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Study Letter
ARTICLE IN PRESS
doi:
10.25259/IJDVL_812_2023

Addressing diagnostic challenges in suspected contact dermatitis to cosmetics: Can standard series and patient material suffice for patch test?

Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India
Corresponding author: Dr. Kaushal Verma, Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi. prokverma@hotmail.com
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This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Verma K, Ahuja R, Taneja N. Addressing diagnostic challenges in suspected contact dermatitis to cosmetics: Can standard series and patient material suffice for patch test? Indian J Dermatol Venereol Leprol. doi: 10.25259/IJDVL_812_2023

Dear Editor,

Contact dermatitis to cosmetics has shown a variable prevalence ranging from 9.8 to 16.5%, among all suspected cases of contact dermatitis.1,2 The commonly implicated allergens in patients with cosmetic contact dermatitis include cetrimonium bromide (CTAB), p-phenylenediamine (PPD) and fragrance mix.3 There are several allergens like p-phenylenediamine, fragrance mix, colophony, etc., in the cosmetic series which are also a part of the Indian Standard Series (ISS).

In this study, we evaluated the patch test positivity to allergens in the cosmetic series in patients with suspected allergic contact dermatitis to cosmetics and determined the common allergens which were a part of ISS. The patch test records of adult patients (≥18 years) with suspected contact dermatitis to cosmetics attending our department between January and December 2022 were analysed. All patients were patch tested with the Indian cosmetic series and relevant patient material.

Of the 60 eligible patients, 24 (40%) were males and 36 (60%) females between 18 and 75 years (mean age 40.4 ± 12.4 years) of age. Thirty seven patients (61.7%) had diffuse hyperpigmentation, i.e., non-eczematous pigmented contact dermatitis (PCD), while the remaining 23 (38.3%) had acute to subacute dermatitis. All patients had a history of cosmetic use including hair dye (n = 49), hair oils (n = 42), shampoos and cleansers (n = 38), skin-lightening creams (n = 35), perfumes/deodorants (n = 32), moisturising creams (n = 32), bindi/sindoor (n = 14), shaving creams (n = 12), lipsticks (n = 8) and sunscreens (n = 6).

Patch test reading was taken at 48 (day 2) and 96 h (day 4) after patch test application. The day 4 reading was regarded as confirmatory. Twenty one patients (35%) demonstrated a positive patch test reaction to allergens of the cosmetic series and/or patient material. Interestingly, a higher percentage of patients with acute to subacute allergic cosmetic dermatitis (12/23; 52.2%) had positive patch test reactions compared to those with PCD (9/37; 24.3%) (p = 0.02). The primary allergens identified in the cosmetic series were PPD, colophony and thiomersal. Moreover, there was a significant overlap between allergens commonly found in the ISS and cosmetic series, including PPD (n = 9), colophony (n = 3), fragrance mix (n = 2) and paraben (n = 2). Among the 16 patients who reacted positively to the cosmetic series, in 13 patients, the allergens were also a part of the ISS, yielding a statistically insignificant difference in positivity rates (p = 0.52) [Table 1].

Table 1: Patients with positive patch test reaction to allergens of cosmetic series and/or patient material, and their relevance
S. No. Clinical diagnosis Cosmetic series Patient material Relevance
1. Pigmented contact dermatitis to hair dye PPD Hair dye cream and developer Current
2. Contact dermatitis to facial cosmetics - Face cream Current
3. Pigmented contact dermatitis to facial cosmetics Hexamine - Doubtful
4. Contact dermatitis to hair dye PPD Lavender absolute Hair dye cream and developer Current
5. Contact dermatitis to hair dye PPD* Hair dye cream Current
6. Contact dermatitis to sindoor Thiomersal Sindoor Current
7. Pigmented contact dermatitis to cosmetics - Hair dye cream Past
8. Contact dermatitis to lip cosmetics - Lipstick Current
9. Pigmented contact dermatitis to cosmetics

PPD*

Benzyl salicylate

Fragrance mix*

Hair dye cream and developer

Sunscreen

Current
10. Contact dermatitis to bindi/sindoor Colophony* Liquid sindoor Current
11. Pigmented contact dermatitis to cosmetics - Skin serum, face pack Past
12. Contact dermatitis to hair dye PPD* Hair dye cream Current
13. Pigmented contact dermatitis to cosmetics Thiomersal Negative Doubtful
14. Contact dermatitis to hair dye PPD* Loreal hair dye Current
15. Pigmented contact dermatitis to cosmetics Paraben - Current
16. Contact dermatitis to lip cosmetics - Lip balm Current
17. Contact dermatitis to henna Colophony* Mehendi Doubtful
18. Contact dermatitis to bindi Colophony* - Current
19. Pigmented contact dermatitis to hair dye PPD* Hair dye cream and developer Current
20. Contact dermatitis to hair dye PPD* - Current
21. Pigmented contact dermatitis to cosmetics PPD*, Fragrance mix* Hair dye cream and developer Current
Allergens common to cosmetic series and ISS: Indian Standard Series; PPD: p-phenylenediamine

In our study, out of 60 suspected cases of contact dermatitis, 21 (35%) patients had a positive patch test to allergens of the cosmetic series and/or patient material. In some previous studies from India, the positivity with the cosmetic series has varied from 59.2 to 72.6%.3,4 This low positivity rate in our study is possible because of the large number of patients with PCD, where the patch test positivity is low. Ghuse et al. reported 30% (15/50 patients) patch test positivity in patients of facial melanosis suspected to be caused by contact allergens. An additional five (10%) patients were photopatch test positive.5 Similarly, Hassan et al. showed that among eight patients of Riehl’s melanosis, only two (25%) had a positive patch test for allergens of the cosmetic series.6 The most common allergen detected by Sharma et al. on positive patch testing, in 72.8% (52/74) patients with PCD were cetrimonium bromide (CTAB) and gallate mix.3 However, gallate mix has been removed from the current cosmetic series and this may be contributing to the low yield of positive results, especially in patients with PCD.

Rastogi et al. evaluated 50 patients of suspected cosmetics-induced facial dermatoses and reported that positive reactions occurred significantly more commonly with ISS than with allergens of the cosmetic series (p = 0.053). In their study, PPD was the most common allergen seen in nine (18%) patients which are there in both ISS and the cosmetic series. NiSO4 was positive in eight patients (16%); which is not a part of the cosmetic series.7 Many allergens in the cosmetic series that are commonly implicated as the cause of cosmetic dermatitis are present in ISS too.

Patch testing with the standard series may miss some possible allergens and it would be prudent to patch test with the cosmetic series in all patients suspected to have cosmetic dermatitis. However, the standard series and the patient’s own material may be patch-tested to detect the causative allergens in resource-limited settings. Moreover, there is a considerable difference in the cost of ISS (costs approx. 100 INR) and the cosmetic series (costs approx. 200 INR) (Systopic Laboratories, New Delhi).

Hence, patch testing with ISS and patient material appears to be a reasonable and cost-effective alternative in patients with suspected contact dermatitis to cosmetics, in case of non-availability of cosmetic series and cost constraints.

Ethical approval

The Institutional Review Board approval is not required as this was a retrospective analysis of patient data records.

Declaration of patient consent

This was a retrospective analysis of patient data records.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

References

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