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The red face: Contact and photocontact dermatitis
The Red Face: Contact and Photocontact Dermatitis A. DOOMS-GOOSSENS,
MD
C
ontact and photocontact dermatitis reactions frequently occur on the face. Moreover, the allergens involved can reach the skin of the face in several different ways, and the nature of the causal factors and/or sensitization sources varies greatly.
Occasional Contact With an AllergenContaminated Surface
Ways in Which Allergic Reactions Occur on the Face Direct Application The more common sources of allergens that are directly applied to the face are given in Table 1 .l Often involved in facial dermatitis are topical pharmaceutical products and cosmetics. With the latter, unusual clinical presentations may sometimes occur that are very similar to seborrheic eczema, lupus erythematosus, and the like, particularly if preservative agents such as methyl(chloro)isothiazolinone are involved.* Figure 1 illustrates this for a contact allergy to the preservative agent methyldibromoglutaronitrile, which is present in Euxyl K400. In the case of intolerance to hair-care products (used on the scalp where the skin is thicker), particular sites like the forehead, the temples, the area in front of the ears, and even the eyelids are often involved (Fig 2). The eyelids are the most vulnerable sites, primarily because of the thinness of the epidermis, which facilitates the penetration of allergens. When, for example, cosmetics are applied to the entire face or even the scalp, the eyelids may be the only part of the face on which a reaction occurs. As for contact dermatitis on the lips, the allergen may be contained in lipstick and topical pharmaceutical pro-
From the Department of Medicnl Research (Dermatology), University Hospital, Leuven, Belgium. Address correspondence to: A. Dooms-Goossens, Department ofDermatology, UZ St. RafaPl, 3000 Leuven, Belgium.
0
1993 by
ducts such as antiviral agents (Fig 3), but dental products and foods, such as spices, must also be considered.3 Occasionally, appliances such as spectacle frames, goggles, masks, and even musical instruments provoke lesions at specific sites.
Elsevier Science Publishing Co., Inc. 0738-081x/93/$6.00 l
Allergenic surfaces or allergen-contaminated surfaces, such as pillows, telephones, and headrests, can induce a contact dermatitis reaction on particular sites of the face. Figure 4 shows how a pillow contaminated with a procaine-containing hair lotion caused lesions on the cheeks and also the eyelids of a sensitized patient.4
Airborne Contact Allergens can be released into the atmosphere and then settle on exposed skin. The harmful agents can be vapors, droplets, or dust particles and are most often occupation related. There are many potential sources such as plant materials and woods, industrial and pharmaceutical chemicals, plastics, rubbers, glues, metals, insecticides, pesticides, animal-feed additives, solvents, and many other substances (see Refs 1 and 5 for reviews). Figure 5 illustrates an airborne cement dermatitis. The upper eyelids are again particularly susceptible to airborne allergens, as particles can readily collect in the folds. Moreover, conjunctivitis may also occur. An airborne contact dermatitis can be differentiated -although this is often difficult-from photodermatitis by involvement of the anatomically shadowed portions of the face, such as the upper eyelids, the forehead covered by hair, and the area under the nose.
Photoinduced
Reactions
Contact with a photoallergen and exposure to sunlight, particularly UVA light, can induce photocontact dermati-
289
290
DOOMS-GOOSSENS
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Table 2. Dermatitis of the Face Caused by Direct Application of the Allergen Face in general
Cosmetics (and cosmetic appliances), topical pharmaceuticals Hair-care products, head coverings, sweatbands Spectacle frames, face masks, goggles Goggles, masks, depilatory tweezers Eye makeup, eyelash curlers, hair-care products Eye makeup, topical pharmaceutical products, contact lens solutions Cosmetics Nasal medications, tubes, handkerchiefs (perfumed), snuff, drugs Lipstick, topical and oral medications, food, beverages, food and beverage containers, spices, tobacco, sucked-on articles, dental products, depilatory agents, musical instruments, masks, tubes Shaving products, hat straps, chin rests
Forehead Bridge of the nose Eyebrows Upper eyelids Lower eyelids Cheeks Nostrils Lips, mouth, and perioral area
Chin and submandibular
area
tis. The most common photoallergens in the 1960s were antibacterial agents (salicylanilides) in soaps6; the most common in the 1970s and 1980s were perfume components such as musk ambrette’ (Fig 6). Both antibacterial agents and perfume components are also associated with the occurrence of persistent light reactions.6*8 Today, sunscreens are the most common photoallergens. The extensive use of sunscreening agents not only in sunscreen products as such but also in skin-care products such as day creams makes them particularly liable to be the source of photoallergic reactions on the face.
Other People People can transmit allergens to their partners, friends, colleagues, and others to cause “connubial” or “consort” dermatitis. Among the frequent causes are cosmetics (perfumes, makeup, and hair-care products) and medications, although plants and profession-related substances have been reported (see Ref 10 for a review) (see Fig 4, in which the particular hair lotion was being used by the patient’s husband).’
Transfer The allergen can be conveyed by the hands to more sensitive areas like the mouth region or the eyelids. Such a dermatitis is called ectopic, a term coined by Fisher to indicate a dermatitis displaced from its usual site.” An airborne factor or systemic contact dermatitis (see below) cannot always be excluded, however, particularly if the facial eruption is symmetric. Cosmetics such as nail polish (Fig 7) and also indus-
Figure 1. “Unusual” allergic contact dermatitis in response to use of a face cream as a result of methyldibromoglutaronitrile sensitivity (Euxyl K400).
trial, pharmaceutical, and other products have been reported as allergen sources that are transferred to relatively remote sites by the hands. Figure 8 shows a person with an ectopic dermatitis caused by primula in which the linear patches are typical of a plant-related contact allergy.
Systemic Exposure Individuals previously sensitized by skin contact can react systemically to the same or chemically related allerFigure 2. Allergic contact dermatitis resulting from use of a hair-care product.
DOOMS-GOOSSENS CONTACT AND PHOTOCONTACT DERMATITIS
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1993;11:289-295
Figure 3. Allergic contact cheilitis caused by tromantadine, antiviral agent.
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an
gen. In fact, a systemically administered allergen may reach the skin through the circulatory system and produce a hematogenous contact-type derrnatitis.12 The most frequent reactions are focal flares at sites of previous lesions (e.g., previous positive patch-test sites) as well as skin eruptions at sites not related to previous exposures, as is the case with dyshidrotic hand eczema and the baboon syndrome. l3 Such a reaction may also occur on the face, for example, as periorbital edema.
Id-Type Spreads An allergic contact dermatitis that involves other areas of the body may spread to the face and presents often as a symmetric eruption of the eyelids (Fig 9).
Figure 5. Airborne allergic contact dermatitis induced by cement dust.
The Nature of Facial Allergens and Causal Factors To determine the nature of the allergens and the allergen sources that cause facial dermatitis, we analyzed the results obtained with patients examined in our contact allergy unit.
Patients and Methods Figure 4. Allergic dermatitis caused by contact with a pillow contaminated by a hair lotion containing procaine (used by the husband).
The patients (N = 8877) who consulted our unit between January 1978 and July 1992 were tested with the ICDRG standard series, supplemented, if appropriate, by other series (such as a topical pharmaceutical, cosmetic, or profession-related series) and/or ingredients of the products supplied by the patient. The materials used were either Vander Bend Silver Patch or, later, Square Chambers (Van der Bend, The Netherlands) fixed on Micropore (3M, United States) and covered either by Tarpal (Smith & Nephew, France) or, later, by Mefix (Miilnlycke, Spain). In the consideration of the most common allergens in a particular patient group, there is always the problem of the ubiquitous allergens, such as nickel, fragrance mix, and paraphenylenediamine, which may be but are not necessarily relevant for a particular patient group suffering from facial contact allergy. Therefore, we compared two patient groups: the first group suffered from contact
292
DOOMS-GOOSSENS
Clinics in Dermatology 1993:11:289-295
Figure 6. Photoallergic contact dermatitis resulting from use of an aftershave lotion containing musk ambrette.
dermatitis localized on the face only, the second group had allergic contact dermatitis on other parts of the body except the face. The allergens that occurred with a statistically significant difference (chi square analysis) in the first group compared with those occurring in the second group were taken into account. This provides a list of what may be considered “typical facial allergens.”
Results Of a population of 8877 patients tested in our contact allergy unit between January 1978 and July 1992, 4663 presented with a contact and/or photocontact allergy. Of these, 1542 (one third!) suffered from contact dermatitis on the face, occasionally including other body sites, and 480 (10.3%: 404 females, 76 males) had contact dermatitis exclusively on the face. In 277 cases, the forehead and/or cheeks and/or nose and/or chin and/or entire face; in 202 cases the eyelids; and in 136 cases the lips and/or perioral area were affected. This group of patients was compared with the group of 3121 patients (2124 females, 997 males) who suffered from contact dermatitis on other parts of the body. Table 2 lists the “typical allergens” encountered in patients suffering exclusively from a facial dermatitis. The allergens that were included gave a positive reaction in at least two patients.
Figure polish.
7.
“Ectopic” dermatitis resulting from the use of nail
The causal factors or sensitization sources were, in 188 cases, topical pharmaceutical products (iatrogenic cause); in 187 cases, cosmetics; in 166 cases, metal jewelry and appliances (eg, spectacle frames) and/or metal objects by which the face was affected through transfer by the hands (ectopic dermatitis); in 93 cases, profession-related substances; in 21 cases, household products; and in 17 cases, hobby-related substances. Of course, several causal factors or sensitization sources are possible for an individual patient.
Discussion Nickel is certainly a ubiquitous allergen in all patient groups in which females predominate and, thus, will be a coincidental finding in many patients suffering from intolerance to costume jewelry, but this may have no relevance whatsoever to the dermatitis being investigated. Although out of 186 nickel-allergic patients, 181 were female, a nickel allergy seems to be a statistically relevant finding in patients suffering from contact dermatitis on the face. This is due to contact with metal appliances such as spectacle frames and depilatory tweezers, costume jewelry such as earrings that come in contact with the cheeks, metal dental materials that provoke cheilitis,14 sucked-on articles such as pens, paper clips, and needles, and eye shadow contaminated with metal particles causing eyelid dermatitis. 15,16Moreover, the transfer of nickel
DOOMS-GOOSSENS CONTACT AND PHOTOCONTACT DERMATITIS
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Table 2. Typical “Facial”Allergens Allergen 1. Nickel sulfate 2. Neomycin 3. Tromantadine 4. Methyl (chloro) isothiazolinone 5. Benzoyl peroxide 6. p-Toluenesulfonamide formaldehyde resin 7. Benzophenylsalicylate (salol) 8. Chloroacetamide 9. Diazolidinylurea 10. Imidazolidinylurea 11. Oleamido propyldimethylamine 12. Benzophenone-3’ 13. Dimethylthiourea 14. Polymyxine-B sulfate 15. Phenylephrine l
Figure
8.
“Ectopic dermatitis”
resulting from primula,
particles by the hands to the eyelids in patients who frequently handle metal objects, such as cashiers, hairdressers, secretaries, and nurses, airborne’ and even systemic reactions to nickel that cause periorbital edema” are not uncommon sources of nickel-induced facial dermatitis. In only two of the five men with a contact allergy to nickel could the dermatitis have been relevant to the facial dermatitis and was thought to be caused by transfer. Among the “typical” facial iatrogenic allergens (see
Figure 9. An idlike spread of an allergic contact dermatitis elsewhere on the body.
Number of Cases 186 36 25 24 14 9 8 6 4 3 2 2 2 2 2
As a photoallergen.
Table 2), we found neomycin (often used in nasal and ophthalmic preparations), tromantadine (an antiviral agent that frequently causes contact cheilitis), benzoyl peroxide (used to treat acne), polymyxin-B sulfate (an antibiotic often used in association with neomycin to treat eye infections), and phenylephrine (a mydriatic and conjunctival decongestant used in ophthalmology). Cosmetics constitute another important source of facial contact dermatitis, particularly preservative agents, which represent the second most important cosmetic sensitizers after perfumes. la As typical causes of facial eruptions, we found the methyl(chloro)isothiazolinone mixture, which may sometimes give rise to unusual clinical pictures,* chloroacetamide, and the formaldehyde releasers diazolidinylurea and imidazolidinylurea. This is due mainly to their presence in products used for facial skin care (day and night creams, cleansers) and makeup (eg, foundations).*s Oleamidopropyl dimethylamine, a cationic emulsifier in a particular baby body lotion and frequently used as a facial cleanser for women, is a well-known sensitizer.19 Benzophenylsalicylate or salol used as a sunscreen was, in all cases, the cause of contact cheilitis because of its presence in a very popular brand of lipstick. Benzophenone-3, another sunscreen agent, was responsible for two cases of allergic photocontact dermatitis. As for cosmetic dermatitis, p-toluenesulfonamide formaldehyde resin, the allergen in nail polish, was the source in nine cases of “ectopic” contact dermatitis on the face. Finally, dimethylthiourea, an antioxidant present in diazo-sensitized paper,20 was found to be the occupation-related cause of an airborne contact dermatitis confined only to the face in two women working in the textile industry.
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DOOMS-GOOSSENS
A large range of other allergens that do not appear on the list of “typical” facial allergens should, of course, also be considered as potential causes of facial contact or photocontact dermatitis. We discuss only a few of the most frequently occurring ones here, most of which were related to cosmetics. Among the more important allergens are balsam of Peru (43 cases), which was found to be particularly related to contact dermatitis of the face in Edman’s study, in which chi square analysis was also used to establish the relationship between particular allergens and sites of contact dermatitis.21 Together with fragrance mix (40 cases), it expresses an intolerance to perfumed products applied directly to the skin such as aftershave lotions but also to substances conveyed by airborne or connubial contact. The eyelids are particularly prone to such involvement. A cobalt sensitivity was found in 42 cases, 38 of which were associated with nickel. Of the four women who reacted to cobalt only, one was a diamond polisher, her dermatitis clearly being a work-related airborne cobalt sensitivity’; two were suspected of reacting to eye cosmetics, although the cobalt content could not be verified; and the fourth patient had a dermatitis on her eyelids, the allergenic metal particles being conveyed by her hands. A paraphenylenediamine (PPD) sensitivity (35 cases) generally reflects a contact sensitivity to permanent hair dyes containing PPD itself or related dyes, which often cross-react with other p-aminobenzene compounds such as benzocaine (31 cases). Colophony (27 cases) is an allergen encountered in cosmetics such as eye makeupz2 or in relation to a perfume allergyz3; it may also be a source of dermatitis of plants and woods (eg, pine trees) and industrial materials, even by airborne contact.’ A contact allergy to wool alcohols (two cases) can be the result of facial cosmetic preparations, even though it is sometimes secondary to a topical medicament-induced sensitivity.18 Thiomersal (19 cases) is, in most cases, not a relevant allergen, but it may be a source of intolerance to eye cosmetics and contact lens solutionsz4 Potassium dichromate (10 cases) may be responsible for eyelid dermatitis, because of its presence in eye shadow, as well as of facial airborne dermatitis, because of cement (eg, Fig 5). Formaldehyde (eight cases) is a potential source of cosmetic sensitivity, including hair-care products such as shampoos, which may affect primarily the eyelids. The exact nature of facial allergens that might be found in different studies depends, of course, on many factors, including the nature of the substances tested (one can find only what one searches for, what one tests), but certainly also on the frequency of exposure and of use of individual products. A study of contact dermatitis reactions on the face conducted by the International Contact Dermatitis Computer Group and presented at the 8th
International Symposium on Contact Dermatitis in Cambridge (March 20 - 22,1986) gave some striking examples in this regard. Although most facial allergens observed were the same for the United Kingdom, Sweden, Germany, and Belgium, significant differences emerged with respect to some of them. For example, “typical” facial allergens in the United Kingdom were reported to be quatemium-15 and phosphorous sesquisulfide. Indeed, formaldehyde releasers like quatemium-1525 have frequently been reported to be causes of cosmetic facial dermatitis in the United Kingdom. (In contrast, the methyl(chloro)isothiazolinone mixture became a much more important allergen in this regard on the European continent in countries like The Netherlands, Belgium,26 Switzerland,*’ and Italy .*s The other striking example was phosphorous sesquisulfide, an allergen present in “strike-anywhere” matches, which are very popular in the United Kingdom but are not marketed in the Scandinavian countries or any other country in Western Europe. 29 They have caused many cases of facial dermatitis, particularly in men. There may be regional differences for many other allergens as well, and only comparisons between results obtained in different countries will reveal these differences.
Conclusions Contact dermatitis on the face is a frequent finding, particularly in women, and the many different allergens can be delivered to the face in several ways: by direct application or contact with allergenic surfaces, by airborne transfer, by connubial contact, and by transfer from other body sites. The reactions may also be photoinduced, the result of systemic exposure, or the result of an idlike spread of a contact dermatitis elsewhere on the body, The number of positive reactions to a particular allergen depends on its rate of occurrence in the environment and may or may not be occupation-related. In our patient series, the most common facial allergens were metals (nickel) and ingredients in topical medicaments and cosmetics, but substances such as professional and plant allergens cannot be ignored. Identification of the allergens, of course, depends on whether they are considered potential allergens in the diagnostic process and thus are sought. Moreover, there may be interesting differences from one country to another.
References 1. Dooms-Goossens AE, Debusschere KM, Gevers DM, et al. Contact dermatitis caused by airborne agents. J Am Acad Dermatol 1986;15:1-10.
Clinics in Dermatology 1993;11:289-295
2. Morren M-A, Dooms-Goossens A, Delabie J, et al. Contact allergy to isothiazolinone derivatives: Unusual clinical presentations. Dermatology 1992;184:260-4. 3. Dooms-Goossens A, Dubelloy R, Degreef H. Contact and systemic contact-type dermatitis to spices. Dermatol Clin 1990;8:89-93. A, Swinnen E, Vandermaesen J, et al. 4. Dooms-Goossens Connubial dermatitis from a hair lotion. Contact Dermatitis 1987;16:41-2. c5* Dooms-Goossens A, Deleu H. Airborne contact dermatitis: An update. Contact Dermatitis 1991;25:211-7.
6. Herman P’S, Sams WM. Soap photodermatitis: Photosensitivity to halogenated salicylanilides. Springfield: Charles C Thomas, 1972. 7. Kroon S. Musk ambrette, a new cosmetic sensitizer and photosensitizer. Contact Dermatitis 1979;5:337-8. 8. Burrey JN. Persistent light reaction associated with sensitivity to musk ambrette. Contact Dermatitis 1981;7:46-7. 9. Schauder S. Literaturiibersicht iiber Unvertrlglichkeitsreaktionen auf lichtfilterhaltige Produkte van 19471989. Z Hautkr 1990;65:982-98. A, et al. 10. Morren M-A, Rodrigues R, Dooms-Goossens Connubial contact dermatitis: a review. Eur J Dermatol 1992;2:219-23. 11. Fisher AA. Unique features of nail polish dermatitis in contact dermatitis: Questions and answers. Part II. Cutis 1982;29:22. 12. Fisher AA. Systemic contact-type dermatitis. In: Contact Dermatitis. 3rd ed. Philadelphia, Lea & Febiger: 1986: 119 30. 13. Andersen KE, Hjorth N, Menne T. The baboon syndrome: Systemically induced allergic contact dermatitis. Contact Dermatitis 1984;20:97-120.
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16. Goh CL, NG SK, Kevok SF. Allergic contact dermatitis from nickel in eye shadow. Contact Dermatitis 1989;20:380-1. 17. McT Wilson AG, Gould DJ. Nickel dermatitis from a dental prosthesis without buccal involvement. Contact Dermatitis 1989;21:53. 18. Dooms-Goossens A, Kerre S, Drieghe J, et al. Cosmetic products and their allergens. Eur J Dermatol1992;2:465 -8. 19. de Groot AC. Oleamidopropyl dimethylamine. In: Adverse reactions to cosmetics (thesis). The Netherlands: State University of Groningen, 1988: 169-80. 20. Dooms-Goossens A, Boyden B, Ceuterick A, et al. Dimethylthiourea, an unexpected hazard for textile workers. Contact Dermatitis 1979;5:367-70. 21. Edman B. Sites of contact dermatitis in relationship to particular allergens. Contact Dermatitis 1985;13:129-35. 22. Karlberg AT, Liden C, Ehrin E. Colophony in mascara as a cause of eyelid dermatitis. Acta Derm Venereol (Stockh) 1991;71:445-6. 23. Hjorth N. Eczematous allergy to balsams, allied perfumes and flavouring agents. Copenhagen: Munksgaard, 1961: 137-40. 24. Bang-Pedersen N. Allergic contact merthiolate in soft contact lenses. 1978;4:165.
conjunctivitis from Contact Dermatitis
25. Ford GP, Beck MH. Reactions to Quatemium-15, Bronopol and Germall 115 in a standard series. Contact Dermatitis 1986;14:271-4. 26. Cronin E, Hannuksela M, Lachapelle J-M, et al. Frequency of sensitization to the preservative Kathon CG. Contact Dermatitis 1988;18:274-9. 27. Pasche F, Hunziker N. Sensitization to Kathon CG in Geneva and Switzerland. Contact Dermatitis 1989;20:115-9.
14. Temesvari E, Racz I. Nickel sensitivity from a dental prosthesis. Contact Dermatitis 1980;18:50-1.
28. Tosti A. Prevalence and sources of Kathon CG sensitization in Italy. Contact Dermatitis 1988;18:173-4.
15. Van Ketel WG, Liem DH. Eyelid dermatitis from nickel contaminated cosmetics. Contact Dermatitis 1981;7:217.
29. Cronin E. Contact dermatitis. Edinburgh/London/New York: Churchill Livingstone, 1980: 825 -8.
MD
C
ontact and photocontact dermatitis reactions frequently occur on the face. Moreover, the allergens involved can reach the skin of the face in several different ways, and the nature of the causal factors and/or sensitization sources varies greatly.
Occasional Contact With an AllergenContaminated Surface
Ways in Which Allergic Reactions Occur on the Face Direct Application The more common sources of allergens that are directly applied to the face are given in Table 1 .l Often involved in facial dermatitis are topical pharmaceutical products and cosmetics. With the latter, unusual clinical presentations may sometimes occur that are very similar to seborrheic eczema, lupus erythematosus, and the like, particularly if preservative agents such as methyl(chloro)isothiazolinone are involved.* Figure 1 illustrates this for a contact allergy to the preservative agent methyldibromoglutaronitrile, which is present in Euxyl K400. In the case of intolerance to hair-care products (used on the scalp where the skin is thicker), particular sites like the forehead, the temples, the area in front of the ears, and even the eyelids are often involved (Fig 2). The eyelids are the most vulnerable sites, primarily because of the thinness of the epidermis, which facilitates the penetration of allergens. When, for example, cosmetics are applied to the entire face or even the scalp, the eyelids may be the only part of the face on which a reaction occurs. As for contact dermatitis on the lips, the allergen may be contained in lipstick and topical pharmaceutical pro-
From the Department of Medicnl Research (Dermatology), University Hospital, Leuven, Belgium. Address correspondence to: A. Dooms-Goossens, Department ofDermatology, UZ St. RafaPl, 3000 Leuven, Belgium.
0
1993 by
ducts such as antiviral agents (Fig 3), but dental products and foods, such as spices, must also be considered.3 Occasionally, appliances such as spectacle frames, goggles, masks, and even musical instruments provoke lesions at specific sites.
Elsevier Science Publishing Co., Inc. 0738-081x/93/$6.00 l
Allergenic surfaces or allergen-contaminated surfaces, such as pillows, telephones, and headrests, can induce a contact dermatitis reaction on particular sites of the face. Figure 4 shows how a pillow contaminated with a procaine-containing hair lotion caused lesions on the cheeks and also the eyelids of a sensitized patient.4
Airborne Contact Allergens can be released into the atmosphere and then settle on exposed skin. The harmful agents can be vapors, droplets, or dust particles and are most often occupation related. There are many potential sources such as plant materials and woods, industrial and pharmaceutical chemicals, plastics, rubbers, glues, metals, insecticides, pesticides, animal-feed additives, solvents, and many other substances (see Refs 1 and 5 for reviews). Figure 5 illustrates an airborne cement dermatitis. The upper eyelids are again particularly susceptible to airborne allergens, as particles can readily collect in the folds. Moreover, conjunctivitis may also occur. An airborne contact dermatitis can be differentiated -although this is often difficult-from photodermatitis by involvement of the anatomically shadowed portions of the face, such as the upper eyelids, the forehead covered by hair, and the area under the nose.
Photoinduced
Reactions
Contact with a photoallergen and exposure to sunlight, particularly UVA light, can induce photocontact dermati-
289
290
DOOMS-GOOSSENS
Clinics in Dermatology 1993;11:289-295
Table 2. Dermatitis of the Face Caused by Direct Application of the Allergen Face in general
Cosmetics (and cosmetic appliances), topical pharmaceuticals Hair-care products, head coverings, sweatbands Spectacle frames, face masks, goggles Goggles, masks, depilatory tweezers Eye makeup, eyelash curlers, hair-care products Eye makeup, topical pharmaceutical products, contact lens solutions Cosmetics Nasal medications, tubes, handkerchiefs (perfumed), snuff, drugs Lipstick, topical and oral medications, food, beverages, food and beverage containers, spices, tobacco, sucked-on articles, dental products, depilatory agents, musical instruments, masks, tubes Shaving products, hat straps, chin rests
Forehead Bridge of the nose Eyebrows Upper eyelids Lower eyelids Cheeks Nostrils Lips, mouth, and perioral area
Chin and submandibular
area
tis. The most common photoallergens in the 1960s were antibacterial agents (salicylanilides) in soaps6; the most common in the 1970s and 1980s were perfume components such as musk ambrette’ (Fig 6). Both antibacterial agents and perfume components are also associated with the occurrence of persistent light reactions.6*8 Today, sunscreens are the most common photoallergens. The extensive use of sunscreening agents not only in sunscreen products as such but also in skin-care products such as day creams makes them particularly liable to be the source of photoallergic reactions on the face.
Other People People can transmit allergens to their partners, friends, colleagues, and others to cause “connubial” or “consort” dermatitis. Among the frequent causes are cosmetics (perfumes, makeup, and hair-care products) and medications, although plants and profession-related substances have been reported (see Ref 10 for a review) (see Fig 4, in which the particular hair lotion was being used by the patient’s husband).’
Transfer The allergen can be conveyed by the hands to more sensitive areas like the mouth region or the eyelids. Such a dermatitis is called ectopic, a term coined by Fisher to indicate a dermatitis displaced from its usual site.” An airborne factor or systemic contact dermatitis (see below) cannot always be excluded, however, particularly if the facial eruption is symmetric. Cosmetics such as nail polish (Fig 7) and also indus-
Figure 1. “Unusual” allergic contact dermatitis in response to use of a face cream as a result of methyldibromoglutaronitrile sensitivity (Euxyl K400).
trial, pharmaceutical, and other products have been reported as allergen sources that are transferred to relatively remote sites by the hands. Figure 8 shows a person with an ectopic dermatitis caused by primula in which the linear patches are typical of a plant-related contact allergy.
Systemic Exposure Individuals previously sensitized by skin contact can react systemically to the same or chemically related allerFigure 2. Allergic contact dermatitis resulting from use of a hair-care product.
DOOMS-GOOSSENS CONTACT AND PHOTOCONTACT DERMATITIS
Clinics in Dermatology
1993;11:289-295
Figure 3. Allergic contact cheilitis caused by tromantadine, antiviral agent.
291
an
gen. In fact, a systemically administered allergen may reach the skin through the circulatory system and produce a hematogenous contact-type derrnatitis.12 The most frequent reactions are focal flares at sites of previous lesions (e.g., previous positive patch-test sites) as well as skin eruptions at sites not related to previous exposures, as is the case with dyshidrotic hand eczema and the baboon syndrome. l3 Such a reaction may also occur on the face, for example, as periorbital edema.
Id-Type Spreads An allergic contact dermatitis that involves other areas of the body may spread to the face and presents often as a symmetric eruption of the eyelids (Fig 9).
Figure 5. Airborne allergic contact dermatitis induced by cement dust.
The Nature of Facial Allergens and Causal Factors To determine the nature of the allergens and the allergen sources that cause facial dermatitis, we analyzed the results obtained with patients examined in our contact allergy unit.
Patients and Methods Figure 4. Allergic dermatitis caused by contact with a pillow contaminated by a hair lotion containing procaine (used by the husband).
The patients (N = 8877) who consulted our unit between January 1978 and July 1992 were tested with the ICDRG standard series, supplemented, if appropriate, by other series (such as a topical pharmaceutical, cosmetic, or profession-related series) and/or ingredients of the products supplied by the patient. The materials used were either Vander Bend Silver Patch or, later, Square Chambers (Van der Bend, The Netherlands) fixed on Micropore (3M, United States) and covered either by Tarpal (Smith & Nephew, France) or, later, by Mefix (Miilnlycke, Spain). In the consideration of the most common allergens in a particular patient group, there is always the problem of the ubiquitous allergens, such as nickel, fragrance mix, and paraphenylenediamine, which may be but are not necessarily relevant for a particular patient group suffering from facial contact allergy. Therefore, we compared two patient groups: the first group suffered from contact
292
DOOMS-GOOSSENS
Clinics in Dermatology 1993:11:289-295
Figure 6. Photoallergic contact dermatitis resulting from use of an aftershave lotion containing musk ambrette.
dermatitis localized on the face only, the second group had allergic contact dermatitis on other parts of the body except the face. The allergens that occurred with a statistically significant difference (chi square analysis) in the first group compared with those occurring in the second group were taken into account. This provides a list of what may be considered “typical facial allergens.”
Results Of a population of 8877 patients tested in our contact allergy unit between January 1978 and July 1992, 4663 presented with a contact and/or photocontact allergy. Of these, 1542 (one third!) suffered from contact dermatitis on the face, occasionally including other body sites, and 480 (10.3%: 404 females, 76 males) had contact dermatitis exclusively on the face. In 277 cases, the forehead and/or cheeks and/or nose and/or chin and/or entire face; in 202 cases the eyelids; and in 136 cases the lips and/or perioral area were affected. This group of patients was compared with the group of 3121 patients (2124 females, 997 males) who suffered from contact dermatitis on other parts of the body. Table 2 lists the “typical allergens” encountered in patients suffering exclusively from a facial dermatitis. The allergens that were included gave a positive reaction in at least two patients.
Figure polish.
7.
“Ectopic” dermatitis resulting from the use of nail
The causal factors or sensitization sources were, in 188 cases, topical pharmaceutical products (iatrogenic cause); in 187 cases, cosmetics; in 166 cases, metal jewelry and appliances (eg, spectacle frames) and/or metal objects by which the face was affected through transfer by the hands (ectopic dermatitis); in 93 cases, profession-related substances; in 21 cases, household products; and in 17 cases, hobby-related substances. Of course, several causal factors or sensitization sources are possible for an individual patient.
Discussion Nickel is certainly a ubiquitous allergen in all patient groups in which females predominate and, thus, will be a coincidental finding in many patients suffering from intolerance to costume jewelry, but this may have no relevance whatsoever to the dermatitis being investigated. Although out of 186 nickel-allergic patients, 181 were female, a nickel allergy seems to be a statistically relevant finding in patients suffering from contact dermatitis on the face. This is due to contact with metal appliances such as spectacle frames and depilatory tweezers, costume jewelry such as earrings that come in contact with the cheeks, metal dental materials that provoke cheilitis,14 sucked-on articles such as pens, paper clips, and needles, and eye shadow contaminated with metal particles causing eyelid dermatitis. 15,16Moreover, the transfer of nickel
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Table 2. Typical “Facial”Allergens Allergen 1. Nickel sulfate 2. Neomycin 3. Tromantadine 4. Methyl (chloro) isothiazolinone 5. Benzoyl peroxide 6. p-Toluenesulfonamide formaldehyde resin 7. Benzophenylsalicylate (salol) 8. Chloroacetamide 9. Diazolidinylurea 10. Imidazolidinylurea 11. Oleamido propyldimethylamine 12. Benzophenone-3’ 13. Dimethylthiourea 14. Polymyxine-B sulfate 15. Phenylephrine l
Figure
8.
“Ectopic dermatitis”
resulting from primula,
particles by the hands to the eyelids in patients who frequently handle metal objects, such as cashiers, hairdressers, secretaries, and nurses, airborne’ and even systemic reactions to nickel that cause periorbital edema” are not uncommon sources of nickel-induced facial dermatitis. In only two of the five men with a contact allergy to nickel could the dermatitis have been relevant to the facial dermatitis and was thought to be caused by transfer. Among the “typical” facial iatrogenic allergens (see
Figure 9. An idlike spread of an allergic contact dermatitis elsewhere on the body.
Number of Cases 186 36 25 24 14 9 8 6 4 3 2 2 2 2 2
As a photoallergen.
Table 2), we found neomycin (often used in nasal and ophthalmic preparations), tromantadine (an antiviral agent that frequently causes contact cheilitis), benzoyl peroxide (used to treat acne), polymyxin-B sulfate (an antibiotic often used in association with neomycin to treat eye infections), and phenylephrine (a mydriatic and conjunctival decongestant used in ophthalmology). Cosmetics constitute another important source of facial contact dermatitis, particularly preservative agents, which represent the second most important cosmetic sensitizers after perfumes. la As typical causes of facial eruptions, we found the methyl(chloro)isothiazolinone mixture, which may sometimes give rise to unusual clinical pictures,* chloroacetamide, and the formaldehyde releasers diazolidinylurea and imidazolidinylurea. This is due mainly to their presence in products used for facial skin care (day and night creams, cleansers) and makeup (eg, foundations).*s Oleamidopropyl dimethylamine, a cationic emulsifier in a particular baby body lotion and frequently used as a facial cleanser for women, is a well-known sensitizer.19 Benzophenylsalicylate or salol used as a sunscreen was, in all cases, the cause of contact cheilitis because of its presence in a very popular brand of lipstick. Benzophenone-3, another sunscreen agent, was responsible for two cases of allergic photocontact dermatitis. As for cosmetic dermatitis, p-toluenesulfonamide formaldehyde resin, the allergen in nail polish, was the source in nine cases of “ectopic” contact dermatitis on the face. Finally, dimethylthiourea, an antioxidant present in diazo-sensitized paper,20 was found to be the occupation-related cause of an airborne contact dermatitis confined only to the face in two women working in the textile industry.
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A large range of other allergens that do not appear on the list of “typical” facial allergens should, of course, also be considered as potential causes of facial contact or photocontact dermatitis. We discuss only a few of the most frequently occurring ones here, most of which were related to cosmetics. Among the more important allergens are balsam of Peru (43 cases), which was found to be particularly related to contact dermatitis of the face in Edman’s study, in which chi square analysis was also used to establish the relationship between particular allergens and sites of contact dermatitis.21 Together with fragrance mix (40 cases), it expresses an intolerance to perfumed products applied directly to the skin such as aftershave lotions but also to substances conveyed by airborne or connubial contact. The eyelids are particularly prone to such involvement. A cobalt sensitivity was found in 42 cases, 38 of which were associated with nickel. Of the four women who reacted to cobalt only, one was a diamond polisher, her dermatitis clearly being a work-related airborne cobalt sensitivity’; two were suspected of reacting to eye cosmetics, although the cobalt content could not be verified; and the fourth patient had a dermatitis on her eyelids, the allergenic metal particles being conveyed by her hands. A paraphenylenediamine (PPD) sensitivity (35 cases) generally reflects a contact sensitivity to permanent hair dyes containing PPD itself or related dyes, which often cross-react with other p-aminobenzene compounds such as benzocaine (31 cases). Colophony (27 cases) is an allergen encountered in cosmetics such as eye makeupz2 or in relation to a perfume allergyz3; it may also be a source of dermatitis of plants and woods (eg, pine trees) and industrial materials, even by airborne contact.’ A contact allergy to wool alcohols (two cases) can be the result of facial cosmetic preparations, even though it is sometimes secondary to a topical medicament-induced sensitivity.18 Thiomersal (19 cases) is, in most cases, not a relevant allergen, but it may be a source of intolerance to eye cosmetics and contact lens solutionsz4 Potassium dichromate (10 cases) may be responsible for eyelid dermatitis, because of its presence in eye shadow, as well as of facial airborne dermatitis, because of cement (eg, Fig 5). Formaldehyde (eight cases) is a potential source of cosmetic sensitivity, including hair-care products such as shampoos, which may affect primarily the eyelids. The exact nature of facial allergens that might be found in different studies depends, of course, on many factors, including the nature of the substances tested (one can find only what one searches for, what one tests), but certainly also on the frequency of exposure and of use of individual products. A study of contact dermatitis reactions on the face conducted by the International Contact Dermatitis Computer Group and presented at the 8th
International Symposium on Contact Dermatitis in Cambridge (March 20 - 22,1986) gave some striking examples in this regard. Although most facial allergens observed were the same for the United Kingdom, Sweden, Germany, and Belgium, significant differences emerged with respect to some of them. For example, “typical” facial allergens in the United Kingdom were reported to be quatemium-15 and phosphorous sesquisulfide. Indeed, formaldehyde releasers like quatemium-1525 have frequently been reported to be causes of cosmetic facial dermatitis in the United Kingdom. (In contrast, the methyl(chloro)isothiazolinone mixture became a much more important allergen in this regard on the European continent in countries like The Netherlands, Belgium,26 Switzerland,*’ and Italy .*s The other striking example was phosphorous sesquisulfide, an allergen present in “strike-anywhere” matches, which are very popular in the United Kingdom but are not marketed in the Scandinavian countries or any other country in Western Europe. 29 They have caused many cases of facial dermatitis, particularly in men. There may be regional differences for many other allergens as well, and only comparisons between results obtained in different countries will reveal these differences.
Conclusions Contact dermatitis on the face is a frequent finding, particularly in women, and the many different allergens can be delivered to the face in several ways: by direct application or contact with allergenic surfaces, by airborne transfer, by connubial contact, and by transfer from other body sites. The reactions may also be photoinduced, the result of systemic exposure, or the result of an idlike spread of a contact dermatitis elsewhere on the body, The number of positive reactions to a particular allergen depends on its rate of occurrence in the environment and may or may not be occupation-related. In our patient series, the most common facial allergens were metals (nickel) and ingredients in topical medicaments and cosmetics, but substances such as professional and plant allergens cannot be ignored. Identification of the allergens, of course, depends on whether they are considered potential allergens in the diagnostic process and thus are sought. Moreover, there may be interesting differences from one country to another.
References 1. Dooms-Goossens AE, Debusschere KM, Gevers DM, et al. Contact dermatitis caused by airborne agents. J Am Acad Dermatol 1986;15:1-10.
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2. Morren M-A, Dooms-Goossens A, Delabie J, et al. Contact allergy to isothiazolinone derivatives: Unusual clinical presentations. Dermatology 1992;184:260-4. 3. Dooms-Goossens A, Dubelloy R, Degreef H. Contact and systemic contact-type dermatitis to spices. Dermatol Clin 1990;8:89-93. A, Swinnen E, Vandermaesen J, et al. 4. Dooms-Goossens Connubial dermatitis from a hair lotion. Contact Dermatitis 1987;16:41-2. c5* Dooms-Goossens A, Deleu H. Airborne contact dermatitis: An update. Contact Dermatitis 1991;25:211-7.
6. Herman P’S, Sams WM. Soap photodermatitis: Photosensitivity to halogenated salicylanilides. Springfield: Charles C Thomas, 1972. 7. Kroon S. Musk ambrette, a new cosmetic sensitizer and photosensitizer. Contact Dermatitis 1979;5:337-8. 8. Burrey JN. Persistent light reaction associated with sensitivity to musk ambrette. Contact Dermatitis 1981;7:46-7. 9. Schauder S. Literaturiibersicht iiber Unvertrlglichkeitsreaktionen auf lichtfilterhaltige Produkte van 19471989. Z Hautkr 1990;65:982-98. A, et al. 10. Morren M-A, Rodrigues R, Dooms-Goossens Connubial contact dermatitis: a review. Eur J Dermatol 1992;2:219-23. 11. Fisher AA. Unique features of nail polish dermatitis in contact dermatitis: Questions and answers. Part II. Cutis 1982;29:22. 12. Fisher AA. Systemic contact-type dermatitis. In: Contact Dermatitis. 3rd ed. Philadelphia, Lea & Febiger: 1986: 119 30. 13. Andersen KE, Hjorth N, Menne T. The baboon syndrome: Systemically induced allergic contact dermatitis. Contact Dermatitis 1984;20:97-120.
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16. Goh CL, NG SK, Kevok SF. Allergic contact dermatitis from nickel in eye shadow. Contact Dermatitis 1989;20:380-1. 17. McT Wilson AG, Gould DJ. Nickel dermatitis from a dental prosthesis without buccal involvement. Contact Dermatitis 1989;21:53. 18. Dooms-Goossens A, Kerre S, Drieghe J, et al. Cosmetic products and their allergens. Eur J Dermatol1992;2:465 -8. 19. de Groot AC. Oleamidopropyl dimethylamine. In: Adverse reactions to cosmetics (thesis). The Netherlands: State University of Groningen, 1988: 169-80. 20. Dooms-Goossens A, Boyden B, Ceuterick A, et al. Dimethylthiourea, an unexpected hazard for textile workers. Contact Dermatitis 1979;5:367-70. 21. Edman B. Sites of contact dermatitis in relationship to particular allergens. Contact Dermatitis 1985;13:129-35. 22. Karlberg AT, Liden C, Ehrin E. Colophony in mascara as a cause of eyelid dermatitis. Acta Derm Venereol (Stockh) 1991;71:445-6. 23. Hjorth N. Eczematous allergy to balsams, allied perfumes and flavouring agents. Copenhagen: Munksgaard, 1961: 137-40. 24. Bang-Pedersen N. Allergic contact merthiolate in soft contact lenses. 1978;4:165.
conjunctivitis from Contact Dermatitis
25. Ford GP, Beck MH. Reactions to Quatemium-15, Bronopol and Germall 115 in a standard series. Contact Dermatitis 1986;14:271-4. 26. Cronin E, Hannuksela M, Lachapelle J-M, et al. Frequency of sensitization to the preservative Kathon CG. Contact Dermatitis 1988;18:274-9. 27. Pasche F, Hunziker N. Sensitization to Kathon CG in Geneva and Switzerland. Contact Dermatitis 1989;20:115-9.
14. Temesvari E, Racz I. Nickel sensitivity from a dental prosthesis. Contact Dermatitis 1980;18:50-1.
28. Tosti A. Prevalence and sources of Kathon CG sensitization in Italy. Contact Dermatitis 1988;18:173-4.
15. Van Ketel WG, Liem DH. Eyelid dermatitis from nickel contaminated cosmetics. Contact Dermatitis 1981;7:217.
29. Cronin E. Contact dermatitis. Edinburgh/London/New York: Churchill Livingstone, 1980: 825 -8.