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Sunscreen allergy in Singapore
Sunscreen
Allergy
in Singapore
Por Ang, See Ket Ng, and Chee Leok Goh We report the epidemiology of sunscreen allergy over a period of 5 years at the National Skin Centre. A total of 61 patients with suspected allergy to sunscreen underwent patch or photopatch testing to our sunscreen series from 1992 to 1996. The results were retrospectively analysed and evaluated. Out of these 61 patients, 5 were found to have positive patch test reactions to sunscreens. 2 were photoallergic, and 3
were allergic to main causative thoxycinnamate thoxybenzophenone sunscreen contact tice. Copyright 0 1998
USE OF sunscreens by the general public has increased steadily over the last decade, as people become more aware of the harmful effects of ultraviolet radiation, such as photoaging and carcinogenesis. Health agencies worldwide also recommend the use of sunscreens as a means of lowering the risk of developing skin cancer. Sunscreen ingredients are also increasingly being added to cosmetic products, such as moisturisers and lipsticks. Adverse reactions from sunscreen are well known and have been reported in the literature. These include contact dermatitis, both allergic and irritant, as well as phototoxic and photoallergic reactions. Other reactions reported include contact urticaria and subjective (sensory) irritation.’ We aim to find out how common sunscreen allergy is in our practice at National Skin Centre, in view of the rising use of sunscreen in our population.
were photoallergic, and 3 were allergic. Their ages ranged from 27 to 43, and four were female. Two patients were positive to 2-ethylhexylp-methoxycinnamate (Parsol MCX) alone, 1 to both 2-ethylhexylp-methoxycinnamate (Parsol MCX) and 2-hydroxymethoxmethylbenzophenone (mexenone), 1 to 2-hydroxy-4-methoxybenzophenone (oxybenzone) alone, and 1 to both oxybenzone and 2-ethylhexy-4dimethylaminobenzoic acid (Padimate 0). The results are summarized in Table 2. It is also interesting to note that out of the 56 other patients who were tested negative to the sunscreen series, 8 were found to have allergic reactions to fragrance mix and/or Balsam of Peru.
T””
METHODS The records of 61 patients with suspected sunscreen contact dermatitis from 1992 to 1996 were retrospectively analysed and evaluated. Forty-eight patients were photopatch tested, and the rest patch tested to our sunscreen series in the standard way (Table 1). Test allergens were applied on the upper back and read at 72 hours after a 4%hour occlusion. For photopatch testing, the photoallergens were applied in duplicate and occluded with opaque material for 48 hours, followed by irradiation of one set with 10 J/cm* of ultraviolet light A (UVA). The final results were recorded at 96 hours. A l+ reaction or greater was considered a positive reaction.
RESULTS Out of the 61 patients, 5 were found to have positive reactions to sunscreen ingredients. Two
Fmn the National Skin Centre, Singapore. Address reprint requests to Par Ang, MBBS, MRCP National Skin Centre, I Mandalay Rd, Singa$nm 308205. Copytight 0 1998by WB Saunders Comjmny 1046.199Xl9810901-0009%03.00/0
42
(UK),
American
active ingredients in sunscreens. The allergens were 2-ethylhexyl-4-me(Parsol MCX) and 2-hydroxy-4-me(oxybenzone). We conclude that allergy is uncommon in our pracby W.B.
Saunders
Company
DISCUSSION The incidence of allergy to sunscreen ingredients is thought to be low. The North American Contact Dermatitis Group found that 80% of cosmetic-induced dermatitis were caused by allergic contact dermatitis, most ofwhich to fragrances and preservatives.2 Nater and De Groot report that the incidence of side effects from sunscreen is about 1% to 2% with a low-to-medium risk index.3 Wennersten et al4 found that the frequency of hypersensitivity to sunscreens in their patient population is about O.l%, whereas English and Cronin5 found that 5% of their patients tested with sunscreens had positive reactions. Fischer and Bergstrom’ found that only 5% of pharmaceutical customers complaining of adverse reactions from sunscreens were allergic to active sunscreen ingredients, with most other allergies detected to fragrance and Balsam of Peru. In a prospective randomized population-based study, 18.9% of the general population reported adverse reactions to sunscreen;
Journal
of Contact
Dermatitis,
Vol9,
No 1 (March),
1998: pp 42-44
SUNSCREEN
ALLERGY
IN SINGAPORE
43
Table 1. National
Skin Centre
Sunscreen
Series
Ingredient p-Aminobenzoic acid (PABA) 2Ethylhexyl-4-dimethylaminobenzoic
acid (Padimate
2-Hydroxy-4methoxybenzophenone 2-Hydroxy-methoxmethylbenzophenone 2-Ethylhexyl-4-methoxycinnamate 4-Isopropyl-dibezoylmethane
(Oxybenzone) (Mexenone)
0) (Eusolex (Eusolex
6007)
4360)
(Parsol MCX) (Eusolex 8020)
4-tert,butyl-4-methoxy-dibenzoylmethane 3-(4.Methyl-bizylidene) camphor Ethoxy-ethyl-p-methoxycinnamate Z-Phenylbenzinidazol
Concentration
5 Sulfonic
(Parsol 1789) (Eusolex 6300) (Givtan F) (before 1994) acid (from
1994)
figures quoted in the previous studies. The frequency of positive reactions to fragrance and Balsam of Peru (8 of 61) in the patients studied is also consistent with previous observations that most contact allergies to cosmetic products (including sunscreens) were caused by fragrances and preservatives. The incidence of sunscreen allergy may be rising. DeLeo et al7 reported an increasing trend of photoallergy to sunscreen ingredients in recent years, together with a decreasing trend of photoallergy to fragrances. Although it is difficult to see a definite trend because of the small number of cases, we will be interested to see if the incidence rises in the near future. The true prevalence of sunscreen allergy might be higher. We recommend that all patients with suspected sunscreen allergy be photopatch tested to the sunscreen series. In our patients, not everyone underwent testing to the actual cosmetic/ sunscreen product, either because they were no longer in possession of the product or failed to bring it on the day of the test. There were two patients with positive reactions to the sunscreen product, but showed negative reactions to the sunscreen ingredients. A few reasons could account for this observation. The concentration of the allergens in the sunscreen series may not be high enough to elicit a reaction. The upper limit of nonirritating
Table 2. Cases
of Allergy
to Sunscreen
Petrolatum
2% 2%
Petrol&urn Petrolatum
2% 2% 2%
Petrolatum Petrolatum Petrolatum
2% 2%
Petrolatum Petrolatum
5%
Petrolatum
2%
dose is not completely defined. The specific vehicle in which the allergens are dissolved or suspended is also very important. The International Contact Dermatitis Research Group uses petrolatum as diluent, which appears to be adequate to elicit reactions in many patients. However, bioavailability of the antigen may be too limited in some cases. Mathias et al8 required ethanol to demonstrate para-aminobenzoic acid (PABA) sensitivity, and Schauder and Ippeng noted more pronounced reactions to avobenzone in isopropylmyristate than petroleum jelly. The optimal concentration and vehicle for each ingredient remains an area for study. The UVA dose could be a factor as well. Some have suggested increasing the UVA dose or even adding suberythemogenic doses of UVB to overcome the problem of false-negatives.‘O Lastly, the patient could be allergic to untested components or excipients in the sunscreen. Manufacturers can help by providing test kits. CONCLUSION We conclude that sunscreen allergy is uncommon in our contact dermatitis clinic. The main causative allergens are 2-ethylhexyl-4-methoxycinnamate (Parsol MCX) and 2-hydroxy-4-methoxybenzophenone (oxybenzone). The incidence could rise in the near future.
Ingredients
Age
St%
1992
27
F
Face, arms,
1993 1994 1994
32 40 43
F F M
Arms Face, legs Arms
Parsol
1995
24
F
Lips
Oxybenzone
Sites
Vehicle
5%
From
Allergens
Photoallergens
back
MCX
1992 to 1996
+
Mexenone ++ Parsol MCX +
Sunscreen
Cinnamate (not done)
Sunscreen Moisturiser
+
Oxybenzone + Padimate 0 + (not done)
Sunscreen Lip balm
44
ANG,
NG, AND
GOH
REFERENCES 1. Fischer complaints
T, Bergstrijm
about
sunscreen
K:
Evaluation
cosmetics
sold
of customers’ by the
Swedish
6. Foley P, Nixon to sunscreens:
reactions
pharmaceutical company. Contact Dermatitis 25:319-322, 1991 2. Eiermann HJ, Larsen W, Maibach HI, et al: North American Contact Dermatitis Group: Prospective study of cos-
based
metic
dermatitis: Results 1990.ArchDermatol 8. Mathias
reactions:
1977-1980.
J Am
Acad
Dermatol
6:909-917,
1982 3. NaterJP, De Groot AC. Unwanted Effects of Cosmetics and Drugs Used in Dermatology, 2 ed. Amsterdam, The Netherlands, Elsevier, 4. Wennersten tact dermatitis:
1985, p. 360 G, Thune P, Jansen
CT,
photodermatitis to 114:1665-1666,1978
et al: Photocontact
para-aminobenzoic
photo-
140-147,
to sun-
10. Dromgoole SH, Maibach intolerance: contact and photocontact
17:159-162,
1987
in Australia.
MJ: Photoallergic
Br J contact
acid.
Arch
Dermatol
9. Schauder S, Ippen H: Photoallergic and allergic dermatitis from dibenzoylmethanes. Photodermatology
photosensitivity (CPS) occurrence, allergens and practical testing. Semin Dermatol5:277-289, 1986 5. English JSC, White IR, Cronin E: Sensitivity Dermatitis
frequency of population-
of photopatch testing in New York 1985. 128~1513-1518, 1992 C, Maibach HI, Epstein J: Allergic contact
contact
Contact
status with emphasis
use of sunscreens
128:512-518, 1993 7. DeLeo A, Suarez SM, Maso
on allergic
screens.
Current
study on the regular
Dermatol
R, Marks R, et al: The results of a longitudinal
urticaria.
con3:
1986
JAm
Acad Dermatol22:1068-1078,
HI: Sunscreening agent sensitisation and contact 1990
THIRD INTERNATIONAL CONGRESS ON CU’TANEOUS ADVERSE DRUG REACTIONS May 5,1998 Bamberg, Germany The Third International Congress on Cutaneous Adverse Drug Reactions will be held on May 5,1998 in Bamberg, Germany. The deadline for abstracts is January 31, 1998. For more information, please contact Maja Mockenhaupt, MD, Dokumentationszentrum schwerer Hautreaktionen (dZh), Hauptstrasse 7, 79104 Freiburg, GERMANY.
Allergy
in Singapore
Por Ang, See Ket Ng, and Chee Leok Goh We report the epidemiology of sunscreen allergy over a period of 5 years at the National Skin Centre. A total of 61 patients with suspected allergy to sunscreen underwent patch or photopatch testing to our sunscreen series from 1992 to 1996. The results were retrospectively analysed and evaluated. Out of these 61 patients, 5 were found to have positive patch test reactions to sunscreens. 2 were photoallergic, and 3
were allergic to main causative thoxycinnamate thoxybenzophenone sunscreen contact tice. Copyright 0 1998
USE OF sunscreens by the general public has increased steadily over the last decade, as people become more aware of the harmful effects of ultraviolet radiation, such as photoaging and carcinogenesis. Health agencies worldwide also recommend the use of sunscreens as a means of lowering the risk of developing skin cancer. Sunscreen ingredients are also increasingly being added to cosmetic products, such as moisturisers and lipsticks. Adverse reactions from sunscreen are well known and have been reported in the literature. These include contact dermatitis, both allergic and irritant, as well as phototoxic and photoallergic reactions. Other reactions reported include contact urticaria and subjective (sensory) irritation.’ We aim to find out how common sunscreen allergy is in our practice at National Skin Centre, in view of the rising use of sunscreen in our population.
were photoallergic, and 3 were allergic. Their ages ranged from 27 to 43, and four were female. Two patients were positive to 2-ethylhexylp-methoxycinnamate (Parsol MCX) alone, 1 to both 2-ethylhexylp-methoxycinnamate (Parsol MCX) and 2-hydroxymethoxmethylbenzophenone (mexenone), 1 to 2-hydroxy-4-methoxybenzophenone (oxybenzone) alone, and 1 to both oxybenzone and 2-ethylhexy-4dimethylaminobenzoic acid (Padimate 0). The results are summarized in Table 2. It is also interesting to note that out of the 56 other patients who were tested negative to the sunscreen series, 8 were found to have allergic reactions to fragrance mix and/or Balsam of Peru.
T””
METHODS The records of 61 patients with suspected sunscreen contact dermatitis from 1992 to 1996 were retrospectively analysed and evaluated. Forty-eight patients were photopatch tested, and the rest patch tested to our sunscreen series in the standard way (Table 1). Test allergens were applied on the upper back and read at 72 hours after a 4%hour occlusion. For photopatch testing, the photoallergens were applied in duplicate and occluded with opaque material for 48 hours, followed by irradiation of one set with 10 J/cm* of ultraviolet light A (UVA). The final results were recorded at 96 hours. A l+ reaction or greater was considered a positive reaction.
RESULTS Out of the 61 patients, 5 were found to have positive reactions to sunscreen ingredients. Two
Fmn the National Skin Centre, Singapore. Address reprint requests to Par Ang, MBBS, MRCP National Skin Centre, I Mandalay Rd, Singa$nm 308205. Copytight 0 1998by WB Saunders Comjmny 1046.199Xl9810901-0009%03.00/0
42
(UK),
American
active ingredients in sunscreens. The allergens were 2-ethylhexyl-4-me(Parsol MCX) and 2-hydroxy-4-me(oxybenzone). We conclude that allergy is uncommon in our pracby W.B.
Saunders
Company
DISCUSSION The incidence of allergy to sunscreen ingredients is thought to be low. The North American Contact Dermatitis Group found that 80% of cosmetic-induced dermatitis were caused by allergic contact dermatitis, most ofwhich to fragrances and preservatives.2 Nater and De Groot report that the incidence of side effects from sunscreen is about 1% to 2% with a low-to-medium risk index.3 Wennersten et al4 found that the frequency of hypersensitivity to sunscreens in their patient population is about O.l%, whereas English and Cronin5 found that 5% of their patients tested with sunscreens had positive reactions. Fischer and Bergstrom’ found that only 5% of pharmaceutical customers complaining of adverse reactions from sunscreens were allergic to active sunscreen ingredients, with most other allergies detected to fragrance and Balsam of Peru. In a prospective randomized population-based study, 18.9% of the general population reported adverse reactions to sunscreen;
Journal
of Contact
Dermatitis,
Vol9,
No 1 (March),
1998: pp 42-44
SUNSCREEN
ALLERGY
IN SINGAPORE
43
Table 1. National
Skin Centre
Sunscreen
Series
Ingredient p-Aminobenzoic acid (PABA) 2Ethylhexyl-4-dimethylaminobenzoic
acid (Padimate
2-Hydroxy-4methoxybenzophenone 2-Hydroxy-methoxmethylbenzophenone 2-Ethylhexyl-4-methoxycinnamate 4-Isopropyl-dibezoylmethane
(Oxybenzone) (Mexenone)
0) (Eusolex (Eusolex
6007)
4360)
(Parsol MCX) (Eusolex 8020)
4-tert,butyl-4-methoxy-dibenzoylmethane 3-(4.Methyl-bizylidene) camphor Ethoxy-ethyl-p-methoxycinnamate Z-Phenylbenzinidazol
Concentration
5 Sulfonic
(Parsol 1789) (Eusolex 6300) (Givtan F) (before 1994) acid (from
1994)
figures quoted in the previous studies. The frequency of positive reactions to fragrance and Balsam of Peru (8 of 61) in the patients studied is also consistent with previous observations that most contact allergies to cosmetic products (including sunscreens) were caused by fragrances and preservatives. The incidence of sunscreen allergy may be rising. DeLeo et al7 reported an increasing trend of photoallergy to sunscreen ingredients in recent years, together with a decreasing trend of photoallergy to fragrances. Although it is difficult to see a definite trend because of the small number of cases, we will be interested to see if the incidence rises in the near future. The true prevalence of sunscreen allergy might be higher. We recommend that all patients with suspected sunscreen allergy be photopatch tested to the sunscreen series. In our patients, not everyone underwent testing to the actual cosmetic/ sunscreen product, either because they were no longer in possession of the product or failed to bring it on the day of the test. There were two patients with positive reactions to the sunscreen product, but showed negative reactions to the sunscreen ingredients. A few reasons could account for this observation. The concentration of the allergens in the sunscreen series may not be high enough to elicit a reaction. The upper limit of nonirritating
Table 2. Cases
of Allergy
to Sunscreen
Petrolatum
2% 2%
Petrol&urn Petrolatum
2% 2% 2%
Petrolatum Petrolatum Petrolatum
2% 2%
Petrolatum Petrolatum
5%
Petrolatum
2%
dose is not completely defined. The specific vehicle in which the allergens are dissolved or suspended is also very important. The International Contact Dermatitis Research Group uses petrolatum as diluent, which appears to be adequate to elicit reactions in many patients. However, bioavailability of the antigen may be too limited in some cases. Mathias et al8 required ethanol to demonstrate para-aminobenzoic acid (PABA) sensitivity, and Schauder and Ippeng noted more pronounced reactions to avobenzone in isopropylmyristate than petroleum jelly. The optimal concentration and vehicle for each ingredient remains an area for study. The UVA dose could be a factor as well. Some have suggested increasing the UVA dose or even adding suberythemogenic doses of UVB to overcome the problem of false-negatives.‘O Lastly, the patient could be allergic to untested components or excipients in the sunscreen. Manufacturers can help by providing test kits. CONCLUSION We conclude that sunscreen allergy is uncommon in our contact dermatitis clinic. The main causative allergens are 2-ethylhexyl-4-methoxycinnamate (Parsol MCX) and 2-hydroxy-4-methoxybenzophenone (oxybenzone). The incidence could rise in the near future.
Ingredients
Age
St%
1992
27
F
Face, arms,
1993 1994 1994
32 40 43
F F M
Arms Face, legs Arms
Parsol
1995
24
F
Lips
Oxybenzone
Sites
Vehicle
5%
From
Allergens
Photoallergens
back
MCX
1992 to 1996
+
Mexenone ++ Parsol MCX +
Sunscreen
Cinnamate (not done)
Sunscreen Moisturiser
+
Oxybenzone + Padimate 0 + (not done)
Sunscreen Lip balm
44
ANG,
NG, AND
GOH
REFERENCES 1. Fischer complaints
T, Bergstrijm
about
sunscreen
K:
Evaluation
cosmetics
sold
of customers’ by the
Swedish
6. Foley P, Nixon to sunscreens:
reactions
pharmaceutical company. Contact Dermatitis 25:319-322, 1991 2. Eiermann HJ, Larsen W, Maibach HI, et al: North American Contact Dermatitis Group: Prospective study of cos-
based
metic
dermatitis: Results 1990.ArchDermatol 8. Mathias
reactions:
1977-1980.
J Am
Acad
Dermatol
6:909-917,
1982 3. NaterJP, De Groot AC. Unwanted Effects of Cosmetics and Drugs Used in Dermatology, 2 ed. Amsterdam, The Netherlands, Elsevier, 4. Wennersten tact dermatitis:
1985, p. 360 G, Thune P, Jansen
CT,
photodermatitis to 114:1665-1666,1978
et al: Photocontact
para-aminobenzoic
photo-
140-147,
to sun-
10. Dromgoole SH, Maibach intolerance: contact and photocontact
17:159-162,
1987
in Australia.
MJ: Photoallergic
Br J contact
acid.
Arch
Dermatol
9. Schauder S, Ippen H: Photoallergic and allergic dermatitis from dibenzoylmethanes. Photodermatology
photosensitivity (CPS) occurrence, allergens and practical testing. Semin Dermatol5:277-289, 1986 5. English JSC, White IR, Cronin E: Sensitivity Dermatitis
frequency of population-
of photopatch testing in New York 1985. 128~1513-1518, 1992 C, Maibach HI, Epstein J: Allergic contact
contact
Contact
status with emphasis
use of sunscreens
128:512-518, 1993 7. DeLeo A, Suarez SM, Maso
on allergic
screens.
Current
study on the regular
Dermatol
R, Marks R, et al: The results of a longitudinal
urticaria.
con3:
1986
JAm
Acad Dermatol22:1068-1078,
HI: Sunscreening agent sensitisation and contact 1990
THIRD INTERNATIONAL CONGRESS ON CU’TANEOUS ADVERSE DRUG REACTIONS May 5,1998 Bamberg, Germany The Third International Congress on Cutaneous Adverse Drug Reactions will be held on May 5,1998 in Bamberg, Germany. The deadline for abstracts is January 31, 1998. For more information, please contact Maja Mockenhaupt, MD, Dokumentationszentrum schwerer Hautreaktionen (dZh), Hauptstrasse 7, 79104 Freiburg, GERMANY.