Patient Presentation
A 12-year-old male came to clinic for his health maintenance examination. He was healthy but had fallen off his bike into some weeds the day before. He and his mother had cleaned it well with soap and water and then used some iodine solution on his leg scrapes. He noticed that it was a little swollen and pinker than yesterday. He denied any problems itching, swallowing, breathing, or with his eyes or mouth. The past medical history showed a history of poison ivy reaction the year before.
The pertinent physical exam showed a healthy male with normal vital signs and growth parameters between 75 and 99%.
His left lower calf had significant abrasions on the lateral and anterior surfaces that were mildly swollen. He had some minor abrasions on the other leg and back of his left hand. Remnants of brown discoloration of the surrounding calf skin were seen. There were no obvious hives, vesicles or drainage. It wasn’t more tender than expected for the amount of time since the injury occurred. The rest of his examination was normal.
The diagnosis of a healthy male was made with a significant abrasion. “You obviously have some bad road rash, but it doesn’t look like it is infected now. You were good to clean it up like you did. Lots of water and gentle soap is usually all you need. I think the iodine is possibly irritating it though. Iodine can actually cause some irritation when used on open skin. You don’t seem to be having an allergic reaction to it, and it also doesn’t look like this is poison ivy or something else like that that you might have fallen into. I would just keep this clean washing it gently with soap and water. Don’t use the iodine or something else on top. You can use a very thin layer of petroleum jelly to keep it moist. But if it gets more swollen, you have streaks of red coming from it, it’s more painful or you have a fever, then you need to tell your Mom right away,” the pediatrician counseled.
Discussion
Povidone-iodine (polyvinylpyrrolidone iodine or PVP-I) is one of the most common antiseptics for more than 150 years. It is used for antisepsis mainly topically but also in mucosal cavities (i.e. mouth, nose, throat, vagina, etc.) or surfaces (i.e. umbilical cord). It has been used to treat chronic mucosal infections such as adult chronic rhinosinusitis. It’s irritant properties are used for chemical pleurodesis.
A common trade solution is Betadine® which contains “90% water, 8.5% PVP and 1% available iodine and iodine with a free iodine concentration of 1 parts-per-million.” PVP-I is a brown/orange color and iodine is the active agent. Preparations include solutions, foams, ointments and scrubs. They may contain additional active ingredients as well including alcohol. The free iodine is concentration dependent and its bactericidal effect is bell-shaped. “As the content of free iodine increases from 1 ppm [parts per million], effectiveness reaches a maximum at about 0.1% strength or 1:100 dilution, but then decreases with further increased iodine concentration.”
The mechanism of action is thought to be that the iodine molecule being very small is able “…to penetrate into microorganisms and oxidizes key proteins, nucleotides and fatty acids, eventually leading to cell death.” It works against enveloped and non-enveloped viruses, Gram-positive and Gram-negative bacteria (including antibiotic and antiseptic resistant ones), protozoa and fungi. It is effective against fungi and bacterial biofilms. Effectiveness is a combination of PVP-I concentration, contact time, surface, specific use and organism. One potential problem with PVP-I use is that it may take more contact time than people are willing to allow it (i.e. amount of drying time).
Home use should follow the manufacturer’s instructions and should not be used past the expiration date as the effectiveness may be compromised. Some individuals will say it is still effective past the expiration date but the variability of storage conditions makes replacement an appropriate recommendation. PVP-I should be stored safely away from children, at room temperature and protected from heat.
Learning Point
Potential problems of using PVP-I include:
- Irritant contact dermatitis which occurs more commonly in damaged skin, or skin that is compromised in some manner such as premature neonates
- Allergic reactions including anaphylaxis
- Thyroid dysfunction usually suppression – uncommon but more common in neonates especially premature neonates
- Aspiration pneumonia
- Risks from other included product ingredients – e.g. alcohol
Questions for Further Discussion
1. What are other common antiseptics used in health care?
2. How much iodine is recommended for a general diet?
3. When do you recommend using topical antibiotics for small wounds?
Related Cases
- Disease: Povidone-Iodine | Wounds
- Symptom/Presentation: Infections
- Specialty: Dermatology | Emergency Medicine | Infectious Diseases
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Wounds and Injuries
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
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Kusari A, Han AM, Virgen CA, et al. Evidence-based skin care in preterm infants. Pediatr Dermatol. 2019;36(1):16-23. doi:10.1111/pde.13725
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Chorney SR, Rizzi MD, Dedhia K. Considerations for povidone-iodine antisepsis in pediatric nasal and pharyngeal surgery during the COVID-19 pandemic. Am J Otolaryngol. 2020;41(6):102737. doi:10.1016/j.amjoto.2020.102737
Lepelletier D, Maillard JY, Pozzetto B, Simon A. Povidone Iodine: Properties, Mechanisms of Action, and Role in Infection Control and Staphylococcus aureus Decolonization. Antimicrob Agents Chemother. 2020;64(9):e00682-20. doi:10.1128/AAC.00682-20
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
Pediatric Education 