Detergents, bath preparations, and other skin cleansers

6

Detergents, Bath Preparations, and Other Skin Cleansers

Mark 1.Oestreicher, MD

From Adult and Pediatric Dermat~logg Specialists, Trumbull, Conmct‘icut

Soaps and Synthetic Detergents The dermatologic expression “If it is dry, wet it and if it is wet, dry it” points out that water is a good cleaning agent by itself. In treating acute or chronic forms of dermatitis, wet dressings remove water-soluble soils, serous and purulent exudates, and crust. Water alone, however, is seldom sufficient to clean the skin of its oily soils. They require a solvent or soap and an emulsifier for removal. In the clinical practice of dermatology, there are not too many questions more commonly asked than “How should I wash my face?” Patients may question the benefit of makeups and other cosmetics but will most likely use some cleansing preparations once or more times a day. Advertising equates soap with freshness, youth, and success. Many types of cleansers are available in today’s marketplace. Many come in a variety of shapes, colors, and sizes with moisturizers, deodorants, or other additives. These have changed the appearance and texture of the product, but soap, first discovered by the Phoenicians in 600 BC,is not much different now than many centuries ago.’ Soaps may be for “oily skin, ” “oily to normal skin,” “normal skin,” “normal to dry skin,““dry skin,” and “sensitive skin.” What are, if any, the differences between them? True water-soluble soaps are made by the saponification of animal or vegetable fats (Fig. 6-l) and have an alkaline pH. Sodium soaps are the neutralization product of fatty acids such as lauric, myristic, palmitic, stearic, and oleic. These are known as hard soaps and can be manufactured as bars, cakes, and powders. Potassium soaps have a greater solubility in water and are used in liquid and “soft” soaps. Synthetic detergent or “syndet” cleansing bars have a greater pH range. The chemical composition of syndet bars and soaps are very different, but the cleansing functions are the same. Either may contain preservations, colored dyes, emollients such as glycerol or cocoa butter, or perfumes. As with other cosmetics, even “unscented”soaps do have a fragrance, one to mask the unpleasant odor of the raw materials. Skin cleansers are sometimes combined with emollients such as liquid 29

30

Clinics in Dermatology

M. I. Oestreicher

CHPOH

CH2OCOR

I +

CHOCOR

I CHPOCOR

3NaOl-l or 3 KOH

Triclyceride

FIG. 6-l.

Saponification

-+

CHOH

+FlCOONa

CH20H Glycerol

+ Soap

of fats.

petrolatum, lanolin, etc. These help to counteract drying of the skin by prolonged exposure to regular soap bars that emulsify and remove the skin’s lipid barrier. Superfatted soaps contain unsaponified fat, unreacted fatty acid, or emollients such as lanolin or cold cream; however, the emulsifying action of the soap itself may prevent significant quantities of the superfatted ingredients from being retained on the skin.2 Deodorant soaps contain antibacterial agents such as triclosan and trichocarbon to be retained on the skin in amounts sufficient to suppress activity of skin microorganisms. Allergic sensitization to these “rinse off’ products is uncommon but not rare. The most well-known example is allergic contact photosensitization associated with the addition of halogenated salicylanilides in Great Britain and Europe to soaps and cleansers. While most of the substances are no longer used in consumer products in this country or in Europe, patients are occasionally encountered with persistent light reactions irritated by these agents lo-15 years ago. They should, therefore, be considered as possible etiologic agents in a differential diagnosis of photosensitivity. Present statutes do not require that all agents incorporated into a nondrug or noncosmetic preparation be identified on the package, and so some unlisted ingredients may be photosensitizers. Various dye additives can also cause allergic sensitization. Jordan4 reported a woman who was previously sensitized to D&C yellow 11 dye in yellow Irish Spring. He called attention to the fact that the periaxillary accentuation of the rash coupled with dorsal hand involvement was helpful diagnostically in differentiating the generalized rash from a viral exanthem or other causes. Much more common than allergic

sensitization are irritant side effects of cleansers labeled variously as housewife’s eczema, soap dermatitis, or winter itch. Whether or not soaps are irritants, are injurious to the skin, or injure only dermatitic skin has proponents on both sides. Jordan et a15described 239 cases of “soap dermatitis” in housewives. Suskind et al.6 in studying hand dermatitis in hospitalized patients found that repeated immersion of one hand in warm soap solution did not worsen the disease. Stoughton et al.7 found no difference in patients with hand dermatitis whether soap was used or not. Scala et al.,8 working with guinea pigs, concluded that with normal use most syndets have no harmful effects on the skin. Forbidding soap and bathing for childhood atopic dermatitis is still a popular regimen. Sulzburger et al.,9 thought that winter eczema of the elderly could be precipitated by soap. Uehara and Takadalo reported on 130 patients with atopic dermatitis who were treated with daily bathing with commercially available alkaline soaps followed by application of emollient moisturizers. Greater than 90% of the patients improved during the 4 weeks of observation. They concluded that the brief use of soap for bathing is not contraindicated in atopic dermatitis and that the skin should always be kept clean by using soap followed by appropriate topical remedies immediately thereafter. They theorized that soap removed crusts and scales that impeded absorption of topical medications or removed scales and other secretions that may aggravate atopic dermatitis. The crusts may also favor a growth of StaphvLococcus aureus, which plays a role in aggravating atopic dermatitis. Out of this mire of diverse opinions, Forsch

July-September1988 Volume 6 Number3

DeteraentsandCleansers

and Kligman” described a laboratory procedure to distinguish soaps and rate them as to irritancy. This landmark study tested 18 brandnamed soaps. Duhring Chambers were utilized, not usage tests. These were occluded on the ventral skin of the forearm of preselected subjects. On the eighth day after initial application, test sites were graded on a scale from l-4 for erythema (slight to fiery red), scaling (fine to severe), and fissures (fine cracks to wide fissures with exudation). The overwhelming conclusion was that there were actually great differences in soap spanning the range from marginal to severe irritancy (Table 6-l). Many soaps advertised as mild fell in the mid range; Dove, a syndet bar with sodium isethionate as its major component, was found the mildest and Lava the harshest. Another syndet bar, Zest, a combination of alkyl sulfates and sodium soaps, was rated severely irritating. Superfatted soaps did not live up to their reputation as being milder by depositing a protective layer of oil on the skin. Fissuring signified more intense damage and was usually preceded by crusted or exudative dermatitis. The researchers concluded that the irritancy of a given soap is a product of the surfactantinduced permeability increase of the stratum

31

corneum as well as its ability to produce inflammation. Forschlz in a later study also commented on the conflicting results in test models dealing with soap irritation. He compared the Chamber test with antecubital washing and facial washing tests. He tried to answer the question of which soaps can be recommended for patients with severe fissured and cracked painful dermatitis. He defended his exaggerated-use tests by stating that the current cosmetic industry standards are not rigorous enough to detect irritation with small sample sizes. When comparing mild with harsh soaps, the Chamber test and the wash tests correlated well. For products considered to be only slightly different in the Chamber test, the antecubital washings revealed a different result. Specifically, testing of Neutrogena and Ivory, almost identical in the Chamber test, showed Neutrogena to be much milder in the washing test (Table 6-2). Facial washing tests (Bminute washes over both cheeks followed by immediate rinsing) showed a possible further discrepancy between the Chamber and wash test scores. Dove, which showed a small but significant difference in mildness over the Neutrogena in the Chamber test, was identical to it in the facial wash test

TABLE 6-l. Comparison of Soaps (Duplicate Study) (Means for 10 Subjects)’ Erythema Soaps 1. Dove 2. Avaenobar 3. Purpose 4. Dial 5. Alpha Keri 6. Fels Naptha 7. Neutrogena 8. Ivory 9. Oilatum 10. Lowila 11. Jergens 12. Lubriderm 13. Cuticura 14. Basis 15. IrishSpring 16. Zest 17. Camay 18. Lava

Fissuring

Scaling

Totals

(1)

(2)

(1)

(2)

(1)

(2)

(1)

(2)

0.2fO.l 1.4f 0.3 l.OztO.3 1.OfO.l 1.3f0.3 1.7kO.2 1.3f0.2 1.3f0.3 1.8f0.3 1.7f0.2 2.0 f 0.3 1.7zto.5 2.2 f 0.3 2.1 k 0.4 2.2 f 0.3 3.1k0.2 2.7 f0.2 2.8 f 0.2

0.3fO.l l.Of 0.2 1.2f0.2 1.2Iko.2 1.1jIO.l 1.1kO.l 1.OfO.l 1.3f 0.3 1.6f0.2 1.4fO.l 1.8f 0.2 1.5f 0.2 2.0 k 0.3 3.0f0.2 2.5 f 0.2 2.5 f 0.3

0.3f0.2 0.8 f 0.3 1.3f0.2 1.4zto.3 1.2fO.l 0.9f0.3 1.5f0.3 1.5f 0.2 l.Of0.2 l.Of0.2 l.Of0.2 1.3io.2 1.4*0.3 1.3f0.2 1.8f 0.2 1.9f0.3 2.2 f 0.2 2.1 f 0.2

0.2*0.1 0.5 f 0.2 1550.2 l.lf0.2 1.OfO.l l.lf0.2 1.2f0.2 1.4f 0.2 l.OztO.2 0.950.2 1.0f 0.2 1.0f 0.1 1.4f 0.2 1.8f0.2 2.2f 0.2 2.2 f0.2

0 0 0 0 0 0 0 0 0 0.5f0.2 0.3 f 0.2 0.4 f 0.2 0.3 It0.2 0.6 f 0.3 O.Of 0.0 l.lf0.4 1.5f 0.3 1.5f0.3

0 0 0 0 0 0 0 0 0 0.2 * 0.1 0.5 f0.2 0.4f0.2 1.OfO.l 1.5f 0.3 1.8f0.4

0.5 2.2 2.3 2.4 2.5 2.6 2.8 2.8 2.8 3.2 3.3 3.4 3.9 4.0 4.0 6.1 6.4 8.4

0.5 1.5 2.7 2.4 2.1 2.5 2.0 2.7 2.7 2.3 3.0 3.0 3.8 5.8 6.5 6.5

*Reproduced with permission from Forsch and Kligman."

M. I. Oestreicher

32

TABLE

6-2. Discordant Results Between the Chamber and Washing Tests Washing Test

Chamber Test Scaling

Erythema

1.4 f 0.2 1.3 f 0.2

1.3 f 0.3 1.0 f 0.1

ivory Neutrogena

PH

Neutrogena

a.8

Dial Purpose Ivory Basis Cuticura Irish Spring

10.0 9.8 9.6 9.6 9.5 9.4

Lava

0.8 9-10 9-10

Camay

Discomfort

3.0 * .3 0.9 i .4

2.7 f 3 1 .o f .6

6-3. pH Values ot Common Soaps and Syndets

Soaps

Tone

Erythema

conditions such as cleansing efficacy and irritancy of the products under normal use were more appropriate than the Chamber patch test evaluations. Comparison of irritancy of soaps and syndets via patch tests neglected the deactivation of soaps to fatty acids likely to take place during normal product use by overwhelming the buffering capacity acid mantle. The advantages of syndets over soaps may have been overstated in the past. As far as additives are concerned, the addition of moisturizing agents such as glycerin, mineral oil, and cocoa butter does not significantly reduce the irritancy potential of soaps since, generally, little of these ingredients are actually left on the skin after rinsing. Bars containing a percentage of soap are more irritating regardless of special ingredients. Soap is a surface active agent, and its degreasing action may lower the epidermal lipids by one third.14 Since integrity of the epidermis maintains skin hydration, when barrier function is decreased as in dermatitis, there is an increase in water loss across the epidermis. This results in dryness and flaking. Products such as dishwashing detergents and metal soaps (salts of aluminum, calcium, magnesium, and zinc) used in polishes and paints are especially formulated to remove grease and oil and

scores. Other factors contributing to the irritancy potential of a soap bar include its chemical structure, pH, and additives. Most investigators agree that the carbon length chain, whether in a soap bar or syndet, is one of the factors that contributes to irritancy.‘s Highmolecular weight tallow soaps (sodium tallowate) seem to be less irritating than lowmolecular weight coconut soaps (sodium cocoate). The coconut soaps are more soluble in water and therefore penetrate the stratum corneum more readily. Most soaps currently are formulated with a combination of shortchain and long-chain carbon components. Normal skin pH is between 5 and 6. Soaps are alkaline as described above, with most having a pH between 9 and 10.8. This stress on the skin buffering system may alone cause irritation in some people. 14A pH table of common soaps and syndets is seen in Table 6-3. Washing the skin with soap causes a temporary increase in skin pH. This shift is reversed in 2 hours after washing by the buffering system of the skin. In contrast, application of a Duhring test chamber’5 with an 8% soap solution causes a pH change lasting more than 24 hours. On the basis of the above studies by Forsch and other investigators, it is felt that parameters more strongly related to in-use TABLE

Clinics in Dermatology

Syndets Aveenobar Emulave Lowila Dove Eucerin Caress JohnsonandJohnson Baby Soap Zest

PH 5.4 5.9 6.9 7.2 Near normal Near normal Near normal 9.4

July-September 1988 Volume 6 Number 3

Detergents and Cleansers

are particularly irritating to the skin. Results of patch test studies have shown that a 24-hour exposure to 5%solution of soap resulted in transepidermal water loss values 50%higher than at sites treated with mild syndet,n although there was no clinical difference in the skin’s appearance. What conclusions can be sought? Based on the presented data, the pH may have little or no influence on the irritancy of soaps and syndets. Normal skin pH may be rapidly restored after washing with alkaline soap as the result of the buffering capacity of the skin’s surface. Crow16agreed that the fear of alkaline soaps had been exaggerated in the past. Presently available laboratory comparisons may not be fully accurate except to break down soaps and syndets into categories of very mild and very harsh. Strube and Nicolll7 mention that although laboratory tests may not be accurate, clinical tests have shown differences in mildness between soaps and syndets under normal conditions of use. Irritancy responses are usually detected by the user before clinical dermatitis appears, and a complaint of “skin tightness”may be the only sign of skin damage. Synthetic detergent bars, when compared in patients with healthy skin and in those with dermatitis, resulted in fewer complaints of skin dryness and irritation. Patients with different skin textures have different expectations. Patients with acne and oily skin look for a degreasing or a harsher soap, whereas those with atopic skin may use only the mildest of soaps. A product that has passed the Chamber and wash tests without substantial irritation is probably the best choice for such a patient. The most important thing for patients to remember is to use a mild cleansing product and not to overuse it. No matter how gentle or mild it may be, overuse without replenishment of an emollient will always have the potential for irritation. Cleansing Creams Soap and water are more effective than creams for cleansing the skin; however, make-

33

up, especially waterproof products such as eye makeup or theatrical or masking cosmetics (including Dermablend, Lydia O’Leary cover up), are more readily removed with cleansing cream than with soap and water. All cleansing creams are derived from “cold cream,” a formula invented by the Greeks 1800 years ago. The original cold cream was made of olive oil, beeswax, and water.18 Rose petals were added for fragrance. It received its name “cold” cream because it produced a cooling sensation when applied to the skin due to water evaporation. The oil and wax cleanse the skin by liquefying upon contact, thereby loosening the dirt, oily secretions, and dead cells on the skin’s surface. These could then be removed easily with a cloth. If cream was left on the skin, it acted as an emollient to soften and relieve excess dryness. Cold cream has undergone numerous formulation changes, but the basic formula (oil, wax, water) and the essential purpose of cleansing and softening the skin are the starting points of all modern products. Cleansing creams are now thinner, lighter, and less oily in feeling than simple cold creams. The original cold creams were unstable, had poor appearance, and suffered from lack of reproducibility. At the turn of the last century, cold creams were rendered more stable by the inclusion of borax, which reacted with the free acids present in the beeswax to form a sodium soap rendering the cold creams more stable.19 Cream cleansers are based on the solvent action of mineral oil on oils and grease binding grime or makeup to the skin. Their ingredients (and potential irritants) also include emulsifiers, detergents, antiseptics, solvents, and emollients. With the addition of ingredients such as salicylic acid, resorcinol, and sulfur, even with women with oily skin can use cleansing creams. Other ingredients serve different purposes. Cetyl alcohol in a 1% concentration acts as an emollient and an emulsion stabilizer. Spermaceti is an emollient that makes creams lighter in appearance and more opaque. Although soap-and-water washing performs the same function, a cleansing cream may have certain advantages. Heavy oil-based makeup, as mentioned, is more readily removed by a cleansing cream specifically formulated to dis-

Clinics 34

M. I. Oestreicher

solve greasy binding materials that hold pigments to the skin. Latven*O investigated the effects of cleansing creams on sebum removal. The plaques of sebum were surprisingly resistant to removal by scrubbing with soap and water but were removed by using various commercially available cleansing creams. Other advantages of cleansing creams are convenience of use, low potential for irritation, and deposition of emollient on the skin afterwards. Water removes water-soluble soil, but the addition of a detergent is necessary for removal of oil-soluble material. Oil solvents remove oilsoluble soil, but too efficient removal by either fat solvents or detergents can leave the skin “defatted” and dry. Thus, a good cleansing cream must remove all undesirable soil and leave the skin in good condition. For people with normal to dry or very dry and sensitive skin, soaps and syndets may theoretically remove too much of the epidermal lipid layer and predispose to dryness. Emulsifiers in cleansing creams have less surface activity than soaps, and when the product is wiped off, an oily residual film is left, a combination of residual epidermal lipids and the cleansers’ oil phase. Over time, the original beeswax and soap formula has been modified, and now there are three types of emulsion cleansing creams*l: a beeswax borax type; a soap type, predominantly triethanolamine based; and “modern types,” which are emulsifier blends with nonionics. Auxiliary emulsifiers, such as nonionits, provide improved emulsion stability and contribute to the cleansing action of the product. The solvent action of mineral oil in these modern types has been enhanced by additives such as fatty esters, ethers, and alcohols. These additives decrease the oily feel of mineral oil. The use of the nonionic emulsifiers permit minimal pH change of the skin. This is not possible with the beeswax or soap emulsifiers. They also permit the incorporation of cationic conditioners to lessen the oily feel further and improve the emollient effects of the cleansing cream. When all is said and done, most people should cleanse twice a day in the morning and evening with tepid, not hot, water. All traces of soap should be thoroughly rinsed, and the skin

Derrnotolo~l:

should be dried gently. An emollient moisturizing cream can then be used to combat any dryness or a rough flaky appearance. Syndets are a milder alternative to soaps. Consumers know they may not lather as well or last as long as regular soap bars. Most cleansing creams and lotions are oil-based formulas that act as solvents on the oils and grease that bind the makeup and grime to the skin. Many of these products contain emollient moisturizers that, besides breaking down the greasy material on the skin that can be rinsed off with water, leave the skin soft and smooth. Much of this choice between cleansing creams and soap and water will be left to the consumer, and so we still do not have a definitive answer for the question “What is the best way to wash my face?”

Bath Preparations Bath preparations consist of bath salts, bath oils, bubble baths, and bath powders. They are formulated to make the bather feel relaxed and refreshed, to help soften hard water, and to add a pleasing color or fragrance to the bath. Not the least of objectives should be to cleanse the skin and many even prevent a telltale ring from forming around the tub. Sgaramella and Dellas,** commenting on an exhibition of more than 200 bath products at a recent International Perfumery Congress, eloquently described the psychology of bath products: “The bath is positioned almost universally for relaxation, the privileged moment for one’s self. The bath creates an aura or atmosphere to touch, smell and hear. This relaxes both the physical body and the mind. The formulations are gentle and contain certain additions or specialities for skin care. Shower gels support the active aspect of life, tonic and invigoration in our current fast paced lifestyle. They are practical products supported by ingredients and fragrance that are synonymous with the product. A new products area seems to be evolving which is the all over body shampoo. This product combines the attributes of a shampoo with the qualities of a shower gel: it further enhances the functional, quick and multifaceted lifestyles that are evolving.” Bath salts are of two types, those that are

July-September 1988 Volume 6 Number 3

Detergents and Cleansers

primarily intended to impart perfume and color to the bath and those that, in addition, help soften hard water and make cleansingeasier. The first type is formulated with rock salt crystals (sodium chloride), colored and perfumed. The second type of bath salts, the watersoftening type, is usually based on trisodium phosphate or sodium sesquicarbonate.23 The advantages of this type are as follows: (1) it acts as a water softener, preventing the calcium and magnesium salts in hard water from precipitating out to form insoluble residues. These interfere with the cleansing action of the product, leave a film on the skin, and cause bathtub ring. (2) It lowers surface tension of the water, allowing easier wetting and cleansing of the skin. This type of bath salt has a high pH, and, as already discussed with soaps, patients with sensitive skin may encounter irritant dermatitis with erythema, fissures, or scaling. Popular bath salt fragances include pine, jasmine, gardenia, lavender, and lilac.z4 Popular colors include green (especially with pine), and these may include Ext D&C green #l, D&C yellow #7 (fluorsecin), and D&C yellow #9. Blue and yellow dyes may also be mixed to make green. Yellow or orange dyes are used with jasmine and gardenia scents, eg, FD&C yellow #l and FD&C orange #2. Red and blue, pink, or purple colors are used to make lilac and lavender fragrances. Allergic contact dermatitis to these preparations may be due to the dyes but are primarily to the fragrance. Maibach2srecommends patch testing with 10% in petrolatum, both closed and photopatch tests. Positive should be verified with controls. Bath oils may be miscible or not miscible or emulsifiable in water. The nonmiscibles do not have any cleansing or water-softening properties. They represent solutions of perfume in an oily vehicle. When added to the bath water, they collect on its surface as a fine film that emits the fragrance into the air aided by the warm temperature of the bath. The emulsifiable bath oils contain either a water-dispensable sulfate or a synthetic nonfoaming detergent that also has cleansing and water-softening properties. Bubble baths or foams are the most popular

35

of the bath preparations. Their bubbling action depends on the presence of a surfactant agent (eg, sodium, lauryl sulfate) causing large amounts of foam to develop under a stream of water. They are designed to enliven the routine of the bath and make bathing more relaxing. This may be of particular use for the elderly, entailing less physical effect than is required by scrubbing with soap; however, they are marketed more for children to make bathing fun. They have been associated with genital and urinary tract irritation, especially in young girls.

References 1. Conry T. Consumer’s Guide to Cosmetics. Garden City, NY: Anchor Books, 1980:228-234. 2. Klarmann EG. Cosmetic Chemistry for Dermatologists. Springfield, IL: Charles C Thomas, 1960. 3. De Leo VA, Harber LC. Contact photodermatitis. In: Fisher AA. Contact Dermatitis. Philadelphia: Lea & Febiger, 1986:454-469. 4. Jordan WP. Contact Dermatitis from D & C Yellow 11 dye in a Toilet bar soap. J Am Acad Dermatol. 1981: 4~613-614. 5. Jordan WP, et al. Dermatitis of the hand in housewives. Role of Soap in its etiology, methods and prevention. JAMA. 1940;115:100-1006. 6. Suskind RR, et al. Cutaneous effects of household synthetic detergents and soaps. Arch Dermatol. 196388: 117-124. 7. Stouahton RB. et al. Management of patients with ecsematous diseases: use of Lap vs no-soap. JAMA. 1960;173:1196-1198. 8. Scala J, et al. The percutaneous absorption of ionic surfactants. J Invest Dermatol. 1968;50:371-379. 9. Sulzberger MB, Baer RL. Unusual or abnormal effects of soap on normal skin. In: Medical Uses of Soap. Philadelphia: JB Lippincott, 1946:51-63. 10. Uehara M, Takada K. Use of soap in the management of atopic dermatitis. Clin Exp Dermatol. 1985:10:419-425. 11. Forsch PJ, Kligman AM. The Soap Chamber Test, a new method for assessing the irritancy of soaps. J Am Acad Dermatol. 1979;1:35-41. 12. Forsch PJ. Irritancy of soaps and detergent bars. In: Frost P, Horowitz SN. Principles of Cosmetics for the Dermatologist. St. Louis: CV Mosby, 1982. 13. Bettley FR, Donoghue E. The irritanteffectof normal skin. Br J Dermatol. 1960;72:67-76. 14. Jellinek JS. Formulation and Function New York: Wiley Interscience, 1970.

soap upon

of Cosmetics.

G, et al. Comparative study of skin care 15. Savermann efficiency and in-use properties of soap and surfactant bars. J Sot Cosmet Chem. 1986;37:309-327.

M. 1, Oestreicher

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16. Crow KD. Barriers

Clinics in Dermatology

creams. Practitioner.

17. Strube DD, Nicoll G. Irritancy Cutis. 1987:39:544-549.

lYti7;202:127.

of soaps and syndets.

18. Schoen L, ed. AMA Book of Skin & Hair Care. Philadelphia: JB Lippincott, 1976:27-37. 19. Masters EJ. Cleansing creams & lotions. In: Balsam MS. Sagarin E, eds. Cosmetics: Science and Technology, vol 1.2nd ed. New York: Wiley Interscience, 19’72:1-30. and comparative actions of 20. Latven AR. Fundamental cleansing creams. Am Perfumer and Aromatics, 1958Z (5):29-31. 21. Calvo L. Cleansing creams Toiletries. 1986;101:49-55.

& lotions. Cosmetics

and

Address for correspondence: Mark I. Oestreicher, ists, 160 Hawley Lane, Trumbull, CT 06611.

22. Sgaramella

P, Dellas J. A fragrance and product overview of the worldwide bath and bathing market. Cosmetic and toiletries. 1986;101:80-83.

23. Harry RG. Bath preparation. In: Harry’s Cosmeticology. Revised by Wilkson JB, Moore RJ. New York: Chemical Publishing Co., Inc. 1982235-249. 24. Davenport 0. Bath Preparations. In: Balsam MS, Sagarin E., eds. Cosmetics: Science and Technology, vol 1. New York: Wiley-Interscience, 197X651-659. 25. Maibach HI, Engasser PG. Dermatitis due to cosmetics. In: Fisher AA. Contact Dermatitis. Philadelphia: Lea & Febiger, 1986:368-393.

MD, Adult and Pediatric

Dermatology

Special-