CONTACT DERMAITIS

COSMETIC DERMATITIS

DEFINATION OF COSMETIC: cosmetics have been defined as any preparation applied to the skin , mouth, hair and nails for the

purpose of CLEANSING , ENHANCING APPEARANCE, GIVING PLEASANT SMELL OR PROVIDING PROTECTION. They include-------

perfumes, deodorants, aftershaves, hairsprays, lipstick, nail varnishes and extensions, moisturizers, emolients, cleansers, mascara,

eye shadow, make- up , sunscreen, hair colours and styling gel, soaps, shower gels, bath oils, and toothpaste. THE MOST

FREQUENTLY DETECTED ALLERGENS ARE ------ PRESERVATIVES, PERFUMES, DYES, UV filters, VEHICLES AND EXCIPIENTS, PLANT

EXTRACTS.

COMMONEST ALLERGENS IN COSMETICS ARE FRAGRANCES AND PRESERVATIVES

PATTERN OF DERMATITIS--------

(A) HAIR DYES: These account for the largest number of cases of contact dermatitis due to cosmetics. MOST CASES ARE
CAUSED BY PARAPHENYLENEDIAMINE AND PARA- ORTHOTOLUIDINEDIAMINE ( aniline derivatives) . These

chemicals are colorless until oxidized by hydrogen peroxide in the presence of ammonia . once oxidized, PPD is said to be

no longer allergenic.

The dermatitis varies in severity. The scalp is often relatively spared. In the mildest cases, dermatitis is limited

to the scalp margin and upper eyelids only. In severe cases, it may spread to the entire face, external ears and neck and in the

severest cases, it may extend to all parts of the body. There is usually severe OEDEMA AND WEEPING DERMATITIS. The dermatitis

TENDS TO WORSEN FOR A FEW WEEKS EVEN WHEN THE DYE IS NOT APPLIED AGAIN, because of the persistence of the dye in the

hair. For the treatment of these cases therefore it is essential to USE SYSTEMIC CORTICISTEROIDS FOR A MONTH OR SO AND TO

SHAMPOO THE HAIR DAILY TO REMOVE ANY FREE HAIR DYE.

(B) LIPSTICKS: These produce dermatitis generally because of the DYES USED ---- ANTHRAQUINONE DYES BEING THE
ONES USUALLY RESPONSIBLE. OILS, WAXES, PERFUMES OR PRESERVATIVES are other causes of contact dermatitis.

The dermatitis usually manifests as CHEILITIS WITH FISSURING AND SCALING INVOLVING THE LIPS.

PIGMENTATION of the lips is quite common because lipsticks cause PHOTOCONTACT DERMATITIS MORE FREQUENTLY

THAN CONTACT DERMATITIS. THIS IS DUE TO EOSIN TYPE OF DYE IN THE LIPSTICK.

(C) NAIL POLISH: The nail polishes made of FORMALDEHYDE RESINS ( TOSYLAMIDE FORMALDEHYDE RESIN) CAN CAUSE
CONTACT DERMATITIS . Allergy to other agents e.g. dibutyl phthalate, methyl acrylate and nitrocellulose have also been

described. MORE OFTEN THE DERMATITIS INVOLVES CIRCUMSCRIBED AREAS ON ALMOST ANY PART OF THE BODY WHERE

THE NAIL POLISH COMES IN CONTACT. THE FACE AND NECK ARE INVOLVED IN 80% CASES, EYES IN 50% AND PERIUNGUAL

DERMATITIS IN 60%.

ONYCHOLYSIS can occur but this is more likely with allergy from ACRYLATES IN ADHESIVES FOR FALSE NAILS AND

FROM SCULPTURED NAILS. These may also cause dystrophy and paronychia.

(D) SURMA, KAJAL: cosmetics such as surma and kajal can cause dermatitis on the eyelid margins due to oil in the kajal or

the irritant particles in surma. Eteshadows, mascara or eyebrow pencils are only occasionally responsible for contact

dermatitis which usually occurs on the EYELIDS.

(E) FACE CREAMS: THE CAUSE OF DERMATITIS IS EITHER EMMOLIENTS, FRAGRANCES OR THE PRESERVATIVES ADDED
TO COSMETICS .

(F) TOOTHPASTES: These cause contact dermatitis ON THE CHIN BELOW THE ANGLES OF THE MOUTH. The gums, lips and
mucous membrane of the mouth are generally not involved. In these cases, TOOTHPASTES WITH FOAMING AGENTS GIVE

the positive patch test in almost all cases.

PATCH TESTING: USES COSMETIC ALLERGENS LIKE--------

FRAGRANCE MIX, BALSAM OF PERU, PARABEN MIX, QUATERNIUM-15, FORMALDEHYDE,

METHYLCHLOROISOTHIAZOLINE, METHYLISOTHIAZOLINE, para- PHENYLENEDIAMINE AND COLOPHONIUM.

It is important to test all the cosmetics used by the patient.

• ‘leave on’ products can be tested as it is.

• Because of irritancy, soaps and shampoos should be diluted to 1% aqueous .

• Toothpaste at 25% and hair dyes at 2% , both in petroleum.

• Mascara and nail varnish are often irritant and should be applied to a chamber and allowed to evaporate before applying

them as a patch.

• False negative reactions and marginal irritant reactions are common when testing with cosmetics.

• IDEALLY EACH COMPONENT OF A SUSPECT COSMETIC SHOULD BE TESTED INDIVIDUALLY.

• EACH INGREDIENT MUST BE TESTED AT AN APPROPRIATE CONCENTRATION IN AN APPROPRIATE VEHICLE. THE TEST

SUBSTANCE SHOULD ALSO BE OF SIMILAR SOURCE/ BATCH AND OF PURITY LIKE THE PARENT COSMETIC.

• PHOTOPATCH TEST MAY ALSO BE NEEDED.

FRAGRANCE & FLAVOURING AGENTS ALLERGY:

WHAT ARE THE SOURCES OF FRAGRANCES ?

THE COMPONENTS OF FRAGRANCE ARE EITHER OF NATURAL ORIGIN OR PRODUCED SYNTHETICALLY. NATURAL

SOURCES INCLUDE—EXTRACTS FROM PLANTS, TREES, LICHENS AND ANIMALS ( e.g. MUSK, CIVET). Commercially available

perfumes are mixtures of essential oils from these sources and synthetic compounds with usually 10 and upto several hundred

ingredients. The scent is determined by the amount of volatile substance. FIXATIVES are added to delay evaporation. Common

fixatives are ------ BALSAMS, BENZYL SALICYLATE AND SYNTHETIC MUSKS.

Tree balsams contain different fragrance and flavouring components. BALSAM OF PERU is one such material that has

been studied in depth. It comes from central american tree MYROXYLON PEREIRE. The composition is not definitely known but the

balsam contains------- BENZYL BENZOATE , BENZYL CINNAMATE, CINNAMIC ACID ALCOHOL AND ALDEHYDE, BENZOIC ACID,

VANILLIN, FARNESOL AND NERODINOL. They may cross sensitize with resorchinol monobenzoate used in cellulose ester plastics.

Other balsams are : BALSAM OF TOLU, BALSAM OF SPRUCE, GUM BENZOIN AND STORAX.

WHAT ARE THE SOURCES OF FLAVOURING AGENTS ?

Flavouring agents may similarly be of natural and synthetic origin. Examples of natural flavours include CITRUS

FRUIT PEEL, PEPPERMINT OIL, SPEARMINT AND VANILLA. NATURAL spices include nutmeg, mustard, cinnamon, cloves and oil of

juniper. As with perfumes, flavours are USUALLY AVAILABLE AS MIXTURES.

FRAGRANCE ARE THE SECOND COMMONEST ALLERGEN AFTER NICKEL.

WHERE ARE FRAGRANCE AND FLAVOURING AGENTS FOUND ?

FRAGRANCES ARE UBIQITOUS. Perfumes, cosmetics, moisturizers, deodorants, aftershaves, soaps, bath additives,

aromatherapy oils and toilet tissues and wipes are typical sources. Medicaments, cleansers, fabric conditioners and

polishes may all be perfumed. Flavours and spices are found in FOODS, BEVERAGES, AND DENTAL PRODUCTS INCLUDING

TOOTHPASTE AND LIPSALVES.

CLINICAL FEATURE:

THERE IS TENDENCY TO INVOLVE THE HANDS, FACE , FACE AND AXILLA in women and HANDS, FACE, LOWER LEGS and AXILLA

in men. A STREAKY PATTERN HAS BEEN OBSERVED. D- Limonene is used as industrial and histological solvent and degreasing
agent. IT IS AN ALLERGEN WHEN OXIDISED IN PRESENCE OF AIR-------- CAN CAUSE OCCUPATIONAL HAND DERMATITIS. HAND

DERMATITIS can also occur in bakers and chefs from flavouring agents.

CHEILITIS may be a reflection of allergy to flavouring agents in TOOTHPASTES, LIPSALVES, FOOD AND DRINK.

MUSK AMBRETTE is a synthetic perfume responsible for PHOTOALLERGY.

MANY BALSAMS ARE USED AS MEDICAMENTS AND CAUSE ALLERGY.

INGREDIENTS OF A FRAGRANCE MIX USED IN PATCH TEST:

• CINNAMALDEHYDE

• CINNAMYL ALCOHOL

• EUGENOL

• AMYL CINNAMALDEHYDE

• HYDROXYCITRONNELLOL

• GERANIOL

• ISOEUGENOL

• OAK MOSS ABSOLUTE.

PRESERVATIVES AND ANTISEPTICS ALLERGY:

1. QUATERNARY AMMONIUM COMPOUNDS ( ANTISEPTICS + PRESERVATIVE)

These are water soluble antimicrobials used as disinfectants, sterilizers and skin cleansers., in antiseptic creams and

shampoos. It is also used as preservative in pharmaceutical preparations. The various compounds are :

• CETRIMIDE

• BENZALKONIUM CHLORIDE

• DEQUALINIUM CHLORIDE.

2. MERCURY COMPOUNDS ( PRESERVATIVE)

They are toxic and can sensitize. They are now rarely prescribed for topical use although organic mercurial

chemicals still have a limited role as preservatives. These include PHENYL MERCURIC SALTS ( acetate, borate and nitrate) IN

CONTRACEPTIVES, COSMETICS, EMULSION PAINTS, OPTHALMIC SOLUTIONS, SHAMPOOS AND SHOES LININGS.

THIMEROSAL ( sodium ethyl mercury thiosalicylate) is a PRESERVATIVE. It is used in low concentration mainly

in VACCINES, IMMUNOGLOBULIN SOLUTIONS, EYE, EAR AND NOSE DROPS AND ALSO IN HIGHER CONCENTRATIONS AS A

TOPICAL ANTISEPTICS. Sensitivity may be due to mercury/ thiosalicylic acid/ both. Thiosalicylate sensitive patients show cross

sensitivity to PEROXICAM.

3. CHLORHEXIDINE (ANTISEPTIC)

It is a cationic biguanide and has been used for disinfection of the skin in various preparations based on its

gluconate, digluconate, acetate and diacetate salts. Allergic contact dermatitis occurs in a variety of situation like preoperative

skin cleaning, treatment of leg ulcers and wound dressing.

4. HEXACLOROPHENE (ANTISEPTIC):

It is a halogenated phenolic antiseptic that was previously widely used in cosmetics, soaps and pharmaceutical

vehicles.

5. CHLOROXYLENOL (ANTISEPTIC)
 It is a chlorinated phenol ANTISEPTIC. It is available as DETTOL in India. It is active against streptococci and less so

staphylococci. It is commonly used as an antimicrobial agent in antiseptics , disinfectants and cosmetics.

6. CHLOROCRESOL ( PRESERVATIVE . ALSO USED IN PESTICIDES AND FUNGICIDE)

7. PARABENS ( PRESERVATIVES for cosmetic, drug and food) ------ parabens are ALKYL ESTERS OF p-

AMINOBENZOIC ACID. PROPYL AND METHYL PARABEN ESTERS ARE POPULAR PRESERVATIVES.

8. KANTHON CG ( CHLORMETHYISOTHIAZOLINONE/METHYLTHIAZOLINONE) ( PRESERVATIVE ) --- FORMALDEYDE

RELEASER.

9. IMIDAZOLIDINYL UREA ( PRESERVATIVE) ---------------- IT IS A FORMALDEHYDE RELEASER

10. QUATERNIUM 15 ( ANTISEPTIC) ------------------------ IT IS A FORMALDEHYDE RELEASER.

11. FORMALDEHYDE ( PRESERATIVE mostly in wash off products like SHAMPOO)

12. BRONOPOL ( PRESERVATIVE in cosmetic + ANTISEPTIC) ----- IT IS A FORMALDEHYDE RELEASER.

SHOE DERMATITIS:

These are generally made of leather, rubber, synthetic plastics or canvas. As with cloth, the materials of the shoes are in

native state and non – sensitizing.

SO WHAT CAUSE SENSITIZATION IN SHOES?

# RUBBER -------------THE ANTIOXIDANTS SUCH AS MONOBENZYL ETHER OF HYDROQUINONE

OR, ACCELERATORS SUCH AS MERCAPTOBENZOTHIAZOLE AND

TETRAMETHYLTHIURAM MONOSULPHIDE used during processing of rubber.

# LEATHER ---------------------- THE DICHROMATES OR FORMALDEHYDE USED FOR TANNING .

# ARTIFICIAL LEATHER OR PLASTICS -------------- FORMALDEHYDE OR POLYMERISED ACRYLICS.

# COLOPHONY

# DYE

# LEATHER PRESERVATIVES

# ADHESIVES

CHROMIUM IS THE MOST COMMON ALLERGEN RESPONSIBLE FOR SHOE DERMATITITS IN INDIA.

CLINICAL FEATURE: Sweating causes allergens in shoes to leach out and cause sensitivity. The pattern of distribution will indicate

whether the sensitizer is present in the upper or sole of the shoe.

Dermatitis from the upper commonly starts over the dorsal surface of the big toes and spreads to the

dorsa of the feet and other toes. INTERDIGITAL SPACES ARE USUALLY SPARED. On the heels, the patches of dermatitis may

correspond to the heel cap, and on the foot may correspond to the tongue of the shoe. INSTEP USUALLY SPARED. NICKEL ALLERGY

from shoe buckles and eyelets may cause a localized dermatitis of the adjacent skin.

CLOTHING DERMATITIS:

Clothing dermatitis caused by clothes can be due to :

1. MATERIAL OF CLOTH FIBRES: These include natural fibres like CELLULOSE ( in cotton and linen) and PROTEIN ( in wool and

silk. The artificial fibres consist of synthetic materials such as RAYON, NYLON, ACETATE, ACRYLIC OR POLYESTER. Elastic

fibres are either made from natural or synthetic rubber. UNTREATED NATURAL AND SYNTHETIC FIBRES CAUSE NO SKIN

PROBLEMS ( except sometimes wool and nylon). Contact dermatitis occurs with TREATED FIBRES.

2. CHEMICALS USED IN THE MANUFACTURE OF CLOTHES: These include

• BLEACHES for decolorizing

 • OILS for lubrication

• MORDANTS particularly DICHROMATES for dying the wool

• Starch, glues, vegetable gums

• FORMALDEHYDE AND UREA RESINS for improving the quality of finished cloth.

• ALLERGY TO ELASTIC UNDERGARMENTS can be caused by MERCAPTOBENZOTHIAZOLES, IPPD AND OTHER

RUBBER ANTIOXIDANTS, ACCELERATORS AND CHLORINE BLEACHES.

3. DYES IN CLOTHES: DISPERSE AZO AND ANTHRAQUINONE DYES ARE KNOWN TO CAUSE CONTACT DERMATITIS. Common

dyes are :

• Disperse orange

• Disperse blue ( MOST COMMON)

• Disperse red

• Disperse yellow

4. DETERGENTS USED FOR WASHING CLOTHES : usually cause repeated INSULT DERMATITIS.

CLINICAL FEATURE:

IN SHIRTS: sides and back of the neck because of collar

Anterior and posterior axillary folds sparing the vault.

Cubital fossa if the shirt is long

Distal end of forearms because of cuffs

Belt area.

IN PANTS: popliteal fossa

Front of the shin

Thighs if the pant is too tight.

Belt area.

IN SAREES: belt area,

Sides and back of the neck

Uncovered parts of forearm.

STOCKING DERMATITIS: Dermatitis from nylon stockings is caused by AZO DYES which may cross react with PPD. THE AREAS

AFFECTED ARE THE DISTAL PARTS OF THE FEET, THE POPLITEAL REGION AND THE MIDDLE OF THE THIGHS.

SOCKS :

• Disperse dyes

• Chromate mordants.

PLASTIC DERMATITIS: DERMATITIS IS GENERALLY OCCUPATIONAL. Plastics are polymerized by the addition of curing agents,

stabilizers, plasticizers and catalysts. Antioxidants and accelerators are often added. Any of these can be irritants or sensitizers.

SOLID COMPLETELY POLYMERISED RESINS RARELY CAUSE DERMATITIS WHILE INCOMPLETELY CURED RESINS MAY BE IRRITANTS AND

SENSITIZERS.

FORMALDEHYDE RESINS:
  PHENOL FORMALDEHYDE RESIN ( condensation of formaldehyde with phenol, cresol, resorchinal, p-tertiary butyl

phenol etc.).E.g. paper laminates and Bakelite, adhesives, glues. Occupational groups at greatest risk are :

ADHESIVE WORKERS, PLYWOOD, BOX MAKERS, DENTAL TECHNICIANS, TEXTILE WORKERS, SHOE MAKERS. P-

tertiary butyl alcohol can cause depigmentation in several patients.

 UREA FORMALDEHYDE RESINS : are used as CAPS, ELECTRIC FITTINGS, PRESS PLATES, SURFACE COATINGS,

TEXTILE RESINS.

 MELAMINE: extensively used in tablewares.

• ACRYLATES: USED IN

 LEATHER FINISHING

 ADHESIVES

 PAINTS, OILS, ADDITIVES

 ARTIFICIAL JOINTS,PROSTHESIS

 LENSES,DENTURES,

 ARTIFICIAL RUBBER

 PRINTING.

• EPOXY RESINS: USED IN

 SURFACE COATING

 POWDER PAINTS

 ELECTRICAL INSULATION

 ADHESIVES IN CONSTRUCTION INDUSTRY

 JEWELLARY, DECORATIVE PLATES AND BOWLS

• VINYL PLASTICS ( PVC, POLYVINYLALCOHOL, POLYVINYLACETATE).

RUBBER DERMATITIS:

 Natural rubber is obtained from LATEX, a substance extracted mainly from the HEVEA BRASILIENSIS

tree.

 RUBBER DERMATITIS IS USUALLY CAUSED BY ACCELERATORS, ANTIOXIDANTS AND OTHER

CHEMICALS USED IN THE MANUFACTURE OF RUBBER.

 RUBBER GLOVES are considered to be the MAIN SOURCE OF SENSITIZATION ( THIURAM OR

CARBAMATES are main sensitizers). However , other objects like condoms, shoes, boots, underwear

elastic and belts are also important.

 In the working environment, the principal sensitizers are the AMINE ANTIOXIDANT DERIVATIVES

particularly ISOPROPYLAMINOPHENYL AMINE (IPPD).

CLINICAL FEATURE: A variety of presentation ------ eczematous, keratoses ( of palms and soles), purpura, achromia, urticaria.