Commentary PIGMENTED COSMETIC DERMATITIS HIDEO NAKAYAMA, M.D., REIKO HARADA, M.D., AND MICHIKO TODA, M.D.
Since the latter half of the 195O's, cosmetic dermatitis patients with accompanying bizarre pigmentation have been observed in large numbers in Japan. Dermatitis on their faces has been in some cases severe, while in other cases moderate or slight. The hue of this secondary pigmentation has been black, bluish-purple, brown or ochre, and the shape of the pigmentation has been reticular, diffuse or patchy and, very exceptionally, follicular. In general, it has been persistent, being difficult or impossible to cure with topical corticosteroids. The histopathological feature of this dermatosis showed incontinence of pigment.
From the Department of Dermatology, Saiseikai Central Hospital, Tokyo, Japan
since 1968, as the presence of coexisting or forerunning eczematoid dermatitis had strongly suggested the etiology of this disease to be contact hypersensitivity. A total of 418 chemicals, mainly perfumes, were examined for their irritancy thresholds on 5 to 10 healthy individuals with 48-hour closed patch tests. The nonirritating concentrations at high concentrations were confirmed on 30 to 42 healthy individuals with the 220
Nomenclature From the standpoint of descriptive dermatology, the dermatosis that it seemed to resemble most was Riehl's melanosis, or Kriegsmelanose, prevalent in Germany after World War I. The diagnosis melanosis feminae faciei had been used by many Japanese dermatologists. As the diagnosis for Riehl's melanosis should be reserved for follicular pigmentation of a toxic nature after the repeated use of cosmetics containing mineral oils, and since melanosis feminae faciei does not suggest the presence of recurrent cosmetic dermatitis, the descriptive term pigmented cosmetic dermatitis has been proposed for this disease.i Efforts to discover the contact sensitizers expected to come from ordinary cosmetics and soaps have been made Fig. 1. A case of pigmented cosmetic dermatitis on a 46-year-old woman. Reticular blueblack pigmentation after the recurrent slight dermatitis is seen on the cheek.
Address for reprints: Hideo Nakayama, M.D., Department of Dermatology, Saiseikai Central Hospital, 1-4-17 Mina, Minatoku, Tokyo, Japan. 673
674
INTERNATIONAL JOURNAL OF DERMATOLOGY
Fig. 2. Patch test revealed that she was sensitized with Red-219, an azo-compound commonly used in cosmetics. Strong positive reaction of allergic type Is seen at No. 5 at 72 hours of the patch test with Red-219 at 5% in polyethylene glycol. 55 controls showed negative reactions with the same materials.
chemicals most commonly used in cosmetics and soaps to confirm whether the patch test conditions were nonirritating. A photopatch test was done at the same time as the closed patch test lest phototoxic and photoallergic reactions be overlooked. The cosmetic components which produced strong positive reactions presumed as allergic in nature have been selected from the materials tested for 6 years. Statistical evaluation was made to ascertain whether these positive reactions appeared significantly in the group composed of cosmetic dermatitis patients compared with the control group, consisting of healthy individuals and those with dermatitis other than cosmetic dermatitis. The statistical evaluation was performed with F-test and also with x^-test. Contactants
Six years' study revealed that the following cosmetic components seemed to
Vol. 15
November 1976
Fig. 3. Efi^ect of the allergen control is shown. After the exclusive use of the Allergen Gontrolled System (AGS), she had had no chance of contact with the allergen. She had no recrudescence of the previously recurrent dermatitis; gradual absorption of the generally incurable secondary pigmentation took place. Fig. 3 photograph was taken 1 year after Fig. 1.
be the causative cosmetic contact allergens: benzyl salicylate, ylangylang oil, cananga oil, jasmin absolute, hydroxycitroneilai, methoxycitronellal; sandalwood oil and Red 219 (brilliant lake red R) were considered as new allergens. Benzyl alcohol, cinnamic alcohol, lavender oil, geraniol/geranium oil, trichlorcarbanilide and Irgasan CF3 were confirmed to be cosmetic allergens.^-'* Table 1.
Results oi ACS Treatment
Gomplete or almost complete cure Remarkable improvement
26 '
lmprovement No change Total
i420
, ,. '
. , ,,. ,.
, _:
,7 67
COSMETIC DERMATITIS
No. 9
• Nakayama, et a/.
675
Table 2. A Sample of Cosmetic Allergens: Reactivity of Benzyl Saliclate (5% pet.) Persons tested Patch test reaction Strong positive
With pigmentation
Without pigmentation
Other dermatitis
Healthy
Total
19
7
1
0
27
18
4
0
25
40
336
40
388
(++)-(-!--f-F) Weak positive Negative (—) Total
Control (2)
Cosmetic dermatitis (1)
84
98
114
121
109
118
-
Statistical evaluation betvi/een (1) and (2) F test: F = 29.5 (significant, P < 0.01) x~ test: x2 = 6.90 (significant, 0.01 < P < 0.05)
The cosmetic components which did not produce allergic reactions at nonirritating and high concentrations for cosmetic dermatitis patients were judged safe, if the irritation index was sufficiently low at the same time. From these safe components, cosmetics to cover the bizarre pigmentation were produced and were used exclusively for more than 6 months by the pigmented cosmetic dermatitis patients. A new, exceptionally low irritating detergent to wash the skin, acylglutamate, was also used exclusively by the patients to avoid contact with sensitizers from ordinary soaps and shampoos. These cosmetics and detergents for recurrent contact dermatitis patients were designated as the Allergen Controlled System (ACS) in 1972. The effects of the use of ACS on patients suffering from pigmented cosmetic dermatitis were dramatic. A total of 73 pigmented cosmetic dermatitis patients were treated with ACS without other treatment, except for the use of corticosteroid hormone ointment, for only 2 weeks or so before the beginning of the treatment with ACS, to allow the inflammation to subside. Sixty-seven of 73 patients were followed for more than 2 months to 3 years, and the results are listed in Table 1. The data available for the 26 patients
completely or almost completely cured are as follows: 1. Average age of patient: 46 ± 12 (1 S.D.) 2. From onset to the use of ACS: 44 months average 3. The period required for slight improvement: 2.9 months average 4. The period required for the complete or almost complete cure: 9.5 ± 5.6 months average; (1 S.D.) 5. The period of follow-up after use of ACS: 15 ± 7.5 months average; (1 S.D.)
;:
^
.-. V :
-•
Considering the difficulty in curing these cases and an average period of 44 months from the onset to the use of ACS, the complete or almost complete cure in 9.5 months on the average, and also the fact that the cure was confirmed for 15 months, suggests that allergen control in the patients' contact environments is an effective treatment for this disease. References 1. Nakayama, H., Hanaoka, H., and Ohshiro, A., Allergen controlled system (ACS). Tokyo, Kanehara Shuppan, 1974. 2. Fisher, A. A., Contact Dermatitis. Philadelphia, Lea & Febiger, 1967, pp. 155, 257. 3. Hjorth, N.: Eczematous Allergy to Balsams. Copenhagen, Munksgaard, 1961, p. 22. 4. Masuda, T., et al.. Contact dermatitis due to hexachlorophene, Irgassan CFa, TCC, TBS and diaphene. Jap. J. Dermatol. 81:584, 1971.
Since the latter half of the 195O's, cosmetic dermatitis patients with accompanying bizarre pigmentation have been observed in large numbers in Japan. Dermatitis on their faces has been in some cases severe, while in other cases moderate or slight. The hue of this secondary pigmentation has been black, bluish-purple, brown or ochre, and the shape of the pigmentation has been reticular, diffuse or patchy and, very exceptionally, follicular. In general, it has been persistent, being difficult or impossible to cure with topical corticosteroids. The histopathological feature of this dermatosis showed incontinence of pigment.
From the Department of Dermatology, Saiseikai Central Hospital, Tokyo, Japan
since 1968, as the presence of coexisting or forerunning eczematoid dermatitis had strongly suggested the etiology of this disease to be contact hypersensitivity. A total of 418 chemicals, mainly perfumes, were examined for their irritancy thresholds on 5 to 10 healthy individuals with 48-hour closed patch tests. The nonirritating concentrations at high concentrations were confirmed on 30 to 42 healthy individuals with the 220
Nomenclature From the standpoint of descriptive dermatology, the dermatosis that it seemed to resemble most was Riehl's melanosis, or Kriegsmelanose, prevalent in Germany after World War I. The diagnosis melanosis feminae faciei had been used by many Japanese dermatologists. As the diagnosis for Riehl's melanosis should be reserved for follicular pigmentation of a toxic nature after the repeated use of cosmetics containing mineral oils, and since melanosis feminae faciei does not suggest the presence of recurrent cosmetic dermatitis, the descriptive term pigmented cosmetic dermatitis has been proposed for this disease.i Efforts to discover the contact sensitizers expected to come from ordinary cosmetics and soaps have been made Fig. 1. A case of pigmented cosmetic dermatitis on a 46-year-old woman. Reticular blueblack pigmentation after the recurrent slight dermatitis is seen on the cheek.
Address for reprints: Hideo Nakayama, M.D., Department of Dermatology, Saiseikai Central Hospital, 1-4-17 Mina, Minatoku, Tokyo, Japan. 673
674
INTERNATIONAL JOURNAL OF DERMATOLOGY
Fig. 2. Patch test revealed that she was sensitized with Red-219, an azo-compound commonly used in cosmetics. Strong positive reaction of allergic type Is seen at No. 5 at 72 hours of the patch test with Red-219 at 5% in polyethylene glycol. 55 controls showed negative reactions with the same materials.
chemicals most commonly used in cosmetics and soaps to confirm whether the patch test conditions were nonirritating. A photopatch test was done at the same time as the closed patch test lest phototoxic and photoallergic reactions be overlooked. The cosmetic components which produced strong positive reactions presumed as allergic in nature have been selected from the materials tested for 6 years. Statistical evaluation was made to ascertain whether these positive reactions appeared significantly in the group composed of cosmetic dermatitis patients compared with the control group, consisting of healthy individuals and those with dermatitis other than cosmetic dermatitis. The statistical evaluation was performed with F-test and also with x^-test. Contactants
Six years' study revealed that the following cosmetic components seemed to
Vol. 15
November 1976
Fig. 3. Efi^ect of the allergen control is shown. After the exclusive use of the Allergen Gontrolled System (AGS), she had had no chance of contact with the allergen. She had no recrudescence of the previously recurrent dermatitis; gradual absorption of the generally incurable secondary pigmentation took place. Fig. 3 photograph was taken 1 year after Fig. 1.
be the causative cosmetic contact allergens: benzyl salicylate, ylangylang oil, cananga oil, jasmin absolute, hydroxycitroneilai, methoxycitronellal; sandalwood oil and Red 219 (brilliant lake red R) were considered as new allergens. Benzyl alcohol, cinnamic alcohol, lavender oil, geraniol/geranium oil, trichlorcarbanilide and Irgasan CF3 were confirmed to be cosmetic allergens.^-'* Table 1.
Results oi ACS Treatment
Gomplete or almost complete cure Remarkable improvement
26 '
lmprovement No change Total
i420
, ,. '
. , ,,. ,.
, _:
,7 67
COSMETIC DERMATITIS
No. 9
• Nakayama, et a/.
675
Table 2. A Sample of Cosmetic Allergens: Reactivity of Benzyl Saliclate (5% pet.) Persons tested Patch test reaction Strong positive
With pigmentation
Without pigmentation
Other dermatitis
Healthy
Total
19
7
1
0
27
18
4
0
25
40
336
40
388
(++)-(-!--f-F) Weak positive Negative (—) Total
Control (2)
Cosmetic dermatitis (1)
84
98
114
121
109
118
-
Statistical evaluation betvi/een (1) and (2) F test: F = 29.5 (significant, P < 0.01) x~ test: x2 = 6.90 (significant, 0.01 < P < 0.05)
The cosmetic components which did not produce allergic reactions at nonirritating and high concentrations for cosmetic dermatitis patients were judged safe, if the irritation index was sufficiently low at the same time. From these safe components, cosmetics to cover the bizarre pigmentation were produced and were used exclusively for more than 6 months by the pigmented cosmetic dermatitis patients. A new, exceptionally low irritating detergent to wash the skin, acylglutamate, was also used exclusively by the patients to avoid contact with sensitizers from ordinary soaps and shampoos. These cosmetics and detergents for recurrent contact dermatitis patients were designated as the Allergen Controlled System (ACS) in 1972. The effects of the use of ACS on patients suffering from pigmented cosmetic dermatitis were dramatic. A total of 73 pigmented cosmetic dermatitis patients were treated with ACS without other treatment, except for the use of corticosteroid hormone ointment, for only 2 weeks or so before the beginning of the treatment with ACS, to allow the inflammation to subside. Sixty-seven of 73 patients were followed for more than 2 months to 3 years, and the results are listed in Table 1. The data available for the 26 patients
completely or almost completely cured are as follows: 1. Average age of patient: 46 ± 12 (1 S.D.) 2. From onset to the use of ACS: 44 months average 3. The period required for slight improvement: 2.9 months average 4. The period required for the complete or almost complete cure: 9.5 ± 5.6 months average; (1 S.D.) 5. The period of follow-up after use of ACS: 15 ± 7.5 months average; (1 S.D.)
;:
^
.-. V :
-•
Considering the difficulty in curing these cases and an average period of 44 months from the onset to the use of ACS, the complete or almost complete cure in 9.5 months on the average, and also the fact that the cure was confirmed for 15 months, suggests that allergen control in the patients' contact environments is an effective treatment for this disease. References 1. Nakayama, H., Hanaoka, H., and Ohshiro, A., Allergen controlled system (ACS). Tokyo, Kanehara Shuppan, 1974. 2. Fisher, A. A., Contact Dermatitis. Philadelphia, Lea & Febiger, 1967, pp. 155, 257. 3. Hjorth, N.: Eczematous Allergy to Balsams. Copenhagen, Munksgaard, 1961, p. 22. 4. Masuda, T., et al.. Contact dermatitis due to hexachlorophene, Irgassan CFa, TCC, TBS and diaphene. Jap. J. Dermatol. 81:584, 1971.
