Chlorhexidine Allergy and Anaphylaxis in Healthcare Settings

Chlorhexidine digluconate is a cationic bisbiguanide antiseptic extensively employed for skin disinfection, mouthwash formulations and indwelling device care. Its broad-spectrum activity against bacteria, viruses and fungi has made it a mainstay in surgical antisepsis and infection prevention. However, immediate-type hypersensitivity reactions to chlorhexidine, mediated by antigen-specific immunoglobulin E, have gained increasing recognition as a cause of anaphylaxis in perioperative, dialysis and other invasive procedures. Presentations range from mild urticaria or contact dermatitis to rapid-onset hypotension, bronchospasm and cardiovascular collapse. Under-recognised mild reactions are often dismissed as trivial, yet they may herald life-threatening responses upon re-exposure. Diagnostic challenges arise from the ubiquity of chlorhexidine in multiple formulations and the need for combined skin and in vitro testing to confirm sensitisation. Global surveillance indicates that chlorhexidine anaphylaxis, though rare, carries substantial morbidity and mortality when not anticipated. Heightened awareness, standardised allergy history protocols and alternative antisepsis strategies for at-risk patients are critical to mitigate these adverse events. Recent international guidelines have begun to recommend routine inquiry about prior chlorhexidine exposure and the adoption of non-chlorhexidine alternatives in sensitised individuals to safeguard patient safety across diverse healthcare settings.

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Chlorhexidine Allergy and Anaphylaxis in Healthcare Settings publication trend

The graph below shows the total number of articles in chlorhexidine allergy and anaphylaxis in healthcare settings across all publications each year (not limited to Nature Index journals).

Technical terms

Anaphylaxis: A rapid-onset, systemic allergic reaction that can be life-threatening, characterised by hypotension, bronchospasm and urticaria.

Immunoglobulin E–mediated hypersensitivity: An immediate allergic response triggered by antigen binding to specific immunoglobulin E (IgE) on mast cells and basophils.

Basophil activation test (BAT): An in vitro assay measuring basophil surface marker expression following allergen exposure to identify IgE-dependent sensitisation.

Antiseptic: A chemical agent applied to living tissue to reduce or eliminate pathogenic microorganisms.

References

1. Chlorhexidine Allergy: Mild Allergic Reactions Can Precede Anaphylaxis in the Healthcare Setting. Turkish Journal of Anaesthesiology and Reanimation (2019).
2. Chlorhexidine – a commonly used but often neglected culprit of dialysis associated anaphylactic reactions (case report). BMC Nephrology (2022).
3. Intraoperative chlorhexidine-induced anaphylaxis suggesting an immunoglobulin-E-dependent mechanism indicated by basophil activation tests: two case reports. JA Clinical Reports (2022).