==== Front Crit Care Critical Care 1364-8535 1466-609X BioMed Central London 3411 10.1186/s13054-020-03411-6 Letter Chlorhexidine-dress related contact dermatitis—the precautionary principle is no more relevant! http://orcid.org/0000-0002-2615-6615Eggimann Philippe Philippe.eggimann@chuv.ch 1 Pagani Jean-Luc 2 Revelly Jean-Pierre 2 Que Yok-Ai 3 1 grid.8515.90000 0001 0423 4662Department of Orthopedics and Traumatology, Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, 1211 Lausanne, Switzerland 2 grid.8515.90000 0001 0423 4662Service of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland 3 grid.5734.50000 0001 0726 5157Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland 9 12 2020 9 12 2020 2020 24 68716 11 2020 24 11 2020 © The Author(s) 2020Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.issue-copyright-statement© The Author(s) 2020 ==== Body Dear editor, We read carefully the Buetti et al. [1] post hoc analysis of two open randomized multicenter French studies, comparing non-disinfectant dressings with CHG-releasing sponge (December 2006 to May 2008) [2] and with CHG-releasing gel (May 2010 to July 2011) [3].After adjustment for confounders, gel-dress showed similar risk for MCRI compared to sponge-dress (HR 0.80, 95% CI 0.28–2.31, p = 0.68) and CRBSI (HR 1.13, 95% CI 0.34–3.70, p = 0.85), less dressing disruptions (OR 0.72, 95% CI 0.60–0.86, p < 0.001), and more contact dermatitis (OR 3.60, 95% CI 2.51–5.15, p < 0.01). However, gel-dress increased the risk of contact dermatitis only if CHG was used for skin antisepsis (OR 1.94, 95% CI 1.38–2.71, p < 0.01). Alcoholic-CHG was used for skin preparation in 1533 of gel-dress recipients (72.7%) and only 20 patients with sponge-dress (1.3%) [1]. In a recently published real-world evidence study, the gel-dress was applied with CHG for skin antisepsis [4]. Initial rates of contact dermatitis were consistent with previous findings [3]. Following the implementation of a redesigned dressing in March 2012, contact dermatitis rates dropped from 5.5 episodes/1000 device-days to 0.3/1000 device-days and same levels were reported for both sponge- and the gel-dress [4]. Several factors may have played a role in this improvement. Firstly, re-designed adhesive distribution in the dressing resulted in an improved skin moisture evaporation through the transparent membrane. Secondly, two-step skin preparation (scrubbing) were never incorporated in our guidelines for skin antisepsis with CHG. Thirdly, time allowed for the disinfecting solution to fully evaporate was part of our guidelines at time of introduction of CHG dressings in 2007. This practice may decrease initial moisture build-up on the skin surface. Above-mentioned conclusion on increased risk for skin irritation is highly concerning as it may challenge major elements from widely recommended bundle to prevent CRBSI. Alcoholic solutions of CHG have demonstrated superior efficacy in prevention of infections complications and graded IA by CDC Guidelines [5]. Supported by two randomized studies [1, 2] and confirmed by a real-world study [4], the use of CHG-dressings to reduce CRBSI is also a IA scored recommendation [5]. Accordingly, we congratulate Buetti et al. for their outstanding methodological skills applied in their post hoc analysis, but it is of crucial importance to challenge some of the conclusions. We urge the medical community not to discard either the use of chlorhexidine-dressings and/or alcoholic solutions of CHG for skin preparation. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Acknowledgements None. Authors’ contributions PE, JLP, JPR and YAQ analyzed the data of the studies included in the post hoc analysis published by Buetti et al. and have written the letter submitted for publication. All authors read and approved the final manuscript. Funding Not applicable. All studies mentioned are published and include funding source. Availability of supporting data Not applicable. No new or original data. All studies mentioned are published and include ethical approval and consent to participate. Ethical approval and consent to participate Not applicable. All studies mentioned are published and include Ethical Approval and Consent to Participate. Consent for publication The co-authors agree with the publication of this letter to the editor. Competing interest Philippe Eggimann is consultant for 3M. ==== Refs References 1. Buetti N Ruckly S Schwebel C Chlorhexidine-impregnated sponge versus chlorhexidine gel dressing for short-term intravascular catheters: which one is better? Crit Care 2020 24 458 10.1186/s13054-020-03174-0 32703235 2. Timsit J Schwebel C Bouadma L Chlorhexidine-Impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically Ill adults: a randomized controlled trial JAMA 2009 301 12 1231 1241 10.1001/jama.2009.376 19318651 3. Timsit JF Mimoz O Mourvillier B Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults Am J Respir Crit Care Med 2012 186 12 1272 1278 10.1164/rccm.201206-1038OC 23043083 4. Eggimann P Pagani J Dupuis-Lozeron E Sustained reduction of catheter-associated bloodstream infections with enhancement of catheter bundle by chlorhexidine dressings over 11 years Intensive Care Med 2019 45 823 833 10.1007/s00134-019-05617-x 30997542 5. Centers for Disease Control and Prevention. https://www.cdc.gov/infectioncontrol/guidelines/bsi/index.html#rec52017 and https://www.cdc.gov/infectioncontrol/guidelines/bsi/index.html#rec6.