Introduction

The term cosmetics has a broad definition and includes hair care products, skin care products, nail care products, personal care products, and sunscreens. The definition, however, varies between the United States and Europe. In the United States, the Federal Food, Drug, and Cosmetic Act (FD&C Act) and the Fair Packaging and Labeling Act (FPLA) regulate cosmetics, and the US Food and Drug Administration (FDA) supervises these two acts. Cosmetics is defined under these two Acts as “articles intended to be rubbed, poured, sprinkled or sprayed or introduced into or otherwise applied to the human body or any part thereof for cleansing, beautifying, promoting attractiveness, or altering the appearance” and should not alter the structure or function of the skin. In contrast, drugs are defined as “articles intended for use in the diagnosis, cure, mitigation, treatment or prevention of disease in man.” Cosmeceuticals are cosmetic products that contain bioactive ingredients with the intent to have a beneficial physiologic effect, although there is no legal definition. In Europe, the Cosmetic Directive 76/768/EEC defines a cosmetic product as any substance or preparation “intended to be placed in contact with various external parts of the body or with the teeth and mucous membranes of the oral cavity with a view exclusively or mainly to cleaning them, perfuming them, changing their appearance, and/or correcting body odors and/or protecting them or keeping them in good condition.” Thus some products considered cosmetics in Europe (e.g., antiperspirants) are considered over-the-counter (OTC) drugs in the United States.

Cosmetics are used by many and are an integral part of daily grooming. On average, a survey found that females use approximately 16 facial or cosmetic products containing over 180 ingredients per day while males use an average of 6 personal products containing 85 ingredients. Unfortunately, sometimes these cosmeceutical products intended to enhance beauty can lead to a dermatitis that can be quite unsightly, uncomfortable, annoying, and perplexing to the patient and the physician. Contact dermatitis is one of these adverse reactions and can be either irritant or allergic in nature, with the former being more common. Allergic contact dermatitis (ACD) to cosmetics; personal care products; makeup; body washes; moisturizers; creams; nail, lip, and hair care products; and the devices (e.g., sponges, applicators) used to apply them can result in a clinical dermatitis. These reports are well documented in the literature and clinically can appear as a well-demarcated reaction at the location of product application. However, the dermatitis can be ectopic to the location the product is applied through transfer to a more sensitive area such as the face or eyelids. ACD to cosmeceuticals is not as frequently reported in the literature as one would expect given their widespread usage. This may be due in part to difficulty in testing these products and the lack of standardized allergens. Interestingly, a study from Sweden reported that while the incidence of dermatitis secondary to cosmetics is estimated to be 12%, 47% of patients referred for patch testing had an irritant or allergic dermatitis, highlighting the selection process to refer to patch testing is an early step that can explain the lack of literature on cosmetic allergens.

Cosmetics that are most commonly responsible for ACD include skin hygiene and moisturizing cream, hair dye, artificial nails, and cologne—accounting for ~75% of the positive patch tests.

Vitamins

Antioxidants protect the skin against free radicals and are used in cosmetics generally as antiaging products. While contact dermatitis to cosmeceutical vitamins such as vitamin A (retinol), vitamin C (ascorbic acid), vitamin E (tocopherol acetate), and vitamin K has been reported in the literature, it is rare. Galates are the main culprit within the antioxidants found in cosmetics. Galates are alkyl esters, with the most widely used being dodecyl galate. This is most commonly found in lipsticks, with the patient presentation being cheilitis. A series of patients who underwent patch testing from 1988 to 2005 demonstrated a statistically significant increase in propyl gallate–positive rates on patch testing, which investigators attributed to an increase in use of propyl gallate in the cosmetics industry. However, the authors could not exclude the possibility that a reduction in the use of propyl gallate as an antioxidant in food products has also led to decreased oral tolerance in humans. Recommended patch-test concentrations for gallates are propyl gallate at 1%, octyl gallate at 0.25%, and dodecyl gallate at 0.25%, diluted in petrolatum or olive oil vehicle.

Vitamin A and its derivatives, such as retinoids, retinaldehyde, and retinyl palmitate, typically produce an irritant contact dermatitis with dryness and skin irritation. This irritation is an unwanted side effect of retinization of the face, but it is difficult to avoid if the beneficial collagen regenerative effects are to be experienced. Irritant contact dermatitis can sometimes present identically to ACD, but vesiculation and facial swelling are never an expected part of early retinization of the face. ACD to vitamin A is rare but can be confirmed by positive patch testing. The vitamin A–containing cream can be patch tested “as is,” but many times it is impossible to determine which of the many ingredients in the preparation is the culprit. Most large cosmeceutical manufacturers can provide a sample of the vitamin A raw material they use in their formulation for individual ingredient patch testing. The person to contact at the company and the address can be obtained from the Cosmetic Industry On-Call brochure published as a joint effort between the American Contact Dermatitis Society (ACDS) and the Personal Care Products Council (PCPC; formerly the Cosmetic, Toiletry, and Fragrance Association). More information can be obtained at the PCPC website at http://www.personalcarecouncil.org .

Vitamin C, also known as ascorbic acid, is another vitamin used topically to stimulate collagen synthesis and improve hyperpigmentation secondary to actinic damage. It is difficult to formulate because it is easily oxidized to inactive products upon exposure to ultraviolet (UV) radiation or oxygen. ACD to topical vitamin C is rare, but irritation can occur due to the low pH effects of the ascorbic acid on the skin. The same discussion regarding closed patch testing and ingredient procurement for vitamin A also applies to vitamin C.

Vitamin E is a natural or synthetic component purported to have antioxidant and antiaging properties. It can be found naturally in many substances such as barley, rice, corn, rapeseed, alfalfa, wheat, eggs, and meat as well as contained in many cosmetic products including deodorants, soaps, and creams for moisturizing and burn/scar relief. It is part of a family of compounds called tocopherols and is a common cause of both irritant contact dermatitis and ACD. Eczematous reactions, urticarial contact dermatitis, and erythema multiforme–like eruptions have all been reported with topical alpha-tocopherol use. Many of the casually reported cases of vitamin E allergy appear to be due to consumers breaking open vitamin E capsules intended for oral consumption and rubbing the oil onto wounds or scars to promote healing. While vitamin E formulated in this manner is safe for human oral consumption, it is not intended for topical application. Cosmetic-grade vitamin E properly formulated in a moisturizing cream is rarely allergenic. Patch testing may be useful for making the diagnosis of contact dermatitis from alpha-tocopherol. The recommended concentration for evaluation of localized lesions is 5–20%; however, lower concentrations such as 0.25–1.0% may be sufficient in generalized lesions.

Vitamin K, present in green vegetables and the liver, has been used topically following cosmetic surgical procedures including liposuction, sclerotherapy, and carbon dioxide as well as pulse dye laser procedures. Adverse cutaneous effects are rarely reported; however, dermatitis is more common with lipid-soluble forms such as phytomenadione due to greater percutaneous absorption. In addition, cutaneous hypersensitivity reactions to vitamin K ₁ following subcutaneous or intramuscular injection as well as irritant contact dermatitis from vitamin K ₃ use have all been reported in the literature. Patch testing may be helpful in further assessing for contact dermatitis to vitamin K.

Hydroxy Acids

Hydroxy acids are a group of chemicals frequently found in cosmeceutical products. Contact dermatitis to alpha-hydroxy acids (AHAs), beta-hydroxy acids (BHAs), and polyhydroxy acids (PHAs) is typically in the form of irritant contact dermatitis. The larger size of PHAs reduces skin penetration, which also lessens the opportunity for irritant contact dermatitis to occur. More irritant reactions are seen with the AHAs (e.g., glycolic acid or lactic acid), in the form of stinging and burning due to the low pH of these cosmeceuticals that rapidly penetrate the stratum corneum to reach the nerve endings in the dermis. AHAs that have been partially neutralized produce less contact dermatitis, but they also do not produce dramatic antiaging effects. BHAs, such as salicylic acid, are oil soluble and do not penetrate the stratum corneum well. For this reason, irritant contact dermatitis is lessened, but it can still occur in patients with compromised barrier function.

Botanicals

Botanicals form one of the largest categories of cosmeceutical ingredients in today’s marketplace. Botanicals are often seen by consumers as natural, safer alternatives to their synthetic counterparts. As a result of a strong driving force within the cosmetics industry toward natural products, botanicals are a common cosmeceutical active ingredient. Botanical additives are made from various parts of the plant including the leaves, root, fruits, stems, or flowers. The concentration, composition, efficacy, and antigenicity of a given plant extract may differ depending on the part of the plant from which it was obtained. Different antigens may also be present depending on the time of year the botanical was harvested, where the plant originated, and how the plant material was processed prior to incorporation into a cosmeceutical. Therefore the antigenic component of a particular botanical can vary significantly.

There are a few systematic reviews regarding contact dermatitis and botanicals. Although there are many cases of contact dermatitis to botanicals and essential oils in the literature, most cases of allergic reactions that have been documented are single case reports. Essential oils and fragranced cosmetic products can have an allergen in the form of fragrance (e.g., linalool [dimethyl octadienol], limonene, or majantol [trimethyl-benzenepropanol]). Linalool is a proponent in herb, plant, or woody smells while limonene is a prominent component in citrus peels and produces a citrus scent. These two (linalool and limonene), when exposed to air, are broken down into hydroperoxide components that can be highly allergic. Studies have shown that patients who have a contact dermatitis to the hydroperoxides of linalool or limonene frequently also develop contact dermatitis to other fragrances. Majantol is the smell of lily and commonly found in perfumes or wash-off products. With the increasing use of botanicals in the cosmetics and cosmeceutical arena, more reactions to these extracts are expected. This section will not review all of the individual case reports of allergic reactions to botanicals; rather it will serve to highlight some of the more common botanical culprits.

Aloe is a commonly used botanical extract for its soothing properties on wounds, burns, and irritated skin ( Fig. 21.1 ). It is a mucilage containing thousands of individual chemical entities. This makes determination of the exact allergen impossible. Yet case reports of ACD are found in the literature. Patients who have experienced a suspected ACD to aloe should read ingredient labels and avoid products containing this botanical extract. It is not hard to avoid cosmeceuticals containing aloe.

Aloe vera mucilage is a possible cause of allergic contact dermatitis.

Tea tree oil or melaleuca oil is derived from the Cheel shrub in Australia ( Fig. 21.2 ). It has gained increasing popularity in a variety of OTC products, including antibacterials, antifungals, shampoos, and OTC salon treatment products designed to minimize dandruff or seborrheic dermatitis. Tea tree oil can cause ACD and in one study was found to be the most allergenic botanical extract. Although there are several antigenic components of this oil, the constituents of the oil thought to cause the majority of allergic reactions are d -limonene and terpinen-4-ol; however, not all patients who react to tea tree oil react to these components. Interestingly, in patients with a fragrance allergy, it is also recommended to avoid tea tree oil and derivatives of the Compositae or Asteraceae family allergy.

Homeopathic dandruff shampoos may be a source of tea tree oil exposure.

Ylang-ylang oil has proportionally increased in positive reads on patch testing in 2017–2018 compared to the prior 10 years (2006–2017). Ylang-ylang oil is used for its floral fragrance and is commonly found in lotions, soaps, and detergents. In addition, it has been used in food (ice cream, candies, chewing gum) and in drinks. With the rise in popularity of essential oils, ylang-ylang oil has been used in aromatherapy and postulated to assist with mood, breathing, and as an aphrodisiac. Interestingly, studies from Japan have shown ylang-ylang oil–related dermatitis can cause a pigmented cosmetic dermatitis.

Curcumin is an antioxidant derived from turmeric root. Curcumin is a common additive to Middle Eastern and Indian food as a hot spice. Its use in these cultures dates back to the prerefrigeration era when curcumin was used as a food preservative. It is used in some cosmeceuticals to prevent the product from discoloring or oxidizing on the store shelf. Several currently marketed cosmeceutical moisturizers contain curcumin to prevent the degradation of ceramides added to enhance the skin barrier. Curcumin is a cutaneous irritant and can cause stinging, burning, and itching in patients with atopic dermatitis (AD) or other barrier defects. There are also rare reports of ACD resulting from topical contact with curcumin.

Witch hazel has been used as a cosmeceutical astringent, acne agent, and vasoconstrictor. It is a cause of ACD. Currently, witch hazel is a common additive to cosmeceutical eye creams designed to minimize puffiness and under eye “bags.” Witch hazel allergy should be suspected in patients with periorbital swelling who have begun using a new eye area cosmeceutical.

The Compositae family comprises a group of plants that have sensitizing capabilities. Arnica montana is an important medicinal plant that has been reported to cause ACD ( Fig. 21.3 ). Screening patients with sesquiterpene lactone mix may miss some of these reactions, and therefore testing to the plant or other chemical constituents of the plant is recommended. Chamomile, another member of the Compositae family, is also a cause of ACD ( Fig. 21.4 ). This is interesting given the fact that a chamomile extract known as bisabolol is used as an antiinflammatory in cosmeceutical moisturizers. However, echinacea and marigold are two members of this family that have not been reported to cause ACD. This indicates that there are subtle differences in each of these plant extracts accounting for the presence or absence of the dermatitis-causing allergen.

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