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CME ARTICLES |
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| Year : 2005 | Volume
: 50
| Issue : 4 | Page : 191-195 |
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| Cosmetic dermatitis |
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Alka Dogra, Aman Dua
Department of Dermatology, Dayanand medical college & hospital, Ludhiana ( Punjab), India
Correspondence Address:
Alka Dogra
Department of Dermatology, Dayanand medical college & hospital, Ludhiana ( Punjab)
India
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Keywords: Cosmetics, Allergic dermatitis
How to cite this article:
Dogra A, Dua A. Cosmetic dermatitis. Indian J Dermatol 2005;50:191-5 |
 Introduction | |  |
Cosmetics are articles intended to be rubbed, poured, sprinkled or sprayed on, introduced into or otherwise applied to normal or previously altered human skin or any part thereof, for cleansing, beautifying, promoting attractiveness or altering the appearance and are not intended to alter or interfere with physiological competence of human skin or body. [1]
Reactions to cosmetics constitute a small but significant number of cases of contact dermatitis that can present with varied appearances. It is notable that most patients do not initially suspect a reaction to the cosmetic and are subsequently proven to have evoked allergic responses. [2]
Types of adverse reactions to cosmetics
Allergic Non- allergic
Contact allergic dermatitis Contact irritant
dermatitis
Photo allergic contact dermatitis Phototoxic contact
dermatitis
Contact urticaria Hyperpigmentation &
hypopigmentation
Contact urticaria
Hair and nail breakage.
| Ingredients of cosmetics | | |
1. Preservatives : Parabens (methyl,ethyl, propyl, butyl); formaldehyde; dowicil-200; bronopal; germall 115, II.
2. Solidening agents : Colophony.
(Tacky substance)
3. Dye : Para-phenylene diamine (primary intermediate in permanent dyes)
4. Perfume fixative : Balsam of Peru; musk mix; fragrance mix (cinnamic aldehyde, cinnamic alcohol, eugenol etc.)
5. Emollient : Lanolin (wool alcohol); bees wax; isopropyl myristate; liquid paraffin.
6. Fungicide : Chlorocresol.
7. Solvent, Humectant : Propylene glycol .
8. Antioxidants : Butylated hydroxyanisole (BHA); butylated hydroxytoluene (BHT)
9. Antibacterial : Triclosan.
10. Organic alcohol : Abitol.
| A) Facial makeup preparation | | |
1. Lipsticks : Allergic reactions to lipsticks were common due to dyes producing long-lasting deep colours such as D&C Red 21 (Eosin)[3]. But nowadays, lipsticks are of pale color, therefore eosin is being used less frequently and in low concentrations.
Other sensitizers are castor oil, pigment solvents, antioxidants, sunscreens, lanolin fragrance, colophony and shellac (coating substance).
Clinical presentation of lipstick cheilitis occurs on the vermillion borders of lips which may vary from a mild redness, scaling and fissuring to edematous crusted condition. In some cases, it can lead to photo contact dermatitis, where in addition to it, the patient develops darkening of lips.[4]
To confirm allergic contact dermatitis to lipsticks, open patch and photo patch tests should be performed,"As is" withthe lipsticks used by the patient.
2. Bindis : Bindi is a circular colorful mark applied on the forehead by Indian women. Earlier, the material most commonly used was kumkum. Nowadays, dyes are being used in powder or solution form. Some ladies use lipsticks on their forehead for a bindi. Sticker bindi which consists of plastic material - polyvinyl chloride with resinous adhesive - paratertiary butyl phenol on one side has become fashionable.
Contact Dermatitis may occur due to colophony, abitol (dihydroabetyl alcohol), monobenzone (antioxidant)[5]. Depigmentation of the skin on the area of application occurs due to hypersensitivity to adhesive substances or monobenzone which is psychologically disturbing.[6],[7]
Patch testing is done with adhesive side down of bindis.
3. Rouge or Blush : It is manufactured in various forms - powder, cream, liquid, stick or gel. Some people use lipsticks for the same. D & C yellow 11 causes allergic reactions to rouges as well as to lipsticks.[8]
4. Facial make-up bases and facial powder ingredients: These are applied to the skin to give an appearance of uniform colour and texture. The main ingredients are titanium dioxide, PABA derivatives, fragrances emulsifiers, preservatives, propylene glycol and lanolin.[9] Powder preparations are considered best as they are least allergenic.
| B) Hair care products | | |
1. Hair dyes - These are used to hide gray hair and for beautification. These are classified into mainly five types :
a. Type I - Permanent hair dyes : These are mixtures of colorless, aromatic compounds that act as primary intermediates and couplers. Primary intermediates include paraphenylene diamine (PPD), para-toluene diamine and para-amino phenol. The reactions take place inside the hair shafts that accounts for fastness of these dyes. Ammonia causes the hair to swell-up and increase penetration.
b. Type II - Semi-permanent hair dyes: These contain low molecular weight nitro phenylene diamine and anthroquinone dyes that penetrate hair cortex to some extent. They last approximately five shampoo washes.
c. Type III - Temporary rinses :These are mixtures of mild organic acids and certified dyes that coat the hair shaft.
d. Type IV- Vegetable dyes : They contain henna from leaves of lawsonia indica . Rarely type I & IV hypersensitivity reactions are attributed to henna.
e. Type V - Metallic dyes : Contain lead acetate and sulphur which on deposition as lead oxide sulfides impart yellow -brown to dark gray colour.
Sensitizers in Hair dyes are :
- Paraphenylene diamine (1%) on oxidation produces benzoquinone
- Paratoluene diamine
- Para aminophenol
- Ammonia
- Additives like pyrogallol, resorcinol.
Hair colours have a low concentration of PPD and ammonia free colors are also available.
Patch testing is done with dyes in the form of open and photo patch test.
Clinical features of dermatitis due to hair dyes : Both irritant and allergic contact dermatitis to hair dyes can occur. Usually middle aged and elderly individuals are predisposed. Allergic contact dermatitis is usually seen on upper eyelids, forehead, scalp and even rest of the face. Rarely neck; upper extremities and trunk may be involved.[9] It usually last for 2-3 weeks. Rarely depigmentation due to contact sensitivity to PPD in hair dye occurring over the scalp, extending beyond hair line has been described.[10]
| Other hair care products | | |
:
2. Hair bleaches : Usually contain hydrogen peroxide, ammonium persulphate which can cause urticaria type and allergic reactions.[11]
3. Hair shampoos - They have a very short period of contact time with skin. Usually itching or stinging of eyes are the main complaints. The majority of shampoos are detergent based, containing sodium lauryl ether sulfate, perfumes, antidandruff agents such as selenium sulfide, zinc pyrithrone, conditioners such as lanolin, polypeptides, solvents and surfactants. Clinically the pattern of contact dermatitis is similar to that of hair dyes.[12]
4. Hair waving agents : Contain ammonium thioglycolate which is both an irritant and a sensitizer. Glycerol thioglycolate is also used in cold waving technique.[13]
| C) Dentifrices | | |
Dentrifices are the ingredients in toothpaste, tooth powder etc.
They are made up of :
1. Abrasives 10-40 % - consist of dicalcium phosphate dihydrate, alumina trisilicate, magnesium trisilicate, silica gel causes tooth abrasion.
2. Humectants Glycerol and sorbitol
Causes diarrhoea
3. Detergents Sodium lauryl sulphate
4. Flavours Peppermint, spearmint, oils of cloves, citrus, cinnamon.
5. Preservatives Benzoates
6. Colouring agents Titanium dioxide flavours, preservative, colouring agents.
Clinical features of contact dermatitis due to dentifrices:
Present as desquamation of lips and tongue, peri oral dermatitis, angular cheilitis and gingivitis.[14]
| D) Mouth washes | | |
Ingredients include alcohol, sodium lauryl sulphate, eugenol, menthol, cinnamaldehyde, benzoic acid, Balsam of peru/tolu.
Clinical features of contact dermatitis are similar to that of dentifrices.
| E) Eye make up | | |
Traditional women use kajal and surma on the lid margin. There are mainly carbon compounds and surma contains mercury. Various eye make up preparations are mascara, eyeliner, eye-shadow, eyebrow pencil.
A good history taking is important in patients with eyelid dermatitis because facial, hair and nail cosmetic reactions appear frequently on the eyelids.
Various sensitizing preparations in eye cosmetics include : preservatives such as parabens, phenyl mercuric acetate, imidazolidinyl urea, Quarternium 15 or potassium sorbate, antioxidants, butylated hydroxytoluene, butylated hydroxy anisole propyl gallate, dibert- butyl hydroquinone, resins- colophony, dihydro- abidyl alcohol , lanolin.
Patch testing with eye cosmetics may result in false negative result on back. Provocative test on anti cubital fossa or on eyelid itself may ultimately prove the diagnosis. Positive patch test should be repeated for the confirmation and individual ingredient patch testing must be carried out wherever possible.
Upper eyelid dermatitis syndrome : Various causes have been implicated in this syndrome such as atopic dermatitis, psoriasis, recurrent contact urticaria, irritant or allergic contact dermatitis, infection, collagen vascular disease, mechanical, drugs or idiopathic. Only 4% of reactions have been proven to be due to eye make up.[15]
| F) Shaving preparations | | |
1. Preshave preparations : Softens the beard. Soap / detergents : contain urea, surface active agents, perfume.
2. Shaving Creams.
Ingredients :
With Brush Brushless
Stearic acid Triethalnolamine
Coconut oil Lanolin
Perfume
Glycerine
NaOH/KOH
Sorbitol
| 3. After shave lotions | | |
Mainly contain alcohol, aluminium chlorohydroxide, menthol, camphor and glycerine.
Contact dermatitis to shaving preparations is mainly due to after shave lotions and perfume.
Patch testing with shaving cream is done either with the finished product or with individual ingredients[16],[17]
| G) Manicure products | | |
Professional grooming of finger nails and toe nails is called manicure and pedicure respectively . The products used in this are mainly :
1. Nail polish : Main allergen in nail polish is toluene - sulfonamide, formaldehyde resin. Clinical features of contact dermatitis includes lesions mainly over the upper eyelids, lower half of face, sides of neck and upper chest.[18]
Ten percent toluene sulfonamide in petrolatum is used to perform a closed patch test.
2. Nail polish removers : Contain mainly acetone, alcohol, ethyl acetate, butyl acetate.
Patch tests can be performed with the nail polish or nail polish remover as such but in open patch test with nail polish delayed occlusion patch test and by cup method with nail polish remover.
3. Cuticle removers : Contain mainly 2.5 % KOH/NaOH with propylene glycol.These mainly result in irritant contact dermatitis and paronychial inflammation. Sculptured nails have become popular in recent years. They consist of powdered methacrylate polymer with benzoyl peroxide. Allergic reactions have been reported with methyl methacrylate by Rishcher et al.
| H) Baby products | | |
1. Soaps : are usually mild.
2. Shampoos : The preservatives in baby shampoos may cause allergy.
3. Lotions and Oils: Contain lanolin.
4. Baby powder : Contain tiny particles which can irritate the skin. The fragrance in baby powders can also cause allergy.
5. Bottles, pacifiers, balloons, rubber sheets, nipples, rubber balls :Can cause latex allergy.
6. Wet wipes : Can cause contact dermatitis due to preservatives such as propylene glycol, methyl isothiazolinone and formaldehyde. Fragrance allergy can occur due to wet wipes.
Clinically , hand eczema in baby handlers can occur. Napkin dermatitis and perianal rash can also occur in the baby.
| Patch test | | |
Patch test is useful in knowing the type of reaction to a particular cosmetic - whether irritant or allergic. Also, the standard test series can identify the agents causing them. Cosmetics can be classified according to their usage as "Leave - on" cosmetics such as lipsticks. Their patch test is done "As is". Second variety are the "wash-off" or "Rinse-off" cosmetics - such as shampoos. They are used in the concentration of 10%. Soaps and detergents are used in concentration of 1% . After performing the patch test the reactions are graded on second, fourth and seventh to tenth day depending on its severity. To interpret photocontact dermatitis , photopatch test is performed and is considered to be positive, if test site shows dermatitis on exposure to antigen and sunlight. There must be no reaction at unexposed patch test and central site. [16]
Repeated open application test :In this test, the suspected cosmetic is applied twice daily for 7 days or until an eczematous reaction occurs especially on the outer aspect of upper arm.
Usage test : If patch testing to a strongly suspected test substance is negative, the patients are asked to use the preparation again routinely as they would normally use it. especially bindis.
Elimination test : Fischer has suggested an elimination routine in diagnosis of reactions to cosmetics. All cosmetics are stopped except lipstick, which is allowed if the lips are problem free when dermatitis has cleared, one cosmetic at a time is tested/allowed. If a reaction occurs, the cosmetic used most recently is eliminated.[19]
Safety testing :Is the demand of the day for cosmetics. The FDA accepts only animal safety data. The most widely used animal test is the 'draize eye irritancy test' which involves placing drops of the substance in question into the eye of an albino rabbit. Any redness, swelling, cloudiness of the iris or corneal capacity to clear it is noted.[14]
| Cosmetic intolerance syndrome | | |
Fischer has coined the term "status cosmeticus" for this condition in which a patient is no longer able to tolerate the use of any type of cosmetic. Many of these patient have a atopic background with disturbed body images and dysmorphophobia and complain of physical discomfort without objective evidence.[19]
| Management of the patient | | |
1. Examine every cosmetic and skin care agent
2. Patch and photo patch test to rule out occult allergic and photo allergic contact dermatitis or contact urticaria.
3. Limit skin care to :
Water washing without soaps/detergents
Lip cosmetics
Eye cosmetics
Face powder
Glycerol and rose water as moisturizer (only if needed)
Six to twelve months of avoidance of other skin care agents and cosmetics.
4. Watch for and test, if necessary, depression and other neuropsychiatric aspects.[16]
| Conclusion | | |
The main problem in cosmetic dermatitis is to identify the allergen as number of agents are being used by the patients. Also, in India, there is no legislation regarding labeling on the cosmetics as in west; so no clear cut information regarding ingredients is available.
Though we do elaborate patch testing with cosmetic ingredients, the benefit to the patient is limited because of this patient is limited because of the government should have clear cut rules on the manufacture and labeling of cosmetics and dermatologists should be involved in it.
| References | | |
| 1. | Fischer AA. Cutaneous reactions to cosmetics. 2nd Edition. Philadelphia, Lea & Febiger, 1973 ; 217-41.  |
| 2. | Fischer AA. Contact dermatitis to cosmetics. Contact Dermatitis. 3rd Edition. 1986 ;380-1. |
| 3. | Cronin E. Contact dermatitis to lipsticks. Contact Dermatitis. 1st edn. Churchill Livingstone, 1980:141-9. |
| 4. | Fischer AA. Perleche (angular cheilitis) due to contactants. Cutis 1974;14:499. |
| 5. | Wilkinson JD, Shaws. Contact Dermatitis. In : Champion RH, Burton JC, Ebling FJG, eds. Textbook of Dermatology. 6th edn. Oxford:Blackwell Scientific publication, 1998; Vol 1: 733-819. |
| 6. | Pasricha JS. Contact dermatitis in India, general features. The off-setters, New Delhi. 1988 ; 1-20. |
| 7. | Bajaj AK, Govil DC, Bajaj S. Bindi depigmentation. Arch Dermatol 1983;119:629. |
| 8. | Calnon CD. Quinazoline yellow SS in cosmetics. Contact Dermatitis 1976; 2:160. |
| 9. | DC Groot AC, Weyland JW. Kathon CG- a review. J Am Acad Dermatol 1988; 18. 350-8. |
| 10. | Bajaj AK, Gupta SC, Chatterjee AK, et al. Hair dye depigmentation. Contact Dermatitis 1996; 35 : 56-7. |
| 11. | Fisher AA, Dooms - Goosens A. Persulfate hair bleach reactions. Arch Dermatol 1976;111:1407. |
| 12. | Nacer JP, de Groot AC. Unwanted effects of cosmetics and drugs used in Dermatology, Ind edn. New York : Elsevier, 1985. |
| 13. | Edman WW, Klemm EG . Permanent waves parent review. Cosmetic Toiletries 1979;94:35. |
| 14. | Reynolds EC. Contents of toothpaste-safety implications. Aust Prescr 1994;17: 49-51. |
| 15. | Dooms- Goosens A, Degreef H, Luytens E. Dihydroabietyl alcohol (Abitol), a sensitifer in mascara. Contact Dermatitis, 1979; 5: 350. |
| 16. | Mehta SS, Reddy BSN. Cosmetic dermatitis - Current perspectives. Int J Dermatology 2003; 42: 533-542. |
| 17. | Pasricha JS. Contact Dermatitis caused by shaving creams. Contact Dermatitis in India. 1988; 67-85. |
| 18. | Dawber RPR, Barnan R, de Berker D. Disorders of Nails. In : Champion RH, Burton YC, Ebling FTG, eds. Textbook of Dermatology. 6th edn, Oxford : Black well scientific publication, 1998; 14 : 2866-8. |
| 19. | Fisher AA. Current Contact news (Cosmetic actions and reactions: therapeutic irritant and allergic). Cutis 1990; 26:11. |
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