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ZINC OXIDE-TOPICAL

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Topical zinc oxide products are skin protectants. Zinc oxide-containing topical products may contain vitamin E, A, or D. Refer to specific vitamin managements for more information.

Specific Substances

    1) Topical zinc oxide

Available Forms Sources

    A) FORMS
    1) Zinc oxide is incorporated in powders, creams, ointments, bandages, gauze, and pastes.
    2) Medicinal grade contains 99.5% or more of zinc oxide.
    3) Calamine is a pink powder containing not less than 98% zinc oxide and a small amount of ferric oxide. Zinc oxide is commonly mixed with other topical medicinal agents.
    4) REFERENCES: (Gilman, 1985; Sax & Lewis, 1987; Budavari, 1996; HSDB, 2002)
    B) USES
    1) Zinc oxide is incorporated in powders, creams, ointments, bandages, gauze, and pastes as an astringent and topical protectant. Zinc oxide-containing preparations are used for diaper rash, sunburn prevention, wounds, skin ulcers, and other skin conditions. It is also used in dental cements, disclosure waxes, and impression pastes. Medicinal grade contains 99.5% or more of zinc oxide. Calamine is a pink powder containing more than 98% zinc oxide and a small amount of ferric oxide.
    2) MEDICAL
    a) Zinc oxide is incorporated in powders, creams, ointments, bandages, gauze, and pastes as an astringent and topical protectant. Zinc oxide-containing preparations are used for diaper rash, sunburn prevention, and treatment of wounds, skin ulcers, and other skin conditions.
    3) DENTAL
    a) Used with syrupy phosphoric acid or zinc chloride in dental cements
    b) Used in dental disclosure waxes
    c) Used in zinc oxide-eugenol dental impression pastes
    4) OTHER: Used in cosmetics and driers
    5) REFERENCES: (Hegsted et al, 1945; Hallmans & Liden, 1979; Gilman, 1985; Budavari, 1996; Agren, 1993; Lewis, 1993; HSDB, 2002)

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: Zinc oxide is incorporated in powders, creams, ointments, bandages, gauze, and pastes as an astringent and topical protectant. Zinc oxide-containing preparations are used for diaper rash, sunburn prevention, wounds, skin ulcers, and other skin conditions. It is also used in dental cements, disclosure waxes, and impression pastes. Medicinal grade contains 99.5% or more of zinc oxide. Calamine is a pink powder containing more than 98% zinc oxide and a small amount of ferric oxide.
    B) PHARMACOLOGY: Topical zinc oxide has astringent and bactericidal properties. The exact mechanism of action of zinc oxide is unknown, but it may promote healing by increasing collagen breakdown in necrotic wound tissue.
    C) EPIDEMIOLOGY: Exposure to zinc oxide containing topical products is common; however, severe toxicity has not been reported after ingestion or dermal application.
    D) WITH POISONING/EXPOSURE
    1) Most ingestions involve a mouthful or two of the products and only minor symptoms may occur. Nausea, vomiting, and diarrhea may occur primarily due to the zinc or product emollient base. Refer to "LAXATIVE-EMOLLIENT" document for more information.
    2) A man developed gastroduodenal corrosive injury after the ingestion of 150 g of 10% zinc oxide lotion.
    3) Zinc oxide-containing topical products may contain vitamin E, A, or D. Refer to specific vitamin managements for more information.

Laboratory Monitoring

    A) Usually no laboratory work is necessary. If chronic ingestions of large amounts are suspected, zinc concentrations may be requested.

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.
    B) DECONTAMINATION
    1) INGESTION: Toxicity is negligible. Nausea, vomiting, and diarrhea may occur primarily due to the zinc or product emollient base. Decontamination should not be necessary. DERMAL: No treatment is necessary for dermal exposures.
    C) ANTIDOTE
    1) None. Although chelation therapy will increase the excretion of zinc, it is not likely to be necessary unless large amounts have been taken chronically. Refer to "ZINC COMPOUNDS" document for more information.
    D) ENHANCED ELIMINATION
    1) Hemodialysis, hemoperfusion, and peritoneal dialysis are not necessary in these cases.
    E) PATIENT DISPOSITION
    1) HOME CRITERIA: Exposure to topical zinc-oxide products 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.
    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.

Range Of Toxicity

    A) TOXICITY: A toxic dose has not been established. Ingestion of small amounts of zinc oxide ointment (10% to 40%) by children does not produce significant effects. An adult developed mild gastroduodenal corrosive injury after the ingestion of 150 g of 10% zinc oxide lotion.

Clinical Effects

Summary Of Exposure

    A) USES: Zinc oxide is incorporated in powders, creams, ointments, bandages, gauze, and pastes as an astringent and topical protectant. Zinc oxide-containing preparations are used for diaper rash, sunburn prevention, wounds, skin ulcers, and other skin conditions. It is also used in dental cements, disclosure waxes, and impression pastes. Medicinal grade contains 99.5% or more of zinc oxide. Calamine is a pink powder containing more than 98% zinc oxide and a small amount of ferric oxide.
    B) PHARMACOLOGY: Topical zinc oxide has astringent and bactericidal properties. The exact mechanism of action of zinc oxide is unknown, but it may promote healing by increasing collagen breakdown in necrotic wound tissue.
    C) EPIDEMIOLOGY: Exposure to zinc oxide containing topical products is common; however, severe toxicity has not been reported after ingestion or dermal application.
    D) WITH POISONING/EXPOSURE
    1) Most ingestions involve a mouthful or two of the products and only minor symptoms may occur. Nausea, vomiting, and diarrhea may occur primarily due to the zinc or product emollient base. Refer to "LAXATIVE-EMOLLIENT" document for more information.
    2) A man developed gastroduodenal corrosive injury after the ingestion of 150 g of 10% zinc oxide lotion.
    3) Zinc oxide-containing topical products may contain vitamin E, A, or D. Refer to specific vitamin managements for more information.

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) NAUSEA, VOMITING AND DIARRHEA
    1) WITH POISONING/EXPOSURE
    a) INGESTION: Nausea, vomiting, and diarrhea may occur primarily due to the zinc or product emollient base (JEF Reynolds , 1989).
    B) GASTROINTESTINAL COMPLICATION
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT - A 39-year-old man presented with nausea, vomiting, and abdominal pain 6 hours after ingesting 150 g of 10% zinc oxide lotion. Esophagogastroduodenoscopy 8 hours post-ingestion showed corrosive injury to the stomach (Zargar's grade 2b; circumferential ulcerations and exudates in the whole stomach) and the duodenum (Zargar's grade 1). His symptoms improved 3 days post-ingestion. On the 5th day of admission, a second esophagogastroduodenoscopy revealed regression of the corrosive injury without cicatrization. He did not experience any systemic toxicity (Liu et al, 2006).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Usually no laboratory work is necessary. If chronic ingestions of large amounts are suspected, zinc concentrations may be requested.

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.1) DISPOSITION/ORAL EXPOSURE
    6.3.1.2) HOME CRITERIA/ORAL
    A) Exposure to topical zinc-oxide products can be safely managed at home. Minor gastrointestinal effects such as diarrhea or vomiting may occur.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Patients with deliberate/self harm ingestions should be referred to a healthcare facility.

Monitoring

    A) Usually no laboratory work is necessary. If chronic ingestions of large amounts are suspected, zinc concentrations may be requested.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) INGESTION: Toxicity is negligible. Nausea, vomiting, and diarrhea may occur primarily due to the zinc or product emollient base. Decontamination should not be necessary. DERMAL: No treatment is necessary for dermal exposures.
    6.5.2) PREVENTION OF ABSORPTION
    A) INGESTION: Toxicity is negligible. Nausea, vomiting, and diarrhea may occur primarily due to the zinc or product emollient base. Decontamination should not be necessary.
    6.5.3) TREATMENT
    A) MONITORING OF PATIENT
    1) Usually no laboratory work is necessary. If chronic ingestions of large amounts are suspected, zinc concentrations may be requested.
    B) FLUID/ELECTROLYTE BALANCE REGULATION
    1) Maintain adequate hydration if vomiting or diarrhea become extensive.
    C) CHELATION THERAPY
    1) Although chelation therapy will increase the excretion of zinc, it is not likely to be necessary unless large amounts have been taken chronically. Refer to "ZINC COMPOUNDS" document for more information.

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) No treatment is necessary for dermal exposures.

Enhanced Elimination

    A) SUMMARY
    1) Hemodialysis, hemoperfusion, and peritoneal dialysis are not necessary in these cases.

Range Of Toxicity

Summary

    A) TOXICITY: A toxic dose has not been established. Ingestion of small amounts of zinc oxide ointment (10% to 40%) by children does not produce significant effects. An adult developed mild gastroduodenal corrosive injury after the ingestion of 150 g of 10% zinc oxide lotion.

Therapeutic Dose

    7.2.1) ADULT
    A) GENERAL
    1) There is no therapeutic dose; these products are intended for external use only.
    7.2.2) PEDIATRIC
    A) GENERAL
    1) There is no therapeutic dose; these products are intended for external use only.

Maximum Tolerated Exposure

    A) A toxic dose has not been established.
    B) Ingestion of small amounts of zinc oxide ointment (10% to 40%) by children does not produce significant effects. However, a man developed mild gastroduodenal corrosive injury after the ingestion of 150 g of 10% zinc oxide lotion (Liu et al, 2006).

Pharmacology Toxicology

Pharmacologic Mechanism

    A) ZINC OXIDE
    1) Topical zinc oxide has astringent and bactericidal properties (Agren, 1993), and is used in sunscreens to protect from the effects of UV irradiation (Bestak et al, 1995).
    2) It may promote healing by increasing collagen breakdown in necrotic wound tissue, based on results of in vitro studies (Agren, 1993), but another study involving the application of 2% or 6% zinc oxide in a hydrocolloid occlusive dressing to porcine wounds failed to find significant improvement in wound healing (Agren, 1993). Other vehicles for zinc oxide have been useful in promoting wound healing (Agren, 1993).
    3) Zinc salts are protein precipitants and have been used to decrease the oozing and speed drying of rashes (Hegsted et al, 1945a).

References

General Bibliography

    1) Agren MS: Zinc oxide increases degradation of collagen in necrotic wound tissue (letter). Br J Dermatol 1993; 129:221-223.
    2) Baselt RC & Cravey RH: Disposition of Toxic Drugs and Chemicals in Man, 4th ed, Chemical Toxicology Institute, Foster City, CA, 1995.
    3) Bestak R, Barnetson RSC, & Nearn MR: Sunscreen protection of contact hypersensitivity responses form chronic solar-stimulated ultraviolet irradiation correlates with the absorption spectrum of the sunscreen. J Invest Dermatol 1995; 105:345-351.
    4) Budavari S: The Merck Index, 12th ed, Merck & Co. Inc, Whitehouse Station, NJ, 1996.
    5) Derry JE, McLean WM, & Freeman JB: A study of the percutaneous absorption from topically applied zinc oxide ointment. Journal of Parenteral and Enteral Nutrition 1983; 7:131-135.
    6) Gilman: Goodman and Gilman's The Pharmacological Basis of Therapeutics, 7th ed, Macmillan Publishing Co, New York, NY, 1985.
    7) HSDB: Hazardous Substances Data Bank. National Library of Medicine, Bethesday, MD (Internet Version), Micromedex, Inc, Greenwood Village, CO, 2002.
    8) Hallmans G & Liden S: Penetration of (65)Zn through the skin of rats. Acta Dermatovener (Stockholm) 1979; 59:105-112.
    9) Hallmans G: Local absorption of zinc from wounds treated with various zinc-compounds. Acta Dermatovener (Stockholm) 1978; 58:251-256.
    10) Hegsted DM, McKibben JM, & Drinker CK: The biological, hygienic, and medical properties of zinc and zinc compounds. Public Health Reports 1945; (Suppl 179):1-42.
    11) Hegsted DM, McKibbin JM, & Drinker CK: The biological, hygienic, and medical properties of zinc and zinc compounds. Public Health Reports 1945a; Suppl 179:44.
    12) JEF Reynolds : Martindale: The Extra Pharmacopeia (CD-ROM version). The Pharmaceutical Press. London, UK (Internet Version). Edition expires 1989; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    13) Lewis RJ: Sax's Dangerous Properties of Industrial Materials, 8th Ed, Van Nostrand Reinhold Company, New York, NY, 1993.
    14) Liu CH, Lee CT, Tsai FC, et al: Gastroduodenal corrosive injury after oral zinc oxide. Ann Emerg Med 2006; 47(3):296-.
    15) Naradzay J & Barish RA: Approach to ophthalmologic emergencies. Med Clin North Am 2006; 90(2):305-328.
    16) Peate WF: Work-related eye injuries and illnesses. Am Fam Physician 2007; 75(7):1017-1022.
    17) Sax NI & Lewis RJ: Hawley's Condensed Chemical Dictionary, 11th ed, Van Nostrand Reinhold Co, New York, NY, 1987.