC: Treatment of tinea capitis. Ann Pharmacother 1997; 31(3):338-348.
    2) Budavari S: The Merck Index, 12th edition, Merck & Co, Inc, Whitehouse Station, NJ, 1996.
    3) Burgess JL, Kirk M, Borron SW, et al: Emergency department hazardous materials protocol for contaminated patients. Ann Emerg Med 1999; 34(2):205-212.
    4) Caravati EM: Alkali. In: Dart RC, ed. Medical Toxicology, Lippincott Williams & Wilkins, Philadelphia, PA, 2004.
    5) Chen C, Koch LH, Dice JE, et al: A randomized, double-blind study comparing the efficacy of selenium sulfide shampoo 1% and ciclopirox shampoo 1% as adjunctive treatments for tinea capitis in children. Pediatr Dermatol 2010; 27(5):459-462.
    6) Gilbertson K, Jarrett R, Bayliss SJ, et al: Scalp discoloration from selenium sulfide shampoo: a case series and review of the literature. Pediatr Dermatol 2012; 29(1):84-88.
    7) Henschler D & Kirschner U: Zur resorption and toxicitat von selensulfid. Arch Toxicol (Berl) 1969; 24:341-344.
    8) Naradzay J & Barish RA: Approach to ophthalmologic emergencies. Med Clin North Am 2006; 90(2):305-328.
    9) Noisel N, Bouchard M, & Carrier G: Disposition kinetics of selenium in healthy volunteers following therapeutic shampoo treatment. Environ Toxicol Pharmacol 2010; 29(3):252-259.
    10) Peate WF: Work-related eye injuries and illnesses. Am Fam Physician 2007; 75(7):1017-1022.
    11) Ransone JW, Scott NM, & Knoblock EC: Selenium sulfide intoxication. N Engl J Med 1961; 264:384-385.