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SUNSCREENS

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) SUNSCREENING AGENTS are physical or chemical agents that reflect or absorb ultraviolet radiation. Refer to the following documents for more information: PARA-AMINOBENZOIC ACID (PABA), SALICYLATES, TALC, ZINC COMPOUNDS.

Specific Substances

    1) Sun block
    2) Sunscreen
    3) Sunscreens

Available Forms Sources

    A) FORMS
    SUNBURN AND TANNING HISTORYRECOMMENDED SPF
    Always burns easily, rarely tans20 to 30
    Always burns easily, minimally tans 12 to under 20
    Burns moderately, tans gradually 8 to under 12
    Burns minimally, always tans well 4 to under 8
    Rarely burns, tans profusely2 to under 4

    1) CHEMICAL SUNSCREEN AGENTS absorb UV light within a specific wavelength range and reduce the penetration of UV light through the skin (USP DI, 2003).
    2) PHYSICAL SUNSCREEN AGENTS reduce UV penetration through the skin by creating a physical barrier that reflects, scatters, absorbs, and blocks UV and visible radiations (USP DI, 2003).
    3) CHEMICAL SUNSCREENS: AMINOBENZOIC ACID AND DERIVATIVES
    1) Aminobenzoic acid (para-aminobenzoic acid or PABA)
    2) Lisadimate (glyceryl PABA)
    3) Padimate O (octyldimethyl PABA)
    4) Roxadimate (ethyl 4-bis [hydroxypropyl] aminobenzoate)
    CHEMICAL SUNSCREENS: ANTHRANILATES
    1) Menthyl anthranilate
    CHEMICAL SUNSCREENS: BENZOPHENONES
    1) Dioxybenzone (benzophenone-8)
    2) Oxybenzone (benzophenone-3)
    3) Sulisobenzone (benzophenone-4)
    CHEMICAL SUNSCREENS: CINNAMATES
    1) Octocrylene (2-ethylhexyl-2-cyano-3,3-diphenylacrylate)
    2) Octyl methoxycinnamate (2-ethylhexyl p-methoxycinnamate)
    CHEMICAL SUNSCREENS: DIBENZOYLMETHANES
    1) Avobenzone (t-butyl dimethoxydibenzoylmethane)
    SALICYLATES
    1) Homosalate (homomenthyl salicylate)
    2) Octyl salicylate (2-ethylhexyl salicylate)
    3) Trolamine salicylate (Triethanolamine salicylate)
    MISCELLANEOUS
    1) Phenylbenzimidazole (2-Phenylbenzimidazole-5-sulfonic acid)
    PHYSICAL SUNSCREENS
    1) Titanium dioxide
    2) Zinc oxide

    4) PABA and its esters are common ingredients in sunblocking or sunscreening products (Sandmeyer & Kirwin, 1981).
    5) Most products currently available on the market identify a sun protection factor (SPF) value for the formulation. SPF is based upon the minimal erythema dose (MED) value, which is the dose of radiation at a specific wavelength that will produce a delayed erythemal response. SPF is then defined as the MED protected skin/MED unprotected skin and varies according to the formulation, active ingredients, and skin reactivity. Higher SPFs will inhibit not only burning but also tanning ((Anon, 1997)).
    6) In 1993, the US Food and Drug Administration suggested an upper SPF limit of 30 because it was felt that anything above this offers little additional benefit and may expose people to dangerous levels of chemicals. It is recommended that broad-spectrum products with SPFs of at least 15 be used. Because babies’ bodies may not be developed enough to handle sunscreen chemicals, sunscreens should not be used on babies younger than 6 months of age. For children aged 6 months to 2 years, it is recommended to use a sunscreen with an SPF of at least 4, although 15 or higher is considered best. The following SPF guidelines are recommended based on individual sunburn and tanning history ((Anon, 1997)):
    SUNBURN AND TANNING HISTORYRECOMMENDED SPF
    Always burns easily, rarely tans20 to 30
    Always burns easily, minimally tans 12 to under 20
    Burns moderately, tans gradually 8 to under 12
    Burns minimally, always tans well 4 to under 8
    Rarely burns, tans profusely2 to under 4

    B) USES
    1) SUNSCREENING AGENTS are used to prevent sunburn, actinic keratosis, and premature skin aging and to reduce the incidence of skin cancer.

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: Sunscreening agents are used to prevent sunburn, actinic keratosis, and premature skin aging and to reduce the incidence of skin cancer. Refer to the following documents for more information: PARA-AMINOBENZOIC ACID (PABA), SALICYLATES, TALC, ZINC OXIDE-TOPICAL.
    B) PHARMACOLOGY: UV radiation from the sun is divided into 3 spectrums based on wavelengths: UV-A (320 to 400 nanometers [nm]), UV-B (290 to 320 nm), and UV-C (200 to 290 nm). The cutaneous effects from sun exposure are directly related to the wavelength and the total dose of UV radiation. The wavelength of radiation from the UV-B range produces sunburns, malignancies, and tanning, whereas radiation from the UV-A spectrum produces tanning and may act synergistically with UV-B radiation to promote malignancies. Because of particle size, physical sunscreen formulations scatter or reflect up to 99% of UV radiation throughout the entire spectrum (290 to 700 nm), thereby preventing or minimizing sunburns, photoaging, and tanning. Chemical sunscreen agents absorb UV light within a specific wavelength range and reduce the penetration of UV light through the skin.
    C) EPIDEMIOLOGY: Exposure is common, but severe toxicity is not expected.
    D) WITH POISONING/EXPOSURE
    1) Generally, sunscreening agents are very well tolerated. Contact dermatitis, miliaria, and folliculitis have developed following the application of topical sunscreens. Mild nausea, vomiting, or diarrhea may develop after ingestion of these products.

Laboratory Monitoring

    A) No specific laboratory tests are necessary unless otherwise clinically indicated.
    B) Monitor serum electrolytes in patients with significant vomiting and/or diarrhea.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) MANAGEMENT OF TOXICITY
    1) Treatment is symptomatic and supportive. Maintain adequate hydration if vomiting or diarrhea becomes extensive. Refer to the following documents for further information: PARA-AMINOBENZOIC ACID (PABA), SALICYLATES, TALC, ZINC OXIDE-TOPICALS.
    B) DECONTAMINATION
    1) PREHOSPITAL: INGESTION: Toxicity is negligible. Gastrointestinal decontamination is generally unnecessary.
    2) HOSPITAL: Gastrointestinal decontamination is generally unnecessary. Consider activated charcoal only if coingestants with significant toxicity are involved.
    C) ANTIDOTE
    1) None.
    D) HYPERSENSITIVITY REACTION
    1) MILD/MODERATE: Antihistamines with or without inhaled beta agonists, corticosteroids or epinephrine. SEVERE: Oxygen, aggressive airway management, antihistamines, epinephrine, corticosteroids, ECG monitoring, and IV fluids.
    E) ENHANCED ELIMINATION
    1) Hemodialysis, hemoperfusion, and peritoneal dialysis are not necessary in these cases.
    F) PATIENT DISPOSITION
    1) HOME CRITERIA: A patient with an inadvertent exposure, that remains asymptomatic can be managed at home. Most cases of exposure to sunscreens can be safely managed at home. Minor gastrointestinal effects such as diarrhea or vomiting may occur.
    2) OBSERVATION CRITERIA: Patients with deliberate/self harm ingestions should be referred to a healthcare facility.
    3) ADMISSION CRITERIA: Patients should be admitted for severe vomiting, profuse diarrhea, severe abdominal pain, dehydration, and electrolyte abnormalities.
    4) CONSULT CRITERIA: Consult a poison center or medical toxicologist for assistance in managing patients with severe toxicity or in whom the diagnosis is not clear.
    G) PITFALLS
    1) Missing an ingestion of another chemical or other possible etiologies for a patient’s symptoms. History of exposure may be difficult to obtain in some settings.
    H) DIFFERENTIAL DIAGNOSIS
    1) Other chemicals or drugs that cause gastrointestinal distress.
    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) A minimum toxic dose has not been established. Significant toxicity is not expected.

Clinical Effects

Summary Of Exposure

    A) USES: Sunscreening agents are used to prevent sunburn, actinic keratosis, and premature skin aging and to reduce the incidence of skin cancer. Refer to the following documents for more information: PARA-AMINOBENZOIC ACID (PABA), SALICYLATES, TALC, ZINC OXIDE-TOPICAL.
    B) PHARMACOLOGY: UV radiation from the sun is divided into 3 spectrums based on wavelengths: UV-A (320 to 400 nanometers [nm]), UV-B (290 to 320 nm), and UV-C (200 to 290 nm). The cutaneous effects from sun exposure are directly related to the wavelength and the total dose of UV radiation. The wavelength of radiation from the UV-B range produces sunburns, malignancies, and tanning, whereas radiation from the UV-A spectrum produces tanning and may act synergistically with UV-B radiation to promote malignancies. Because of particle size, physical sunscreen formulations scatter or reflect up to 99% of UV radiation throughout the entire spectrum (290 to 700 nm), thereby preventing or minimizing sunburns, photoaging, and tanning. Chemical sunscreen agents absorb UV light within a specific wavelength range and reduce the penetration of UV light through the skin.
    C) EPIDEMIOLOGY: Exposure is common, but severe toxicity is not expected.
    D) WITH POISONING/EXPOSURE
    1) Generally, sunscreening agents are very well tolerated. Contact dermatitis, miliaria, and folliculitis have developed following the application of topical sunscreens. Mild nausea, vomiting, or diarrhea may develop after ingestion of these products.

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) NAUSEA AND VOMITING
    1) WITH POISONING/EXPOSURE
    a) Nausea, vomiting, or diarrhea may develop after fairly large ingestions of these products.

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) SKIN FINDING
    1) WITH POISONING/EXPOSURE
    a) Acne, irritation, rash, and folliculitis may occur with sunscreen agents (USP DI, 2003).
    b) In a sunscreen trial, 90 of 603 participants experienced pruritus, skin flakiness, dryness, blistering, and rash (urticaria, maculopapular, acne, vesicles, and erythema). Symptoms occurred in greater than 50% of participants between 5 days and 3 months of product use (Foley et al, 1993).
    c) Application of zinc oxide to severely chapped lips resulted in mucocutaneous pigmentation (a black macule that contained zinc granules) (Greenberg et al, 2000).
    d) Contact dermatitis has developed following the use of sunscreens containing PABA and PABA esters, especially glyceryl PABA. Contact dermatitis due to PABA sunscreens has also been associated with excipients and preservatives (Fisher, 1992a).
    e) Contact dermatitis has been reported rarely with the use of benzophenones, cinnamates, salicylates, and anthranilates (USP DI, 2003; Ricci et al, 1998; Fisher, 1992b; Fisher, 1992c; Fisher, 1992d; DeSimone, 1990).
    f) A sunscreen containing a PABA derivative, a benzophenone; octocrylene, a salicylate; and a cinnamate produced a significantly higher irritation score (p=0.04) on the faces of patients with rosacea than did the same sunscreen with added dimethicone and cyclomethicone (Nichols et al, 1998).
    g) Among 370 patients in France with suspected photodermatitis, 15% showed contact allergy or photocontact allergy to sunscreens in patch tests with concentrations of 2% or 10%. Most reactions to sunscreens were related to oxybenzone and isopropyl dibenzoylmethane. Neither of those agents is used currently in sunscreens in France, although they may still be incorporated in some cosmetics (Journe et al, 1999).
    h) CASE REPORT: Milia occurred following allergic contact dermatitis. A 49-year-old man experienced allergic contact dermatitis, consisting of severe erythema and swelling of the limbs, within 24 hours of applying sunscreens to his skin (Reimann P20(R) and Delial F20(R) sunmilk). Eight months later, he had clusters of 1 to 2 mm, asymptomatic white papules on his forearms. PABA and Reimann P20 sunscreen patch tests were strongly positive (Ibbotson et al, 1996).

Immunologic

    3.19.2) CLINICAL EFFECTS
    A) ACUTE ALLERGIC REACTION
    1) WITH POISONING/EXPOSURE
    a) Allergic contact dermatitis has been reported following the use of sunscreen agents (USP DI, 2003).
    b) CASE REPORT: Anaphylactic reaction, observed as generalized cutaneous wheal-and-flare reaction, dyspnea, and fainting, occurred 10 minutes after widespread application of sunscreen. Urticaria, without systemic reaction, developed upon sunscreen contact with a small surface area. Patch testing on a patient produced wheal-and-flare reaction to oxybenzone, with further negative reactions to other elements of sunscreen (Emonet et al, 2001).

Carcinogenicity

    3.21.1) IARC CATEGORY
    A) IARC Carcinogenicity Ratings for CAS150-13-0 (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004):
    1) IARC Classification
    a) Listed as: para-Aminobenzoic acid
    b) Carcinogen Rating: 3
    1) The agent (mixture or exposure circumstance) is not classifiable as to its carcinogenicity to humans. This category is used most commonly for agents, mixtures and exposure circumstances for which the evidence of carcinogenicity is inadequate in humans and inadequate or limited in experimental animals. Exceptionally, agents (mixtures) for which the evidence of carcinogenicity is inadequate in humans but sufficient in experimental animals may be placed in this category when there is strong evidence that the mechanism of carcinogenicity in experimental animals does not operate in humans. Agents, mixtures and exposure circumstances that do not fall into any other group are also placed in this category.
    B) IARC Carcinogenicity Ratings for CAS131-57-7 (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004):
    1) Not Listed
    C) IARC Carcinogenicity Ratings for CAS118-56-9 (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004):
    1) Not Listed
    D) IARC Carcinogenicity Ratings for CAS21245-02-3 (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004):
    1) Not Listed
    E) IARC Carcinogenicity Ratings for CAS4065-45-6 (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004):
    1) Not Listed

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) No specific laboratory tests are necessary unless otherwise clinically indicated.
    B) Monitor serum electrolytes in patients with significant vomiting and/or diarrhea.

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 should be admitted for severe vomiting, profuse diarrhea, severe abdominal pain, dehydration, and electrolyte abnormalities.
    6.3.1.2) HOME CRITERIA/ORAL
    A) A patient with an inadvertent exposure, that remains asymptomatic can be managed at home. Most cases of exposure to sunscreens can be safely managed at home. Minor gastrointestinal effects such as diarrhea or vomiting may occur.
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) Consult a poison center or medical toxicologist for assistance in managing patients with severe toxicity or in whom the diagnosis is not clear.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Patients with deliberate/self harm ingestions should be referred to a healthcare facility.

Monitoring

    A) No specific laboratory tests are necessary unless otherwise clinically indicated.
    B) Monitor serum electrolytes in patients with significant vomiting and/or diarrhea.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) INGESTION: Toxicity is negligible. Gastrointestinal decontamination is generally unnecessary.
    6.5.2) PREVENTION OF ABSORPTION
    A) SUMMARY
    1) Gastrointestinal decontamination is generally unnecessary. Consider activated charcoal only if coingestants with significant toxicity are involved.
    B) ACTIVATED CHARCOAL
    1) CHARCOAL ADMINISTRATION
    a) Consider administration of activated charcoal after a potentially toxic ingestion (Chyka et al, 2005). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.
    2) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    6.5.3) TREATMENT
    A) MONITORING OF PATIENT
    1) No specific laboratory tests are necessary unless otherwise clinically indicated.
    2) Monitor serum electrolytes in patients with significant vomiting and/or diarrhea.
    B) ACUTE ALLERGIC REACTION
    1) SUMMARY
    a) Mild to moderate allergic reactions may be treated with antihistamines with or without inhaled beta adrenergic agonists, corticosteroids or epinephrine. Treatment of severe anaphylaxis also includes oxygen supplementation, aggressive airway management, epinephrine, ECG monitoring, and IV fluids.
    2) BRONCHOSPASM
    a) ALBUTEROL
    1) ADULT: 2.5 to 5 milligrams in 2 to 4.5 milliliters of normal saline delivered per nebulizer every 20 minutes up to 3 doses. If incomplete response administer 2.5 to 10 mg every 1 to 4 hours as needed, or 10 to 15 mg/hr by continuous nebulization as needed (National Heart,Lung,and Blood Institute, 2007). CHILD: 0.15 milligram/kilogram (minimum 2.5 milligrams) per nebulizer every 20 minutes up to 3 doses. If incomplete response administer 0.15 to 0.3 mg/kg (up to 10 mg) every 1 to 4 hours as needed, or 0.5 mg/kg/hr by continuous nebulization (National Heart,Lung,and Blood Institute, 2007).
    3) CORTICOSTEROIDS
    a) Consider systemic corticosteroids in patients with significant bronchospasm.
    b) PREDNISONE: ADULT: 40 to 80 milligrams/day. CHILD: 1 to 2 milligrams/kilogram/day (maximum 60 mg) in 1 to 2 divided doses divided twice daily (National Heart,Lung,and Blood Institute, 2007).
    4) MILD CASES
    a) DIPHENHYDRAMINE
    1) SUMMARY: Oral diphenhydramine, as well as other H1 antihistamines can be used as indicated (Lieberman et al, 2010).
    2) ADULT: 50 milligrams orally, or 10 to 50 mg intravenously at a rate not to exceed 25 mg/min or may be given by deep intramuscular injection. A total of 100 mg may be administered if needed. Maximum daily dosage is 400 mg (Prod Info diphenhydramine HCl intravenous injection solution, intramuscular injection solution, 2013).
    3) CHILD: 5 mg/kg/24 hours or 150 mg/m(2)/24 hours. Divided into 4 doses, administered intravenously at a rate not exceeding 25 mg/min or by deep intramuscular injection. Maximum daily dosage is 300 mg (Prod Info diphenhydramine HCl intravenous injection solution, intramuscular injection solution, 2013).
    5) MODERATE CASES
    a) EPINEPHRINE: INJECTABLE SOLUTION: It should be administered early in patients by IM injection. Using a 1:1000 (1 mg/mL) solution of epinephrine. Initial Dose: 0.01 mg/kg intramuscularly with a maximum dose of 0.5 mg in adults and 0.3 mg in children. The dose may be repeated every 5 to 15 minutes, if no clinical improvement. Most patients respond to 1 or 2 doses (Nowak & Macias, 2014).
    6) SEVERE CASES
    a) EPINEPHRINE
    1) INTRAVENOUS BOLUS: ADULT: 1 mg intravenously as a 1:10,000 (0.1 mg/mL) solution; CHILD: 0.01 mL/kg intravenously to a maximum single dose of 1 mg given as a 1:10,000 (0.1 mg/mL) solution. It can be repeated every 3 to 5 minutes as needed. The dose can also be given by the intraosseous route if IV access cannot be established (Lieberman et al, 2015). ALTERNATIVE ROUTE: ENDOTRACHEAL ADMINISTRATION: If IV/IO access is unavailable. DOSE: ADULT: Administer 2 to 2.5 mg of 1:1000 (1 mg/mL) solution diluted in 5 to 10 mL of sterile water via endotracheal tube. CHILD: DOSE: 0.1 mg/kg to a maximum of 2.5 mg administered as a 1:1000 (1 mg/mL) solution diluted in 5 to 10 mL of sterile water via endotracheal tube (Lieberman et al, 2015).
    2) INTRAVENOUS INFUSION: Intravenous administration may be considered in patients poorly responsive to IM or SubQ epinephrine. An epinephrine infusion may be prepared by adding 1 mg (1 mL of 1:1000 (1 mg/mL) solution) to 250 mL D5W, yielding a concentration of 4 mcg/mL, and infuse this solution IV at a rate of 1 mcg/min to 10 mcg/min (maximum rate). CHILD: A dosage of 0.01 mg/kg (0.1 mL/kg of a 1:10,000 (0.1 mg/mL) solution up to 10 mcg/min (maximum dose 0.3 mg) is recommended for children (Lieberman et al, 2010). Careful titration of a continuous infusion of IV epinephrine, based on the severity of the reaction, along with a crystalloid infusion can be considered in the treatment of anaphylactic shock. It appears to be a reasonable alternative to IV boluses, if the patient is not in cardiac arrest (Vanden Hoek,TL,et al).
    7) AIRWAY MANAGEMENT
    a) OXYGEN: 5 to 10 liters/minute via high flow mask.
    b) INTUBATION: Perform early if any stridor or signs of airway obstruction.
    c) CRICOTHYROTOMY: Use if unable to intubate with complete airway obstruction (Vanden Hoek,TL,et al).
    d) BRONCHODILATORS are recommended for mild to severe bronchospasm.
    e) ALBUTEROL: ADULT: 2.5 to 5 milligrams in 2 to 4.5 milliliters of normal saline delivered per nebulizer every 20 minutes up to 3 doses. If incomplete response administer 2.5 to 10 mg every 1 to 4 hours as needed, or 10 to 15 mg/hr by continuous nebulization as needed (National Heart,Lung,and Blood Institute, 2007).
    f) ALBUTEROL: CHILD: 0.15 milligram/kilogram (minimum 2.5 milligrams) per nebulizer every 20 minutes up to 3 doses. If incomplete response administer 0.15 to 0.3 milligram/kilogram (maximum 10 milligrams) every 1 to 4 hours as needed OR administer 0.5 mg/kg/hr by continuous nebulization (National Heart,Lung,and Blood Institute, 2007).
    8) MONITORING
    a) CARDIAC MONITOR: All complicated cases.
    b) IV ACCESS: Routine in all complicated cases.
    9) HYPOTENSION
    a) If hypotensive give 500 to 2000 milliliters crystalloid initially (20 milliliters/kilogram in children) and titrate to desired effect (stabilization of vital signs, mentation, urine output); adults may require up to 6 to 10 L/24 hours. Central venous or pulmonary artery pressure monitoring is recommended in patients with persistent hypotension.
    1) VASOPRESSORS: Should be used in refractory cases unresponsive to repeated doses of epinephrine and after vigorous intravenous crystalloid rehydration (Lieberman et al, 2010).
    2) DOPAMINE: Initial Dose: 2 to 20 micrograms/kilogram/minute intravenously; titrate to maintain systolic blood pressure greater than 90 mm Hg (Lieberman et al, 2010).
    10) H1 and H2 ANTIHISTAMINES
    a) SUMMARY: Antihistamines are second-line therapy and are used as supportive therapy and should not be used in place of epinephrine (Lieberman et al, 2010).
    1) DIPHENHYDRAMINE: ADULT: 25 to 50 milligrams via a slow intravenous infusion or IM. PEDIATRIC: 1 milligram/kilogram via slow intravenous infusion or IM up to 50 mg in children (Lieberman et al, 2010).
    b) RANITIDINE: ADULT: 1 mg/kg parenterally; CHILD: 12.5 to 50 mg parenterally. If the intravenous route is used, ranitidine should be infused over 10 to 15 minutes or diluted in 5% dextrose to a volume of 20 mL and injected over 5 minutes (Lieberman et al, 2010).
    c) Oral diphenhydramine, as well as other H1 antihistamines, can also be used as indicated (Lieberman et al, 2010).
    11) DYSRHYTHMIAS
    a) Dysrhythmias and cardiac dysfunction may occur primarily or iatrogenically as a result of pharmacologic treatment (epinephrine) (Vanden Hoek,TL,et al). Monitor and correct serum electrolytes, oxygenation and tissue perfusion. Treat with antiarrhythmic agents as indicated.
    12) OTHER THERAPIES
    a) There have been a few reports of patients with anaphylaxis, with or without cardiac arrest, that have responded to vasopressin therapy that did not respond to standard therapy. Although there are no randomized controlled trials, other alternative vasoactive therapies (ie, vasopressin, norepinephrine, methoxamine, and metaraminol) may be considered in patients in cardiac arrest secondary to anaphylaxis that do not respond to epinephrine (Vanden Hoek,TL,et al).

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 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).
    6.9.2) TREATMENT
    A) SKIN IRRITATION
    1) Treat dermal irritation or burns with standard topical therapy. Patients developing dermal hypersensitivity reactions may require treatment with systemic or topical corticosteroids or antihistamines.
    B) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Range Of Toxicity

Summary

    A) A minimum toxic dose has not been established. Significant toxicity is not expected.

Therapeutic Dose

    7.2.1) ADULT
    A) CHEMICAL SUNSCREENS
    1) Chemical sunscreening agents should be applied liberally over exposed areas, 2 hours prior to exposure for those preparations containing PABA or PABA esters or 30 minutes prior to exposure for those preparations containing benzophenones, salicylates, anthranilates, cinnamates, or dibenzoylmethanes. The minimal erythema dose is 2 mg/cm(2) for unprotected skin (FDA, 1978).
    2) The proper amount of sunscreening agent to be applied has been divided based on anatomical parts. Nine portions, each portion approximating one-half teaspoonful, are required to provide protection for the average person. One-half teaspoon (2.5 mL) of sunscreen should be applied to each of the following areas: the face and neck, each arm and shoulder, and each side of the torso. One teaspoon (5 mL) should be applied to each side of the leg and to the top of the foot (DeSimone, 1990).
    B) SPF SELECTION
    1) In a review, the use of SPF (sun protection factor) 30 is recommended for individuals with continual outdoor exposure and SPF 15 for routine use on areas exposed to sun (Stiller et al, 1992). An SPF of at least 15 should be used for type I and II skin, SPF 10 to 15 for type III skin, SPF 6 to 10 for type IV skin, and SPF 4 to 6 for type V skin. Sunscreen is not routinely required for type VI skin.
    a) SKIN TYPES
    1) I. Always burns easily, rarely tans
    2) II. Always burns easily, tans minimally
    3) III. Burns moderately, tans gradually (light-brown, normal)
    4) IV. Burns minimally, always tans well (moderate-brown, normal)
    5) V. Rarely burns, tans profusely (dark-brown, insensitive)
    6) VI. Never burns, deeply pigmented (insensitive)
    b) SPF greater than 15 should be used in patients with a history of skin cancer or photosensitivity disease (Stiller et al, 1992).
    7.2.2) PEDIATRIC
    A) NEONATES: A US Food and Drug Administration panel of experts does not recommend the use of sunscreens for infants aged 6 months and younger on the theoretical basis that percutaneous absorption is greater in infants than in adults, and the excretory system is not fully mature (FDA, 1978).
    B) CHILDREN: Sunscreening preparations possessing an SPF of less than 3 should not be used on children younger than 2 years old.

Workplace Standards

    A) ACGIH TLV Values for CAS150-13-0 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Not Listed

    B) ACGIH TLV Values for CAS131-57-7 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Not Listed

    C) ACGIH TLV Values for CAS118-56-9 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Not Listed

    D) ACGIH TLV Values for CAS21245-02-3 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Not Listed

    E) ACGIH TLV Values for CAS4065-45-6 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Not Listed

    F) NIOSH REL and IDLH Values for CAS150-13-0 (National Institute for Occupational Safety and Health, 2007):
    1) Not Listed

    G) NIOSH REL and IDLH Values for CAS131-57-7 (National Institute for Occupational Safety and Health, 2007):
    1) Not Listed

    H) NIOSH REL and IDLH Values for CAS118-56-9 (National Institute for Occupational Safety and Health, 2007):
    1) Not Listed

    I) NIOSH REL and IDLH Values for CAS21245-02-3 (National Institute for Occupational Safety and Health, 2007):
    1) Not Listed

    J) NIOSH REL and IDLH Values for CAS4065-45-6 (National Institute for Occupational Safety and Health, 2007):
    1) Not Listed

    K) Carcinogenicity Ratings for CAS150-13-0 :
    1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed
    2) EPA (U.S. Environmental Protection Agency, 2011): Not Listed
    3) IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): 3 ; Listed as: para-Aminobenzoic acid
    a) 3 : The agent (mixture or exposure circumstance) is not classifiable as to its carcinogenicity to humans. This category is used most commonly for agents, mixtures and exposure circumstances for which the evidence of carcinogenicity is inadequate in humans and inadequate or limited in experimental animals. Exceptionally, agents (mixtures) for which the evidence of carcinogenicity is inadequate in humans but sufficient in experimental animals may be placed in this category when there is strong evidence that the mechanism of carcinogenicity in experimental animals does not operate in humans. Agents, mixtures and exposure circumstances that do not fall into any other group are also placed in this category.
    4) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed
    5) MAK (DFG, 2002): Not Listed
    6) NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

    L) Carcinogenicity Ratings for CAS131-57-7 :
    1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed
    2) EPA (U.S. Environmental Protection Agency, 2011): Not Listed
    3) IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): Not Listed
    4) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed
    5) MAK (DFG, 2002): Not Listed
    6) NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

    M) Carcinogenicity Ratings for CAS118-56-9 :
    1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed
    2) EPA (U.S. Environmental Protection Agency, 2011): Not Listed
    3) IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): Not Listed
    4) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed
    5) MAK (DFG, 2002): Not Listed
    6) NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

    N) Carcinogenicity Ratings for CAS21245-02-3 :
    1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed
    2) EPA (U.S. Environmental Protection Agency, 2011): Not Listed
    3) IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): Not Listed
    4) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed
    5) MAK (DFG, 2002): Not Listed
    6) NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

    O) Carcinogenicity Ratings for CAS4065-45-6 :
    1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed
    2) EPA (U.S. Environmental Protection Agency, 2011): Not Listed
    3) IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): Not Listed
    4) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed
    5) MAK (DFG, 2002): Not Listed
    6) NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

    P) OSHA PEL Values for CAS150-13-0 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Not Listed

    Q) OSHA PEL Values for CAS131-57-7 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Not Listed

    R) OSHA PEL Values for CAS118-56-9 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Not Listed

    S) OSHA PEL Values for CAS21245-02-3 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Not Listed

    T) OSHA PEL Values for CAS4065-45-6 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Not Listed

Pharmacology Toxicology

Pharmacologic Mechanism

    A) UV radiation from the sun is divided into 3 spectrums based on wavelengths: UV-A (320 to 400 nanometers [nm]), UV-B (290 to 320 nm), and UV-C (200 to 290 nm). The cutaneous effects from sun exposure are directly related to the wavelength and the total dose of UV radiation. The wavelength of radiation from the UV-B range produces sunburns, malignancies, and tanning, whereas radiation from the UV-A spectrum produces tanning and may act synergistically with UV-B radiation to promote malignancies. Because of particle size, physical sunscreen formulations scatter or reflect up to 99% of UV radiation throughout the entire spectrum (290 to 700 nm), thereby preventing or minimizing sunburns, photoaging, and tanning. Chemical sunscreens absorb UV radiation. The different UV-B sunscreening agents found within specific groups absorb radiation over a wide spectrum (Taylor et al, 1990; DeSimone, 1990; FDA, 1978).
    B) The efficacy of a sunscreen is determined by the substantivity of the screening agent and the product's SPF. Substantivity is determined by the physiochemical properties in the formulation of the sunscreening agent and reflects how well the agent penetrates the dermis and attaches to the protein in the stratum corneum. SPFs are determined indoors using solar simulators that are equipped with high-intensity xenon lamps, which produce the spectral quality of UV-B radiation. SPFs are derived by dividing the minimal dose of UV-B radiation required to produce erythema on photo-protected skin compared to the dose of UV-B radiation required to produce erythema on skin that is unprotected. Controversy surrounds the accuracy of solar simulators in indicating the ability of a sunscreening agent to absorb radiation. It should be emphasized that SPFs should be used in a comparative manner and not as an absolute value because a variety factors influence SPFs (eg, concentration of ingredients, application thickness, vehicle, environmental factors, altitude, latitude, and time of day) (Taylor et al, 1990; DeSimone, 1990).

Physicochemical

Molecular Weight

    1) Aminobenzoic acid: 137.14(USP DI, 2003)
    2) Avobenzone: 310.40 (USP DI, 2003)
    3) Dioxybenzone: 244.25 (USP DI, 2003)
    4) Homosalate: 262.35 (USP DI, 2003)
    5) Lisadimate: 211.22 (USP DI, 2003)
    6) Menthyl anthranilate: 151.16 (USP DI, 2003)
    7) Octocrylene: 361.49 (USP DI, 2003)
    8) Octyl methoxycinnamate: 290.40 (USP DI, 2003)
    9) Octyl salicylate: 250 (USP DI, 2003)
    10) Oxybenzone: 228.25 (USP DI, 2003)
    11) Padimate O: 277.41 (USP DI, 2003)
    12) Phenylbenzimidazole sulfonic acid: 274 (USP DI, 2003)
    13) Roxadimate: 281.35 (USP DI, 2003)
    14) Sulisobenzone: 308.31 (USP DI, 2003)
    15) Titanium dioxide: 79.88 (USP DI, 2003)
    16) Trolamine salicylate: 287 (USP DI, 2003)
    17) Zinc oxide: 81.39 (USP DI, 2003)

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