With estimated that about 10% of the general

With the increasing use of cosmetics and
routinely performed diagnostic patch testing, there has been a rise in the
prevalence of contact dermatitis to cosmetics. It is estimated that an adverse reaction to cosmetics
occurs approximately once every 13.3 years per person (1). In a recent review, a weighted
prevalence of ACD to cosmetics was 0.4% for general population and only 9.8% for patients referred for patch
testing (1).Thyssen et
al. reported that 56.7% of women and 33.6% of men in Denmark have
experienced an adverse effect after using cosmetics at least once in a lifetime (6). It is estimated that about 10% of the general population
experience side effects, hypersensitivity or allergy-related irritation of cosmetics (7). In a
questionnaire-based survey of random sample
of 360 female customers of beauty salons in Israel, 11 patients (3.1%) had
patch test proven contact dermatitis to cosmetics (8). Prevalence
of patch test positivity to cosmetic series varies with geographical areas. Frequency of
contact dermatitis to cosmetics was 31% in a study involving 176 patients in
Brazil (9). In our study the
prevalence was 68% was seen, which is similar rate of patch test positivity
(68%)  reported by Penchaliah et al.  and 59.2% by Dogra et al (10,11).

Adverse
reactions to cosmetics include irritant and allergic dermatitis, contact
urticaria, photo-contact dermatitis and hyper- or hypopigmentation. Irritant
reactions constitute vast majority.  In
an interview-based study involving 982 beauticians in Netherlands, Groot et al.
reported cosmetic-related adverse effects (12). Most frequent finding was
redness (61%), followed by scaling (19.3%), acne (14.2%), dry skin (9.1%) and
swelling (7.5%). Hyperpigmentation was not noticed.  Goossens reported the trends of cosmetic
allergy seen in Belgium over a 25-year period in a study of 14,911 patients.
Clinical manifestation was mainly eczematous with no report of PCD (13). Thappa
et al. in their study of cosmetic dermatoses in 71 patients, found PCD to be most common (40 cases), followed by ACD (24
cases), leukoderma (9), hypopigmentation (2) and acneiform eruptions (1) (14). In
a study by Dogra et al. involving patients suspected of contact sensitivity to
cosmetics, majority of patients (59%, n=29/49) presented with ACD pattern while
hyperpigmentation was seen in only 8 cases (11). Since the earliest description
of PCD by Osmundsen in 1969, a series of cases were described mainly from Japan
(4). Thereafter only a handful of cases have emerged from other parts of the
world, including Thailand, Singapore, France, Spain and Italy (Table 4) (4,8,11,15-18).
The unifying feature in these cases was predominantly asymptomatic blotchy or
reticulate slate-grey and brown hyperpigmentation usually involving face in
middle aged females along with a positive patch reaction.

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In our series, a striking majority of patients
(n=74, 69.8%) presented with non-eczematous brownish patchy hyperpigmentation,
localised to face and in some cases, hairline. Antecedent use of a new cosmetic
agent prompted us to think in this direction. Furthermore, a relevant positive
patch test was seen in 72.8% of patients. While the causative allergen was more
apparent in cases presenting with ACD to cosmetics, it was revealed only on patch
testing in cases with PCD. A significant difference in the allergen profile in
the 2 groups suggest that particular allergens, viz., cetrimonium, gallate mix and thiomerosal, may play an
important role in causation of PCD.Cosmetics
include a wide range of personal care products, including skin creams and
cleansers, hair styling, colouring, cleansing and conditioning agents,
sunscreens, dental care products and deodorants. Lately we have observed the
use of skin lightening agents by a fairly large number of patients. These
include over the counter (OTC) preparations and some herbal and ayurvedic
products, the ingredients of which are seldom known. The still prevalent social
stigma associated with dark complexion coupled with absence of a regulatory
system on prescription of such drugs makes their rampant use possible. However,
cosmetic agents are hardly ever blamed by the patients who develop features
suggestive of cosmetic dermatitis, except when the dermatitis is acute. The subtle
clinical presentation of cosmetic induced dermatitis in some cases makes it
essential to take a detailed history and do a patch testing with cosmetic
series of allergens as well as patients’ products so as to elucidate the
offending allergen.The
pooled prevalence of ACD to cosmetic allergens was found to be 9.8% from the patch
test data of the studies in Europe and the United States (1). A doubling of the
prevalence of ACD to cosmetics occurred  in Danish population between years 1990 to
1998  (2). However, one cannot depend on
the standard series for detection of ACD to cosmetics as shown in a recent
study of 794 patients in which 34% of patients would have had at least one
allergen missed if only the NACDG standard screening series of 65 allergens had
been used (3). There is limited data regarding the epidemiology and causative
allergens in cosmetic dermatitis and pigmented cosmetic dermatitis (PCD) in
Asian countries. PCD was first described by Osmundsen
et al., in a series of cases with slate-grey hyperpigmentation
developing after contact with optical whitener, Tinopal in Copenhagen (4). It
is a noneczematous contact dermatitis to sensitizers in cosmetics. PCD is
believed to be induced by very small amounts of contact allergens that are in
almost daily contact with the patients’ skin. This continuous exposure to low
doses of allergens does not result in erythema, papules, or swelling and
itching, as in ordinary contact dermatitis, but is often characterized only by gradual
hyperpigmentation. It largely affects the dark-skinned
population and is frequently encountered among Japanese, Indians, South
Americans, and less often among Europeans. Clinically, it is characterized by
slate-gray-to-brown macules in a diffuse, blotchy or reticulate, pattern
affecting predominantly face with a predilection for females. However, large
scale studies on patch test findings in PCD are lacking. We undertook this
study to describe the clinical and patch test profile of patients presenting
with hyperpigmentation or dermatitis suspected to be due to cosmetics.Since
the earliest description of PCD by Osmundsen in 1969, a series of cases were
described mainly from Japan (4). Thereafter only a handful of cases have
emerged from other parts of the world, including Thailand, Singapore, France,
Spain and Italy (Table 4) (4,8,11,15-18). The unifying feature in these cases
was predominantly asymptomatic blotchy or reticulate slate-grey and brown
hyperpigmentation usually involving face in middle aged females along with a
positive patch reaction.

In
our series, a striking majority of patients (n=74, 69.8%) presented with
non-eczematous brownish patchy hyperpigmentation, localised to face and in some
cases, hairline. Antecedent use of a new cosmetic agent prompted us to think in
this direction. Furthermore, a relevant positive patch test was seen in 72.8%
of patients. While the causative allergen was more apparent in cases presenting
with ACD to cosmetics, it was revealed only on patch testing in cases with PCD.
A significant difference in the allergen profile in the 2 groups suggest that
particular allergens, viz.,
cetrimonium, gallate mix and thiomerosal, may play an important role in
causation of PCD. Interestingly, recent studies from India have also shown high
patch test positivity to these allergens (17, 19). In a study in patients of kumkum
dermatitis from India, PCD was seen in 76% (35/46) cases (17). Thiomerosal (18/25) and gallate mix (12/25,) were most
frequently positive on patch testing. In a study of 58 cases of suspected
contact dermatitis to cosmetics, most common positive on
patch test were cetrimide (20.7%) and thimerosal (15.5%), paraphenylenediamine
(6.9%), and fragrance mix (5.2) (19). However no information is mentioned
regarding patch test profile in patients of PCD and ACD separately in these
studies. Cetrimonium is an antiseptic and major formulation excipient chemical
in cosmetics. Our patients who were patch test positive with cetrimonium were
using various facial cosmetics (cold creams, fairness creams, antiseptic soaps,
face wash/scrubs, shaving creams, and aftershave lotions). Dodecyl gallate,
octyl gallate, and propyl gallate (gallate mix) are antioxidant substances used
as preservatives in cosmetics (lipstick, liposome containing creams, body
lotions, facial moisturizers, facial cleanser, body wash and cleansers, hair
conditioners, and foundation lotions), foods, and the topical pharmaceutical
preparations. The use of liposome containing creams has been implicated for
rise in propyl gallate allergy observed in patients patch tested from 1988 to
2005 over the previous decade (20,21). Skin lightening soaps and fairness
creams usually contain inorganic mercury (ammoniated mercury) while organic
mercury compounds (ethyl mercury or thiomersal, phenyl mercuric salts) are used
as preservatives in cosmetics, eye drops, contact lens solutions, vaccines, and
antiseptics. Al-Saleh and Al-Doush analyzed 38 commercially available skin
lightening creams in 1997 and noted that 45% of the tested samples contained
mercury at levels far surpassing 1 ppm (the maximum permitted limit by FDA) (22).
More recently in 2005, they also analyzed “Fair & Lovely” fairness cream
and found traces of mercury that was otherwise not its listed component (23). In
our patients with positive patch test to ‘Fair n lovely’ cream, thiomerosal was
the commonest allergen (4/6), followed by cetrimonium and gallate mix (2 each).
In India, the easy availability of indigenous topical preparations, OTC
preparations and European as well as western cosmetics makes the range of
products used quite wide. Stigma related to dark skin colour is unfortunately
still exists making the use of skin lightening agents rampant. This is
reflected by the fact that skin lightening creams were second most commonly
used agents (n=108), next only to hair coloring products (n=139). 

ACD
to hair dye allergens produced acute and subcute dermatitis in majority of
patients (n=19) and PCD in fewer (n=8; P