Abstract
Background:
Facial contact dermatitis is an emerging skin disorder due to the use of a large array of materials over the face. It leads to psychological distress in patients, impacting their quality of life. Most of the allergens applied over the face vary as per cosmetic or herbal products’ availability, usage, or religious practices. Identifying and discontinuing the implicated allergens will lead to a better prognosis and reduced morbidity in clinical practice.
Objectives:
To determine the frequency of different allergens responsible for causing facial contact dermatitis, in an urban part of central India, using patch test with the help of Indian standard and cosmetic series.
Materials and Methods:
All suspected patients (>18 years) of facial contact dermatitis visiting the outpatient department of dermatology were patch tested with both Indian standard and cosmetic series.
Results:
Out of 38/58 patch-test-positive patients, 71.06% were females, and 28.94% were males. Most patch-test-positive females were housewives. The most common allergens implicated were thiomersal (17.24%), followed by fragrance mix (15.51%), and paraphenylene diamine (12.06%).
Conclusion:
In our study, forehead and malar areas were most commonly involved indicating fairness creams and perfumes as the important contributors to facial contact dermatitis. Antigen batteries need to be updated with changing social and cultural trends, as many with a consistent history of aggravation with some products tested negative in patch tests.
Keywords: Contact dermatitis, cosmetic dermatitis, facial contact dermatitis, patch testing
Introduction
Dermatitis and eczema are the terms used in tandem to describe a group of disorders that are characterized clinically by redness of the skin and wet-oozy lesions, and histopathologically by intercellular edema (spongiosis) and neutrophilia in the epidermis, swollen capillaries in the dermis, and perivascular lymphocytic infiltrates.[1] One of the exogenous dermatitis is allergic contact dermatitis (ACD), which is an inflammatory skin reaction to direct contact with noxious agents or allergens in the environment or topical preparations.
Contact dermatitis affecting the face is a widely prevalent entity of cosmetic concern because of its visibility, resulting in distress to the patient, and affecting the quality of life. The allergens responsible for facial contact dermatitis differ in different geographical areas, depending on the patient’s age, gender, occupation, economic status as well as cultural environment. Most of these allergens are being applied quite frequently and many times, aesthetic practitioners encounter repeated complaints of facial dermatitis due to this continuous antigen exposure. This study was conducted to determine the frequency of different allergens implicated in facial contact dermatitis by using the patch test with the help of Indian standard and cosmetic series so as to reduce the morbidity associated with facial contact dermatitis.
Materials and Methods
A cross-sectional study was conducted in a tertiary care center in central India over a period of one and a half years. A well-informed bilingual written consent was obtained from clinically diagnosed adult patients with facial contact dermatitis, and they were recruited for patch testing after treating their ongoing dermatitis. A detailed history was recorded along with the clinical examination. Patients with a history of atopic dermatitis or seborrheic dermatitis affecting the face, receiving oral steroids, skin lesions over the back, and having active dermatitis were excluded from the study. The participants in the study were tested with standardized antigens of the Indian standard series and Indian cosmetic series (Systopic Laboratories Pvt. Ltd.® New Delhi) as approved and standardized by the Contact and Occupational Dermatoses Forum of India (CODFI). The readings were recorded at 48 and 72 hours.[2] All the observations were graded according to The International Contact Dermatitis Research Group, descriptive grading scale, 1970.[3] The relevance of a positive patch test has been classified into three categories: possible, probable, and certain.[4]
The dataset underwent analysis utilizing SPSS 21 software. To assess statistical significance, the Chi-square test and Fischer exact test were employed.
Results
Fifty-eight patients suspected of facial contact dermatitis were patch tested and analyzed. In our study, 39 patients were females and 19 were males. Age-wise analysis showed that 31.03% of patients belonged to the age group 31–40 years followed by 40–49 years and 50–59 years (20.69% each). The mean age (years) of the study subjects was 42.28 ± 13 years. It was noticed that 46.55% of patients were housewives followed by business personnel (10.34%), farmers (8.62%), laborers (8.62%), students (6.90%), office workers (5.17%), and teachers (3.45%).
Exposure to products containing the suspected allergens showed gender-wise variations with soap (used by 64.10% of females and 73.68% of males), face creams (used by 69.23% of females and 42.10% of males), and hair dye (used by 53.84% females and 63.15% males) being the commonest ones [Table 1].
Table 1.
Gender distribution of exposure to products containing allergens
| Product used/aggravating factors | No. of exposed males | No. of exposed females |
|---|---|---|
| Aftershave lotion | 5 | 0 |
| Artificial jewelry | 0 | 3 |
| Bindi | 0 | 3 |
| Deodorants | 6 | 11 |
| Face creams | 8 | 27 |
| Face wash and cleansers | 3 | 17 |
| Field dust | 3 | 1 |
| Foundation | 0 | 4 |
| Hair dye | 12 | 21 |
| Hair spray | 1 | 0 |
| Lip guard | 1 | 0 |
| Lipsticks | 0 | 15 |
| Mehndi | 0 | 1 |
| Oil | 5 | 1 |
| Perfume | 5 | 10 |
| Powder | 1 | 3 |
| Sindoor and Kumkum | 0 | 6 |
| Soap | 14 | 25 |
Positive patch-test results were seen among 38 patients (65.52%) out of 58 patients. Out of a total number of 3016 allergen patches applied in this study, positive reactions were obtained in 1.92% (58/3016) patches. Out of patch-test-positive patients, 27 were females and 11 were males.
Out of a total of 38 patch-test-positive patients, 65.78% (25) had facial and extra-facial involvement, while 34.21% (13) had only facial involvement. Even on the face, multiple sites were involved in many patients [Figure 1]. In patch-test-proven facial ACD patients, forearms (n = 10) were the most common site of extra-facial involvement, followed by hands and feet [Table 2].
Figure 1.
Distribution of facial site involvement in facial allergic contact dermatitis
Table 2.
Involvement of extra-facial sites in facial allergic contact dermatitis patients
| Involved extra-facial site | Number of Patients |
|---|---|
| Anterior trunk | 5 |
| Posterior trunk | 7 |
| Arms | 3 |
| Forearms | 10 |
| Hands | 9 |
| Thighs | 1 |
| Legs | 6 |
| Feet | 9 |
The most common allergen with patch-test-positive result was thiomersal (17.24%), followed by fragrance mix (15.51%), paraphenylene diamine (12.06%), parthenium (10.34%), cetrimide (6.89%), colophony (5.17%), nickel (5.17%), geranium oil (3.45%), musk mix (3.45%), thiuram mix (3.45%), and potassium dichromate (3.45%). Antigens that rarely showed patch test positivity were ethylene diamine, chlorocresol, Dettol®, diazolidinyl urea, neomycin, triethanolamine, jasmine mix, Fair and Lovely®, and coconut oil with camphor (n = 1 each) [Table 3]. Three products used by patients and suspected to cause facial ACD were patch tested “as is” and all three came positive for Dettol®, Fair and Lovely®, and coconut oil with camphor.
Table 3.
Frequency of positive allergen reactions observed during patch testing
| Allergens | Frequency |
|---|---|
| Thiomersal | 10 |
| Fragrance Mix | 9 |
| Paraphenylene diamine | 7 |
| Parthenium | 6 |
| Cetrimide | 4 |
| Colophony | 3 |
| Nickel | 3 |
| Geranium oil | 2 |
| Musk mix | 2 |
| Potassium dichromate | 2 |
| Thiuram mix | 2 |
| Chlorocresol | 1 |
| Coconut oil with camphor | 1 |
| Dettol | 1 |
| Diazolidinyl urea | 1 |
| Ethylene diamine | 1 |
| Fair and Lovely | 1 |
| Jasmine mix | 1 |
| Neomycin | 1 |
| Total | 58 |
Multiple antigen positivity was present in 14 out of 38 patients, out of which 28.94% (11) patients showed positivity to two antigens, two patients showed positivity to three antigens (5.26%), and single patient to six antigens (2.63%) which were present in noncontiguous Finn chambers. Out of the total 58 sites tested positive, 60.3% showed an intensity of 1+, 32.7% showed an intensity of 2+, and 6.89% resulted in a 3+ intensity. There were no irritant reactions.
We found that 19 patients showed positive patch-test reactions for allergens belonging only to the Indian standard series, 12 patients showed positive reactions only to cosmetic and fragrance series allergens, and seven patients showed positive reaction with at least one antigen belonging to both the series [Figure 2]. On analyzing the relevance of positive patch-test results, three positive patch-test results had certain relevance which was Dettol®, Fair and Lovely®, and self-made preparation of coconut oil with camphor.
Figure 2.
Comparison of allergen batteries for eliciting positive reactions in patients
Discussion
Contact dermatitis is inflammation of the skin induced by chemicals when they come in contact with the skin. ACD is a type IV delayed hypersensitivity reaction that requires prior sensitization with a genetic predisposition.[1] Patch testing is a very helpful, office-based procedure to elicit the culprit allergen. There are not many studies, particularly on facial contact dermatitis conducted in India, but most of the studies indicate to point prevalence ranging from 3.2 to 61.2%.[5,6,7,8]
In our study, the common age group affected and female predominance were similar to previous studies conducted on facial contact dermatitis.[9] This is probably because of more exposure to cosmetic products among females.
Risk factor evaluation for facial contact dermatitis and ACD in general in various studies showed the use of cosmetic products and occupational exposure as the most common causes.[5,7,10] Common cosmetic products responsible are face creams, hair dyes, lipsticks, soaps, perfumes, and shaving creams.[8,10,11]
There is a gender variability in the usage of cosmetic products with face washes, deodorants, perfumes, and hair dyes being used more commonly by females compared to males, and certain products like bindi, foundations, lipsticks, and artificial jewelry are used exclusively by females. The results in the present study were comparable to a previous study.[6]
The most frequent allergen-containing products causing facial dermatitis have been identified as bindi, hair dye, and facial creams.[5] Whereas Goel et al.[11] observed that the most common cosmetic products causing facial contact dermatitis were fragrances and perfumes in 40% of their study subjects, followed by soaps and shampoos (28%).
We found that in the majority of the facial contact dermatitis patients, facial involvement was associated with concurrent extra-facial involvement (65.78%); with forearms being the most common extra-facial site involved which was in agreement with the findings of a previous study.[6] This shows that a thorough cutaneous examination will help us to suspect and reach a diagnosis of ACD and can even indicate a possible allergen.
The commonest sites of involvement on the face were the forehead and cheeks followed by the neck, generalized facial involvement, periorbital areas, eyelids, ear lobules, and lips in our study [Figure 3a-c]. Rastogi et al.[12] had found the forehead as the most common site (50%) followed by the periorbital region (38%) and cheeks (30%) affected by facial contact dermatitis in a study conducted in Bareilly.
Figure 3.
(a) Erythematous plaque with crusting and ill-defined margin involving central forehead corresponding to the site of Kumkum application; (b) Slight erythema and edema involving eyelids and malar areas due to face cream; (c) Severe allergic contact dermatitis of the face involving bilateral malar and periorbital areas; (d) Patch test: 3+ positive for Dettol® (‘as is’ product tested) along with positivity for chlorocresol (1+) indicating the cross-reactivity
Out of a total number of 3016 allergen patches applied in our study, positive reactions were obtained in 1.92% (58/3016) patches compared to 3.2%, 3.75%, and 2.38% in previous studies.[6,7,12] The higher frequency of patch-test positivity in the other studies could be because those studies were conducted in larger urban centers where the use of cosmetics is more common, especially among women.
In the present study, the most common allergen to show a positive reaction was thiomersal followed by fragrance, paraphenylene diamine, parthenium, cetrimide, and others. Thiomersal (Merthiolate or sodium ethylmercurithiosalicylate) is an organic compound of mercury widely used as a preservative in face creams including fairness creams (Fair and Lovely®), Kumkum, etc.[13] Thiomersal is produced by the reaction of ethyl mercuric chloride with thio-salicylic acid.
Fragrance mix was the second most commonly implicated allergen in our study. Fragrances and perfumes mainly consist of fragrance mix, balsam of Peru, and preservatives with fragrance mix being the most common cause of allergic contact dermatitis. Fragrances account for almost 40% of cases of ACD due to cosmetics.[14,15] The standard series of patch tests contain eight perfume components and can easily detect up to 70% of all perfume allergies.[16] Preservatives in perfumes implicated in ACD are formaldehyde, formaldehyde releasers (imidazolidinyl urea, quaternium 15), and non-formaldehyde releasers. These are present in almost all cosmetic preparations.
Paraphenylene diamine (PPD) was the third most common allergen implicated in facial ACD in the present study which is similar to the findings of the study conducted by Mehta et al.[5] PPD is used widely as a permanent hair dye, but it also shows cross-reactivity with other dyes (aniline and azo), para-amino-benzoic acid, hydroquinones, and sulfonamides.[14] This cross-reactivity could also be a reason behind the increased frequency of PPD allergy.
One of our patients showed a definite relevance with 3+ grade patch-test positivity to both Dettol® liquid and chlorocresol [Figure 3d]. Cross-reactivity of chlorocresol has been reported with chloroxylenol (p-chloro-m-xylenol), another preservative with a very similar chemical structure. Dettol® liquid has chloroxylenol as an ingredient. Lewis and Emmett speculated that this cross-reactivity occurred only when the initial sensitization was to chloroxylenol rather than chlorocresol.[17]
We found that 50% of patch-test-positive patients showed positivity to the cosmetic and fragrance series, out of which 31.5% showed positive patch-test reactions only to the allergens of the cosmetic and fragrance series. This shows that the antigen profile implicated in facial contact dermatitis is changing constantly with time due to the emergence of new cosmetic products. Hence, cosmetic and fragrance series should also be included as a part of routine patch testing along with the Indian standard series in cases of facial ACD patients.
Conclusion
Exposure to face creams could be a reason for the preponderance of facial ACD among females. Forehead and malar areas are more frequently involved as these are the common areas of application of personal usage products. Widespread use of fairness creams could be a contributing factor for increased sensitization to thiomersal and increased prevalence of facial ACD. Patch testing with suspected products used by patients helps to establish the definite relevance of patch tests. Antigen batteries need to be updated constantly as the antigens implicated in facial ACD are also changing constantly with time, with the introduction of new cosmetic products.
Ethical statement
The study was approved by the Institute Ethics Committee on 02/03/2019 with approval number AIIMSRPR/IEC/2019/238. Well-informed bilingual written consent was obtained from study subjects.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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