S M Bradberry1, J A Vale. 1. National Poisons Information Service (Birmingham Centre), West Midlands Poisons Unit, City Hospital NHS Trust, UK.
Abstract
INTRODUCTION: Repeated topical exposure to chromium(VI) may cause an allergic contact dermatitis or the formation of chrome ulcers. Systemic toxicity may occur following the ingestion of a chromium(VI) salt, from chromium(VI)-induced skin burns, or from inhalation of chromium(VI) occurring occupationally. Soluble chromium(VI) salts are usually absorbed more easily and cross cell membranes more readily than trivalent chromium salts, and, therefore chromium(VI) is more toxic than chromium(III). In experimental studies, endogenous ascorbic acid in rat lung, liver, and kidney and human plasma, effectively reduces chromium(VI) to chromium(III). The administration of exogenous ascorbic acid has been advocated therefore in the treatment of systemic chromium poisoning and chromium dermatitis to enhance the extracellular reduction of chromium(VI) to the less bioavailable chromium(III). REVIEW: In vitro experiments confirm that the addition of ascorbic acid to plasma containing chromium(VI) leads to a dose-dependent reduction of chromium(VI) to chromium(III). In animal studies, parenteral ascorbic acid 0.5-5 g/kg significantly reduced chromium-induced nephrotoxicity when administered 30 minutes before parenteral sodium dichromate and up to 1 hour after parenteral sodium chromate dosing. Parenteral ascorbic acid 0.5-5 g/kg also reduced mortality when given orally up to 2 hours after oral potassium dichromate dosing. However, the administration of parenteral ascorbic acid more than 2 hours after parenteral chromate in these experimental studies did not protect against renal damage, and parenteral ascorbic acid given 3 hours postparenteral chromate increased toxicity. In addition, there is no confirmed clinical evidence that the administration of ascorbic acid lessens morbidity or mortality in systemic chromium poisoning. A possible reason for the lack of benefit of ascorbic acid when administration is delayed, is that chromium(VI) cellular uptake has occurred prior to ascorbic acid administration. Topical 10% ascorbic acid has been claimed to reduce significantly the healing time of experimentally induced chrome ulcers in guinea pigs. The proposed mechanism is reduction on the skin surface of chromium(VI) to chromium(III). Several case reports suggest that topical ascorbic acid is effective in the management of chromium dermatitis but this has not been confirmed in controlled clinical trials and, moreover, the practical difficulties of frequent application are likely to limit its usefulness. DISCUSSION: Based on experimental studies, substantial amounts of ascorbic acid would need to be administered, preferably parenterally, soon after exposure to prevent systemic toxicity from chromium(VI) in humans. However, as ascorbic acid is a metabolic precursor of oxalate, the administration of ascorbic acid in high dose could lead to acute oxalate nephropathy, particularly in the presence of renal failure. While smaller doses of ascorbic acid (e.g., 10 g intravenously) are not toxic, such doses probably will not reduce the mortality from systemic chromium poisoning. CONCLUSION: There is currently insufficient evidence to advocate the use of ascorbic acid in the management of systemic chromium toxicity. Topical ascorbic acid may reduce dermal hexavalent chromium exposure, but this observation must be confirmed in controlled studies.
INTRODUCTION: Repeated topical exposure to chromium(VI) may cause an allergic contact dermatitis or the formation of chrome ulcers. Systemic toxicity may occur following the ingestion of a chromium(VI) salt, from chromium(VI)-induced skin burns, or from inhalation of chromium(VI) occurring occupationally. Soluble chromium(VI) salts are usually absorbed more easily and cross cell membranes more readily than trivalent chromium salts, and, therefore chromium(VI) is more toxic than chromium(III). In experimental studies, endogenous ascorbic acid in rat lung, liver, and kidney and human plasma, effectively reduces chromium(VI) to chromium(III). The administration of exogenous ascorbic acid has been advocated therefore in the treatment of systemic chromiumpoisoning and chromiumdermatitis to enhance the extracellular reduction of chromium(VI) to the less bioavailable chromium(III). REVIEW: In vitro experiments confirm that the addition of ascorbic acid to plasma containing chromium(VI) leads to a dose-dependent reduction of chromium(VI) to chromium(III). In animal studies, parenteral ascorbic acid 0.5-5 g/kg significantly reduced chromium-induced nephrotoxicity when administered 30 minutes before parenteral sodium dichromate and up to 1 hour after parenteral sodium chromate dosing. Parenteral ascorbic acid 0.5-5 g/kg also reduced mortality when given orally up to 2 hours after oral potassium dichromate dosing. However, the administration of parenteral ascorbic acid more than 2 hours after parenteral chromate in these experimental studies did not protect against renal damage, and parenteral ascorbic acid given 3 hours postparenteral chromate increased toxicity. In addition, there is no confirmed clinical evidence that the administration of ascorbic acid lessens morbidity or mortality in systemic chromiumpoisoning. A possible reason for the lack of benefit of ascorbic acid when administration is delayed, is that chromium(VI) cellular uptake has occurred prior to ascorbic acid administration. Topical 10% ascorbic acid has been claimed to reduce significantly the healing time of experimentally induced chrome ulcers in guinea pigs. The proposed mechanism is reduction on the skin surface of chromium(VI) to chromium(III). Several case reports suggest that topical ascorbic acid is effective in the management of chromiumdermatitis but this has not been confirmed in controlled clinical trials and, moreover, the practical difficulties of frequent application are likely to limit its usefulness. DISCUSSION: Based on experimental studies, substantial amounts of ascorbic acid would need to be administered, preferably parenterally, soon after exposure to prevent systemic toxicity from chromium(VI) in humans. However, as ascorbic acid is a metabolic precursor of oxalate, the administration of ascorbic acid in high dose could lead to acute oxalatenephropathy, particularly in the presence of renal failure. While smaller doses of ascorbic acid (e.g., 10 g intravenously) are not toxic, such doses probably will not reduce the mortality from systemic chromiumpoisoning. CONCLUSION: There is currently insufficient evidence to advocate the use of ascorbic acid in the management of systemic chromiumtoxicity. Topical ascorbic acid may reduce dermal hexavalent chromium exposure, but this observation must be confirmed in controlled studies.