To the Editors: Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of skin infections. Management of recurrent skin lesions caused by MRSA is challenging and optimal prevention strategies have not been established.1 Decreasing bacterial colonization of the skin has been a widely used strategy, although decolonization regimens vary by physician.2 Chlorhexidine gluconate, hexachlorophene, and household bleach (sodium hypochlorite) have been recommended for use during bathing or showering to help decolonize MRSA on skin surfaces. We recently participated in the medical care of a child with recurrent skin infections in which the family mistakenly used 2 of the above agents (sodium hypochlorite and a chlorhexidine product) simultaneously during the child's bath. Use of these 2 agents together created a color change in the bath water. A 2-year-old girl was seen with a history of recurrent purulent lesions on her lower extremities and perineal area. No cultures of these lesions had previously been obtained. In the clinic, the child was asymptomatic. Cultures of the child's nose and groin were obtained. A prescription for intranasal mupirocin ointment for topical use was given to the mother, as were instructions for the use of household bleach, 1 teaspoon per gallon of water, in the child's bath. When culture results returned showing both methicillin-susceptible S. aureus and MRSA, the mother was contacted. The mother reported that the child's bath water turned brown soon after she began using the sodium hypochlorite (bleach). Upon further questioning, the mom indicated that she was also using another product during the child's bath. This product was determined to contain chlorhexidine gluconate. It was recommended that the mother discontinue the chlorhexidine-containing product and use bleach only. Once the mother stopped using both agents, the bath water no longer turned brown. Reportedly, the brown bath water had not caused any staining or discoloration of the child's skin, bath fixtures, or washcloths. Although the authors are unaware of any pediatric literature involving the simultaneous use of chlorhexidine products and sodium hypochlorite in the management of children with recurrent MRSA infections, there are articles in the dental literature about brown discoloration when “bleaching” teeth with these agents.3,4 The combination of chlorhexidine and sodium hypochlorite can form a precipitate (brown flocculate).3,4 The authors also found reference to brown discoloration when examining the 2008 Data Sheet (package insert) from HiBi (chlorhexidine gluconate 2% wt/vol isopropyl alcohol 70% vol/vol, Mölnlycke Health Care, Manchester, UK). The package insert warns “Do not use chlorhexidine containing products in conjunction with or in area where cleaning agents containing bleach have been used as permanent brown stains can develop on fillings, fixtures, and clothing.” Hibiclens, a frequently used US product containing chlorhexidine gluconate, (Mölnlycke Health Care, Norcross, GA), has a warning in the package insert about using chlorhexidine and chlorine bleach together in the laundry (possible staining). The Hibiclens package insert recommends switching to a peroxide-type bleach to eliminate the reaction and “minimize possible staining.” Chlorhexidine gluconate, when used as a hand cleanser, bonds to a protein on the skin and has residual activity over a relatively long (hours) period of time. Chlorhexidine also bonds to fabrics, especially cotton (Hibiclens package insert, Mölnlycke Health Care, Norcross, GA). Physicians and other healthcare providers need to be aware of a chemical interaction which may occur between chlorhexidine gluconate and sodium hypochlorite and the need to advise patients and families to avoid the simultaneous use of these 2 agents for personal hygiene and laundry. Dennis L. Murray, MD, FAAP, FIDSA Department of Pediatrics Medical College of Georgia Augusta, GA Weng Man Lam, PharmD University of Georgia College of Pharmacy Medical College of Georgia Department of Pharmacy Augusta, GA