Emollient Fire Risk

Emollients are not flammable on their own or on the skin. The hazard starts when emollient rubs off onto clothing, bedding, dressings or furniture covers, dries there and builds up over time. Fabric with dried residue catches fire more easily, and the residue then acts as an accelerant: the fire spreads faster and burns more intensely, so there is less time to put it out before serious or fatal burns (MHRA Drug Safety Update, December 2018 and August 2020). The National Fire Chiefs Council (NFCC) says that putting a match to a sample of the cream itself would not light it. The danger is the soaked fabric. For a toddler on generous Emollient Therapy, that means pyjamas, sleepsuits, cot sheets, sleeping bags and the cotton layers used in Wet Wrap Therapy.

Emollient Therapy [causes] Emollient Fire Risk Clothing and Fabrics [part-of] Emollient Fire Risk Wet Wrap Therapy [relates] Emollient Fire Risk

Regulatory history. The first warning came after a hospital patient died in 2007. The patient went outside to smoke in clothing with dried emollient in it, and the National Patient Safety Agency issued an alert. The MHRA warned again in January 2008 and April 2016, but those warnings covered only products with more than 50% paraffin. In December 2018 the MHRA widened the warning. Products with less than 50% paraffin had been linked to fatal burns, and in tests paraffin-free emollients also acted as accelerants once residue built up on fabric. The MHRA now says there is a fire risk “with all paraffin-containing emollients, regardless of paraffin concentration, and it also cannot be excluded with paraffin-free emollients”. The same may apply to other skin products used over large areas or in large volumes for more than a few days. The MHRA knew of 11 deaths in which paraffin-based emollients probably made a fire faster and more intense, including 5 coroners’ Prevention of Future Deaths reports. Fire and rescue services in England reported a further 50 fire incidents (49 fatal) between 2010 and November 2018 where emollients were used by the victim or present. The MHRA says the true number is probably higher because cases go under-reported. The Commission on Human Medicines decided that the benefits still outweigh this “very rare” risk, and fire-hazard warnings and an alert symbol were added to packaging. On 29 July 2020 the MHRA and NFCC launched a joint awareness campaign with leaflets, posters and stickers for health and care staff.

MHRA [regulates] Emollient Fire Risk National Fire Chiefs Council [opposes] Emollient Fire Risk Mineral Oil [causes] Emollient Fire Risk

Washing does not fully fix it. The MHRA, NHS and NFCC all say that washing fabric at a high temperature reduces emollient build-up but does not remove it completely. The NFCC advises washing clothes, bedding and furniture throws often, at the highest temperature on the care label, and using washable throws on fabric seating. It also says to sit at least 1 metre from open fires and from gas, electric-bar or halogen heaters, and to keep soft furnishings away from heat. Most deaths so far involved adults who smoked, had limited mobility, or both. A toddler is at risk because they cannot move away from a fire. The relevant risks are a child in emollient-soaked nightwear near a bar heater or open fire, a cot or bed close to a heater, residue-laden throws on a sofa by a fireplace, a carer cooking on a gas hob while holding the child, candles, and adults smoking near the child or their bedding. Hot-washing will not make old, heavily soaked sleepwear safe.

Emollient-soaked fabrics near flames or heaters

Pyjamas, cot sheets, sleeping bags, wet-wrap garments and sofa throws soaked with a toddler’s emollient can ignite quickly and burn intensely, whether or not the product contains paraffin. Hot washing reduces the residue but does not remove it. Keep the child and their bedding at least 1 m from open fires, bar or halogen heaters and candles. Never smoke near the child or their bedding. Do not stop the emollient. Manage the fabric instead.

Emollient Fire Risk [relates] Clothing and Fabrics Soak and Seal [relates] Emollient Fire Risk

How strong the evidence is, and what it means for parents. That the hazard is real is confirmed. It rests on coroners’ reports, fire-service incident data and laboratory burn tests reviewed by the MHRA and the Commission on Human Medicines. How big the risk is remains uncertain. Case reports cannot give an incidence, the denominator is millions of emollient users, and the MHRA summaries reviewed here describe no case in a young child. The NHS and the National Eczema Society are clear that the advice is about safe use, not stopping: “people should continue to use these products”. The NES adds that bedding and clothing with dried residue need contact with a naked flame or a similar heat source to catch fire. Parent reports on this specific risk were not found in this round.

Emollient Fire Risk [relates] Atopic Dermatitis National Eczema Society [supports] Emollient Therapy

Connections

• Emollient Therapy — safety hazard of emollient use, source: MHRA 2018
• MHRA — issuing regulator (2008/2016/2018 Drug Safety Updates), source: MHRA DSU
• Clothing and Fabrics — toddler nightwear and bedding carry the residue, source: MHRA 2018; NHS
• Soak and Seal — generous sealing loads fabrics with emollient, source: MHRA 2018
• Wet Wrap Therapy — emollient-soaked cotton layers, source: MHRA 2018 (dressings and bandages named)
• Mineral Oil — paraffin-based products first implicated (>50% paraffin warnings 2008/2016), source: MHRA 2018
• National Fire Chiefs Council — co-ran the 2020 campaign; 1 m heater-distance advice, source: MHRA 2020; NFCC
• National Eczema Society — continue emollients and manage fabrics, source: NES emollients factsheet