Contact Dermatitis Due to Local Cosmetics: A Study from Northern India.

BACKGROUND: Majority of the cosmetics are synthetic in nature and capable of causing dermatitis among frequent users. Some cosmetics (bindi, sindoor, etc.) that cause serious skin inflammation are specific to Indian culture. AIM: To study the prevalence of contact dermatitis due to various cosmetics indigenous among Indian users.
MATERIALS AND METHODS: A cross-sectional study of 2,150 patients who attended dermatitis clinic at a regional hospital in north India. A total of 400 of these were suspected of cosmetic dermatitis based on clinical grounds and were subjected to patch test using Indian Standard Series and Cosmetic series kit.
RESULTS: Among the 400 patients identified for cosmetic dermatitis, 352 (88%) were female and 326 (81.5%) between 20 and 49 years of age. Bindi/kumkum (30%), hair dye (18%), and deodorant/perfume (14%) were primary cosmetics causing contact dermatitis. Patch test with the suspected cosmetics was positive in 52.75% cases. Patients who visited their doctor in the early stages of appearance of symptoms (<3 months) were more likely to have positive patch test.
CONCLUSION: Higher incidence of cosmetic dermatitis is observed in adult females aggravated by use of inferior quality cosmetics. Early detection of the disease can be helpful. Copyright:

Introduction

Awareness regarding skin beauty and cosmetic elegance has received tremendous attention in last 2 decades in India, both among males and females alike. A number of young men and women are concerned about their appearances and overall skin care, and therefore spend both time and money on a variety of skin cosmetics. Hence, these days a large number of cosmetics are manufactured by the medicinal chemists and commonly advertised as antiageing, youth-forever, and wrinkle-free products. Majority of these substances are synthetic in nature, with ingredients capable of causing sensitization leading to cosmetic dermatitis. Clinically, contact dermatitis due to cosmetics is defined as an inflammatory response of the skin when exposed to an exogenous agent. It comprises of Contact Irritant Dermatitis or Contact Allergic Dermatitis, and they both include contact urticaria and photo contact dermatitis.[1]

The problem of contact dermatitis due to cosmetics has attracted considerable attention among the researchers in the West, but remains to be properly studied in the Indian context. Furthermore, a large number of cosmetics, viz., bindi, kajal, surma, sindoor, and tilak are indigenous to Indian culture and makes it more relevant to conduct this study. Therefore, the present study was undertaken to evaluate the prevalence of contact dermatitis due to various ingredients of cosmetics in Agra and adjoining area.

Materials and Methods

The study was carried out between July 2013 to December 2014 on all the patients who attended the Clinical Division of National JALMA Institute of Leprosy and Other Mycobacterial Diseases, Agra, Uttar Pradesh, India, and it involved patients suspected of having contact sensitivity to topical medicaments and common cosmetics. All the patients who exhibited signs of contact reaction to any of the cosmetic products at the site of the application – face, neck, eyelids, scalp, etc., patients suffering from chronic eczema not responding to the conventional treatment with recent history of using cosmetics and those willing to undergo patch testing were included in the study. While patients with acute exacerbation of skin lesions, patients where dermatitis was due to systematically administered agents, and patients who were on systemic corticosteroids or any form of immunosuppressive drugs were excluded from the study.

Patch testing was done after complete subsidence of signs and symptoms and after complete withdrawal of the drugs. The protocol established by the International Contact Dermatitis Research Group (ICDRG) was used for patch testing.[2] We used the standard closed patch test approach. The patch testing was done with the finished commercial product being used by the patient and the antigens of the Indian Standard Series and Cosmetic series kit (Systopic, New Delhi).

For all patch tests, 0.05 ml of the testing substance was placed on a 1 square cm piece of cotton wool, which was placed on a 2.5 square cm of eight-layer cotton gauze that was occluded with a 4 square cm piece of adhesive micropore plaster onto the back of the patient. The duration of occlusion for patch testing was 48 h, after which the patch was removed under the close supervision of the researcher(s). First reading was taken only after 20 min of patch removal. This was done so as to avoid missing weak test reaction. After the 48 h reading was taken, the site of patch test was marked with skin marking pencils and the patient was requested to come back after 24 h for a second reading. Thus, two readings were taken – first one after 48 h and the second one after 72 h.[34] The allergens were also tested using readymade aluminium chambers (Finn Chambers) already mounted on hypoallergenic tape using Indian Standard Series based on the technique initially introduced by Pasricha and Sethi.[5]

Semisolids were directly applied to the chamber that filled more than 50% of the chamber volume. Liquids were placed on a filter paper disc in the chamber and moistened thoroughly. The personal care products were diluted as required to avoid irritant or strong reactions and applied immediately. The choice of vehicle for dilution depended on the characteristics of the product, solubility, and pH.[6] We used distilled water for neutral products (pH 4–9), and for more alkaline or acidic substances, we applied the buffer solutions to reduce irritability. In simple terms, acid buffer is used for the dilutions of the alkaline products (pH > 9), and the alkaline buffer was used to dilute acidic products (pH < 4). Next, the test strip chamber sites were numbered for later identification. It was made sure that the skin was clean, healthy, and free of ointment, lotion, powder, acne, dermatitis, scars, hair, or any other condition that might interfere. The patient was made to stand or sit in a relaxed position with the back bent slightly forward. The prepared patches were applied to the upper back adjacent to the vertebrae. Tape was affixed to the skin at the lower end and slowly rolled up the back, pushing out the air. Chambers were gently pressed on the skin to ensure an even distribution of allergens. The tape was gently but firmly rubbed to ensure good adherence.

The patients were refrained from exposing patch tests to excess moisture or sweat and were called for patch test removal in 48 h.[3] The site of chamber location was marked prior to removal. The Finn chambers were removed from skin contact, occlusion was verified (the ring-shaped depression around each test), and skin reactions were read not less than 20 min after the removal. A second skin reaction reading was taken at 72 h after initial patch placement.[4] The changes observed in skin reactions and patch test reactions were graded using the ICDRG outlines:

- negative reaction

? doubtful reaction, erythema only

+ weak reaction, nonvascular erythema, discreet papules

++ strong allergic reaction, edematous, or vesicular

+++ extreme allergic reaction, bullous, or ulcerative

IR irritant reaction

NT not tested.

Results

Of the 2150 patients that attended contact dermatitis clinic over an 18 month period, 400 patients were suspected to have cosmetic dermatitis on clinical grounds, with a relative prevalence of 18.60%.

Cosmetic dermatitis is common among females with 88% of the observed cases. Almost 80% of the total cases were between 20 and 49 years of age with peak incidence of 56% among females between 20 and 39 years of age. The pediatric and geriatric population is less affected; with the youngest and the oldest patients being 11 and 65 years old, respectively [Table 1].

Table 1

Age and sex distribution of cosmetic dermatitis cases

Age group (years)	Male		Female
	Number	Percent	Number	Percent
10--19	0	0.0	34	8.5
20--29	12	3.0	104	26.0
30--39	8	2.0	120	30.0
40--49	16	4.0	66	16.5
50 and more	12	3.0	28	7.0
Total	48	12.0	352	88.0

While 92% of the patients in our sample correlated aggravation of their problem with the use of suspected cosmetics, 8% patients were unaware of any specific cosmetic product causing their symptoms. Bindi/kumkum, hair-dye, and perfume/deodorant followed by facial cream and lipstick were commonly suspected for cosmetic dermatitis.

Patch testing revealed 211 (52.75%) patients exhibited positive test results leading to suspected personal cosmetic allergen. The common suspected cosmetics in the order of priority were lipstick and hair dye where the patch test turned out to be positive in all the cases. This is followed by perfumes/deodorants (57.14%), facial creams (47.92%), and finally bindi/kumkum (30%). Thus we found that hair dye and lipstick were common sensitizers. However, soap/shampoo/face-wash and eye cosmetic/kajal resulted in zero positive patch test cases [Table 2].

Table 2

Etiological profile of cosmetic dermatitis established with positive patch test

Suspected cosmetic	Number of cases	Patch test results
		Number of positive cases	Percent
Bindi/kumkum	120	36	30.00
Hair dye	72	72	100.00
Facial cream	48	23	47.92
Lipstick	32	32	100.00
Soap/shampoo/face-wash	24	0	0.00
Eye cosmetic/kajal	16	0	0.00
Perfume/deodorant	56	32	57.14
Not aware of the cause	32	16	50.00
Total	400	211	52.75

Duration of the appearance of clinical symptoms of cosmetic dermatitis varied considerably from less than 15 days to more than a year, but primarily the symptoms were visible anywhere between 15 days and 6 months. Almost 87.5% of the patients showed signs of cosmetic dermatitis in the first 6 months since they started using a new cosmetic or switch brand, of which about 70% of the cases were reported in the first 3 months itself. Besides, earlier the appearance of the symptoms of the cosmetic dermatitis, better were the chances of a positive outcome of the patch test. On an average 58% of the patients who showed signs of dermatitis in first 3 months also produced positive patch test results. Last, as the duration of appearance of symptoms increased, the chances of positive outcome of the patch tests decreased [Table 3].

Table 3

Duration of appearance of clinical symptoms of cosmetic dermatitis and corresponding positive patch test results

Duration of appearance of symptoms since the application/change of the cosmetics	Number of cases	Patch test results
		Number of positive cases	Percent
<15 days	41	24	58.53
15--30 days	105	62	59.05
1---3 months	128	72	56.25
3--6 months	76	37	48.68
6--12 months	27	12	44.44
>1 year	23	4	17.39
Total	400	211	52.75

Discussion

Contact dermatitis due to cosmetics is encountered frequently in dermatological practices with a higher incidence of contact dermatitis to cosmetics in females due to more use of cosmetics among them. About 88% of the female patients in our study showed positive signs of contact dermatitis due to cosmetics. Similar sex distribution was observed in the past by de Groot et al.,[7] and Adams et al.[8] In our study, majority of the patients were between 20 and 49 years of age with a peak incidence in 30-39 year age group. This is contradictory to de Groot[7] where 16 to 55 year old patients in The Netherlands were evenly affected, but in line with Dogra et al.[9] who reported that the maximum affected age group was 20--30 years in India.

Contact dermatitis due to cosmetics is not uncommon in India. A large number of cosmetics used in India are common to those used in the West but several others like kajal, surma, kumkum bindi, sindoor, and tilak etc., are indigenous to Indian culture. Patients who use so called cheaper/local brand cosmetics which might be clandestinely manufactured by some unlicensed agency were more susceptible to contact dermatitis as these manufacturers were more prone to use sub-standard or potentially allergic materials which might cause additional problem. This is in agreement with past studies in India by Pasricha[10] and Dogra et al.[9]

The American studies by Marks et al.,[11] and Pratt et al.[12] reported 60% - 70% positive patch test results among all the patients who were clinically diagnosed as cosmetics dermatitis. In the Indian context, unlike Sharma and Chakrabarti[13] who reported 65.5% positive patch test results, our study reports only 52.75% positive patch test. Bindi/kumkum/tikka dermatitis is specific to India but has been reported in other countries with sizeable Hindu population. Positive patch test was found in 30% of the cases of suspected bindi dermatitis in our study, but usage test were positive in all patients. As mentioned by Pandy and Kumar,[14] this can be explained by the cumulative effect of the chemicals present in the glue part of the bindi, which caused dermatitis and slow toxic damage to melanocytes leading to depigmentation. All the patch test results were positive for hair dye and lipstick dermatitis cases, while almost 50% of the patch test results were positive for the patients who had been using facial cream or perfume/deodorant. Our patch test results observed in this study are better than the one reported for the Indian patients in the past by Tomar et al.[15] and Bajaj et al.[16]

Lastly, similar to our findings of significantly high-positive patch test results in situations when the patient approached the doctor in early stages of the appearance of symptoms, Neri et al.[17] for a 9-year-old Indian boy and Nawaf et al.[18] for a 17-year-old Indian girl found positive patch test results within 3 weeks of application of the cosmetics on their skin.

Conclusion

This study provides a comprehensive profile of contact dermatitis due to cosmetics in northern India. Based on the data observed, 400 cases were identified as victim of cosmetic dermatitis with a significant preponderance among 20 - 39 year old females. Bindi/kumkum (30%), followed by hair dye (18%) and deodorant/perfume (14%), were the primary cosmetics causing contact dermatitis. Patch test with the suspected cosmetic was positive in 52.75% cases. Finally, patients who decided to see the doctor in the early stages of appearance of symptoms of dermatitis were more likely to have positive patch test results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.