Alternate Light Source Findings of Common Topical Cosmetics and Three Removal Methods

Abstract

Introduction:

Alternate light sources (ALS) are a tool used by forensic nurses to aid in the physical examination of patients. Prior research has demonstrated some topical make-up products absorb alternate light similar to the absorption noted in bruises. Therefore, the purpose of this study was: 1) to further examine the ALS findings of multiple brands and types of make-up products, and 2) to compare the efficacy of three methods of make-up removal.

Methods:

Fourteen make-up products were applied to the forearms of 100 healthy adult volunteers with varying skin tones then assessed under white light, six alternate light wavelengths, and three color filters producing 19 total wavelength and filter combinations. The results were recorded prior to and following removal procedures by forensic nurse examiners who were blinded to the removal method. A three-arm randomized controlled trial of make-up removal methods (soap and water, isopropyl alcohol swab, make-up removal wipe) was conducted with the participants.

Results:

All 14 make-up products produced absorption in at least 10% of the observations. Fluorescence was observed in more than 10% of the observations for only two products. Following product removal, four products continued to produce statistically significant absorption findings when viewed under an ALS. One product produced significant fluorescence following removal procedures. There were no statistically significant differences between the removal methods noted in any of these analyses.

Conclusion:

Our findings support the importance of using alternate light as one component of a comprehensive forensic examination including history taking and physical examination.

Introduction

Victims of violence may experience a range of physical injuries. Cutaneous bruising from blunt, compressive, or squeezing force trauma is one example. The assessment and documentation of bruises by forensic nurse examiners (FNEs) is part of a comprehensive medical forensic exam and has the potential to provide crucial medicolegal evidence.

When alternate light is shined on an object or part of an object, it can create three different light interactions: absorption (object/area is darker), fluorescence (object/area is brighter), or oblique lighting (small particle evidence is elucidated) and is commonly used in various crime scene investigations (Horiba, n.d., Lupica, 2017). Alternate light sources (ALS) are an emerging technology (U.S. Department of Justice, 2013) that have been used to improve visualization of bruises seen in white or ambient light (Limmen et al., 2013); visibility of strangulation-related bruises not readily seen in white light (Holbrook & Jackson, 2013); and intentionally created latent bruises (Lombardi, Canter, Patrick, & Altman, 2015). Using alternate light in the violet to blue wavelengths (440nm to 470nm) with yellow and orange filters was statistically effective (p < 0.0001) in visualizing blood purposefully injected just below the skin of a pig which was not visible or barely visible to the naked eye in white light (Olds, Byard, Winskog, & Langlois, 2016).

The efficacy of using alternate light compared to white light to enhance the assessment of induced bruises was recently established in a longitudinal, randomized controlled trial (Scafide, Sheridan, Downing, & Hayat, 2020). After institutional review board approval, 157 individuals consented to receive two intentional bruises: one to a randomly selected forearm from a dropped 6-ounce ball bearing down a 5-foot (1.52m) plastic tube; and the second from the applied pressure of a paintball fired to the upper lateral arm from a distance of 20 feet (6.1m).

The study found the escaped hemoglobin from the upper arm bruise had a five-times and four-times better likelihood of being seen at 415nm and 450nm, respectively, with a yellow filter compared to white light. Using alternate light allowed the research team to visualize the escaped blood as absorption (versus fluorescence) even when the bruises were no longer visible to the naked eye in white light (Scafide, Sheridan et al., 2020). This study demonstrated the utility of ALS in visualizing bruises. It may be the catalyst for more forensic nursing programs to begin using alternate light in their injury assessments of patients of all skin tones who report acute or recent blunt or squeezing force trauma.

However, ALS should not be used as a diagnostic tool for bruising (Scafide, Sheridan et al., 2020). Of the potential participants (n=238) screened for the Scafide, Sheridan et al. study, many had to be excluded secondary to absorption of alternate light at the intended bruise sites due to pre-existing skin lesions such as old scars, healing abrasions, tattoos, large moles, and excessive freckles (D. Sheridan, personal communication, April, 2020). Similarly, Olds et al. (2017) research with cadavers found hemangiomas also produced positive absorption findings under alternate light.

In addition to the dermatologic findings noted above, topical products have been found to fluoresce or absorb alternate light, especially when viewed at 415nm and 450nm using an orange filter (Pollitt et al., 2016). In this study, 14 over-the-counter topical products were applied to the forearms of 81 adults, then examined with a HandScope® Xenon HSX 5000 alternate light using six wavelengths: UV (ultraviolet) [310nm – 390nm], CSS [440nm - 520nm], 415nm, 455nm, 515nm, and 535nm) and three filters (yellow, orange, and red). One product in the study, a make-up, absorbed alternate light in 80.9% of observations. This supports the use of alternate light to identify self-applied topical products or the transference of foreign substances from an assailant to a forensic patient (Pollitt et al., 2016; Elkins, 2011; Bisbing & Schneck, 2006). In addition, this finding again highlights the need for alternate light to be used in conjunction with patient history and exam findings under ambient light.

Pollitt and colleagues (2016) recommended cutaneous sites that fluoresce or absorb alternate light be first swabbed for potential evidence, gently cleaned, and re-examined with alternate light to determine if the positive finding persists. Given the high rate of ALS absorption of the make-up product in their findings and how common make-up use is, the researchers recommended additional make-up products be tested on participants with various skin tones using various alternate light waves and color filters. Therefore, the purpose of this study was to follow those recommendations by examining a variety of common make-up products under alternate light to assess for the following: (a) fluorescence or absorption of alternate light; and (b) for products with alternate light findings, to compare the efficacy of three common methods of removing topical products readily available to forensic nurses in clinical practice.

Methods

Overview and Setting

This study was conducted at Mercy Medical Center (MMC), in Baltimore, Maryland after approval by the facility’s institutional review board. A cross sectional descriptive design was used to examine ALS findings of 14 common make-up products and to examine the efficacy of three methods of removing the products from skin. Based on prior research findings, it was hypothesized make-up products would show positive alternate light absorption.

Participants

A convenience sample of 100 healthy adult participants was recruited from the MMC campus through flyers and word of mouth. Eligible participants were at least 18 years of age and able to provide written informed consent. Exclusion criteria included: (a) observable skin conditions or lesions to the forearm in ambient light (e.g., tattoos, fungal infections, psoriasis, scars, sunburn, acne, injury); (b) application of self-tanning cream, spray tan, or tanning accelerator within the past two weeks; and (c) self-reported allergy to cosmetic make-up products. Individuals who were admitted to MMC as patients or were being evaluated as patients at the MMC Emergency Department at the time of data collection were not eligible to participate. Potential participants also completed a pre-screening examination of their forearms for positive findings under ambient light and alternate light, prior to data collection. Participants were compensated with a $5 gift card for their participation.

Measurement Procedures

After providing informed consent, participants completed a demographic screening to ensure they met the inclusion criteria. Researchers then measured the Individual Typology Angle (ITA°) of each eligible participant, using a handheld Konica Minolta CM-700d spectrophotometer, an instrument with demonstrated reliability for skin color measurement (Lee et al., 2008) and intra and inter-examiner reliability in bruise colorimetry measurements (Scafide, Taylor, Sheridan, & Hayat, 2016). Measurements were taken from the anterior surface of each individual’s forearm, in the approximate location where test substances would be applied. Three measurements were taken and averaged by the spectrophotometer to determine the participant’s assigned ITA° value. Each participant was categorized into one of six recognized categories of skin tone (dark, brown, tan, intermediate, light, and very light) as determined by their ITA° value (Del Bino, Sok, Bessac, & Bernerd, 2006).

Using a single-use cardstock grid with pre-cut ½ inch holes, 14 different topical agents were applied (seven to each forearm) with a single use cotton tipped applicator per product to prevent cross contamination. The location of each product was identical on all subjects and all products were allowed to air dry prior to completing any further assessment. All 14 products (see Table 1) were chosen to represent a range of skin tones and product types. In order to minimize findings that would potentially result from skin color-product mismatch, two shades of make-up were used for each product: (a) one in the fair, light, medium complexion range (“light”) and (b) one in the medium, dark, very dark complexion range (“dark”). Based on their ITA° measurement and grouping, participants had either all “light” or “dark” products applied. All products were commercially available on the shelves at local stores at the time of data collection and were selected to be typical “drug store” make-up products (for additional information on the products used, including full listing of ingredients in each product (see Supplemental Digital Content 1).

TABLE 1.

Products

Product Number	Product Name
1L, 1D	Covergirl® Smoothers Pressed Powder
2L, 2D	Covergirl® Professional Loose Powder
3L, 3D	Maybelline Fit Me® Pressed Powder
4L, 4D	L’oréal® True Match™ Super Blendable Foundation Makeup
5L, 5D	Wet n Wild® Fergie BB cream 8-in-1 beauty balm glam maker SPF 15
6L, 6D	Maybelline® Dream Liquid™ Mousse Foundation
7L	Covergirl® Clean Invisible Concealer
7D	Covergirl® Queen Natural Hue Concealer
8L, 8D	Maybelline® Dream Matte® Mousse Foundation
9L, 9D	Covergirl® Clean Oil Control Anti-Luisance
10L, 10D	Rimmel® Lasting Finish Lipstick
11L	Wet n Wild® Coverall® Coverstick
12	Sally Hansen® Water Resistant Airbrush Legs® Makeup Lotion
13	Wet n Wild® Coloricon™ Bronzer SPF 15
14	Wet n Wild® Fergie Centerstage Collection Around-the-Clock Blush

Notes: L=light shade, D=dark shade. Noted where applicable.

Once the make-up was dry, researchers used a HandScope® Xenon HSX 5000 ALS, which emits various wavelengths of light via a rotating wheel, to assess each forearm for fluorescence and/or absorption in a darkened room. Observers recorded the presence of fluorescence, absorption, and/or no finding per each make-up application site. The assessment included observations under all six wavelength settings: UV (310nm - 390nm), 415nm, 450nm, 515nm, 535nm, and CSS (440nm - 520nm) using yellow, orange, red filters for all wavelengths and an additional clear filter for UV producing 19 total wavelength and filter combinations.

For the make-up removal phase, participants were computer randomized into one of the three product removal groups readily available in most hospital settings: (a) soap (MEDI-STAT™ Antimicrobial Hand Soap) and water, (b) 70% isopropyl alcohol wipes (COVIDIEN™ Webcol™ Alcohol Prep), and (c) commercial make-up wipes (Studio 35 Beauty™ Cleansing Towelettes). Product removal methods were chosen based on the likelihood of these methods being available for forensic nurses to utilize in a clinical setting. Each removal method was completed with the primary goal of removing any product visible in white/ambient light. For participants randomly assigned to alcohol swab or make-up remover groups, study staff removed the products. However, participants assigned to the soap and water group cleaned their own forearms while supervised by study staff. The nurse observers who used the ALS to make post-removal assessments were blinded to the removal methods used by each participant. Post-removal, the participant’s skin was re-examined under white light and all previously mentioned alternate light waves and filters for residual fluorescence and absorption.

Interrater Reliability

All data collectors were licensed FNEs and clinically proficient in the use of an ALS. For every tenth participant, observations were completed by two researchers, in order to assess interrater reliability which was calculated using an interclass correlation kappa (ICC = 0.728) (Mandrekar, 2011; Polit & Tatano Beck, 2018). This value represents moderate to good agreement between the two observers for the 350+ observations completed by two nurses.

Data Analysis

Participant demographics, and alternate light source findings were reviewed using descriptive statistics. Hypothesis testing to examine two key questions was conducted. We first examined differences in mean number of positive findings between the three make-up removal methods. Then, we examined the mean number of positive findings post-removal of the 14 products (inclusive of all three cleansing methods) for differences. One-way ANOVA procedures were used for each set of hypothesis tests with significance levels for these tests were set a priori at 0.05. In order to present findings from the study in a clinically meaningful way, results and associated tables have been transformed to percentage of positive findings. Analyses were conducted with SPSS Version 24 (IBM Corporation, 2016) and Stata 12 (StataCorp, 2011).

Results

Participants ranged from 20 – 72 years old (mean 39.81) and were predominantly female (80%, n=80). No statistical differences in key variables (skin color grouping, sex, age) were noted between the three randomly assigned removal methods. See Table 1 for additional information on participant demographics. All 14 make-up products produced absorption results in at least 10% of the cumulative observations (e.g., all wavelengths, all filters), while fluorescence was observed more than 10% of the time for only two products (see Figure 1, Products 10 & 14), and between 1-3% of observations for an additional five products (see Figure 2, Products 3, 4, 5, 11, & 13). Following product removal, four products continued to produce statistically significant absorption (Products #4 p=0.001, #6 p<0.001, #7 p=0.004, & #8 p<0.001) when viewed under an ALS (see Figure 2), while one product continued to produce significant fluorescence (Product 10 p<0.001, see Figure 1). Findings by wavelength and filter combination were also examined, with rates of positive fluorescence ranging from 0 (535nm-yellow & UV-red) – 10% (535nm-red) and absorption from 4.2 (535nm-orange) - 60% (UV-Clear). See Figures 3 and 4 for results of all 19 wavelength and filter combinations.

FIGURE 1.

Fluorescence Findings by Product

FIGURE 2.

Absorption Findings by Product

FIGURE 3.

Fluorescence by Wavelength and Filter Combination

FIGURE 4.

Absorption by Wavelength and Filter Combination

Products 10 and 14 performed similarly overall, but performed differently than the remaining products with a large proportion of positive fluorescence observations and smaller number of positive absorption observations. Thus, analyses for comparing removal methods were conducted including all 14 products and with products 10 and 14 as their own category. Table 3 shows these results. There were no statistically significant differences between the removal methods noted in any of these analyses.

TABLE 3.

Proportion of Positive ALS Findings by Removal Method

	Makeup Wipe	ETOH Wipe	Soap and Water	p-value*
After Application
All Products
Florescence	4.74	4.74	3.68	0.117
Absorption	52.63	55.26	52.11	0.431
All Products Except 10 & 14
Florescence	0.53	1.05	0.53	0.463
Absorption	58.42	60.53	58.42	0.749
Only Products 10 & 14
Florescence	27.37	28.42	24.74	0.093
Absorption	18.95	25.26	15.26	0.003
After Removal
All Products
Florescence	1.05	1.05	0.53	0.564
Absorption	2.63	1.58	3.16	0.211
All Products Except 10 & 14
Florescence	0	0	0	-
Absorption	3.16	2.11	3.68	0.250
Only Products 10 & 14
Florescence	5.79	5.26	5.26	0.691
Absorption	0.53	0	1.05	0.281

^*p values presented for one-way ANOVA.

Discussion

Our findings add to the growing research on the use of ALS in clinical forensic examinations. Alternate light has been used to measure skin and hair color (Shriver & Parra, 2000) and has been used to evaluate scars (Draaijers et al., 2004; Micomonaco et al., 2009). In 2004, alternate light was found useful in demonstrating the presence of hemoglobin and its degradation in bruises (Hughes, Ellis, Burt, & Langlois). Members of this same research team found alternate light was not useful in determining the age of bruises (Hughes, Ellis, & Langlois, 2006). Waryk and Odell (2005) applied the following self-provided products to the forearms of eight volunteers: semen, blood, and saliva, and used a variety of ALS products to test for fluorescence. In addition, each subject had applied to their skin several sexual lubricants and two hand creams. None of saliva, lubricants, or hand creams visibly fluoresced under any of the light sources. The blood placed on the skin absorbed light around 430nm and appeared black (Waryk & Odell, 2005).

Limmen et al. (2012) found alternate light could enhance the visibility of bruises seen in visible (white) light. Holbrook and Jackson (2013) found, retrospectively, that alternate light was helpful in detecting strangulation-related bruises not visible in white light. However, Lombardi et al. (2015) found white light to be more specific to identifying bruises they created by dropping a 4-ounce ball bearing onto participants’ forearms. Studies where alternate light was found helpful in enhancing bruise observations did not control if the positive findings were related to the bruise itself, topical products or pre-existing skin lesions (Holbrook & Jackson, 2013; Mimasaka, Oshima & Ohtani, 2018). Recent research used an ALS to view induced bruises in living participants (Scafide, Sheridan et al., 2020) or to view injected hemoglobin in pig and cadaver models focused on determining which wavelength and filter combinations worked best to view sub-dermal hemoglobin (Olds et al., 2016; Olds et al., 2017).

Similar to prior research findings, we found wavelengths in the 400nm - 500nm range (415nm, 450nm) using yellow and orange filters performed best among those tested. However, we also found a UV wavelength (360nm) worked well for identifying absorption of some topical products in contrast to prior work which examined known sub-dermal findings. While a definitive reason for this is unknown, it may be related to the topical verses sub-dermal nature of the findings. Another potential rationale is that some products included in testing (products #5 and 13) contained UV protective ingredients.

Clinical Implications for Forensic Nursing

The findings of this study are consistent with prior research (Pollitt et al., 2016) which demonstrated that some make-up products, when applied to a variety of skin tones, will absorb or fluoresce under alternate light. This has clinical implications for FNE programs that have incorporated (or will be incorporating) ALS assessments of injuries or to identify trace evidence on the skin not visible in ambient light. Currently, it is a standard of practice to swab areas of the skin that fluoresce during a forensic exam for trace evidence analysis in the lab (Department of Justice, 2013). However, topical products with positive absorption under alternate light may mimic the absorptive findings of hemoglobin under the skin post blunt, compressive, or squeezing force trauma. Thus, the authors believe the following clinical steps during forensic examination should be considered (see Figure 5: Clinical Implications).

FIGURE 5.

Clinical Recommendations

If the patient’s presenting history includes any blunt, squeezing or crushing force trauma, the FNE should ask the patient if they applied any cosmetic products to those areas since the last time bathing or showering. Some patients may have purposely applied make-up products to conceal visible injury sites from others. Others may have applied make-up products as part of their daily skin care prior to the reported assault. If known, the type and brand name of any topically-applied products should be documented. In addition, the FNE needs to consider that any area of absorption and/or fluorescence may have been transferred to the patient by the reported assailant.

The goal of the FNE is not to identify and document in the medical record a topical product type or brand, but rather, to note whether one or more topical products had been recently applied by the patient prior to an ALS examination to aid in interpretation of findings. Swabs of areas of the body that absorb or fluoresce may provide crime labs with enough trace evidence for further chemical analysis, if needed. Of the 14 products used in this study, a few demonstrated a pattern more likely to fluoresce versus absorb. Products with a shimmer or glitter component such as lipsticks and blushes tended to fluoresce. Liquid-based foundations and concealers, including those with SPF (sun protection factor) protection, more consistently absorbed. Pollitt et al. (2016) found sunscreens also produce absorption at a significant rate, primarily under UV light. Of note, some products had both fluorescent and absorptive qualities.

During the ALS body examination, any areas with positive findings for either fluorescence or absorption, should first be photographed as well as documented on a body map. Any ALS-positive area should then be swabbed for trace evidence per the program’s swab evidence protocol. Gentle cleansing of the area is then recommended. Our study findings suggest all three cleansing methods exhibited similar efficacy (soap and water, 70% isopropyl alcohol wipes, or commercial make-up remover wipes). After cleansing, the area of fluorescence and/or absorption should be reevaluated with an ALS and the post-cleaning findings documented again by photographs and body maps.

Limitations

While this study adds to the science of identifying which topical products may produce positive ALS findings with persons of various skin tones, it has several limitations. The sheer volume and ever-changing nature of cosmetic and topical products suggests that forensic nursing research will never be able to catalogue all of the products patients may have on their skin. This study and its predecessor (Pollitt et al., 2016) present only a snapshot of common skin products. Further research that examines physical and chemical properties of the products that produce fluorescence and absorption findings may be particularly beneficial in helping forensic nurses apply those principles broadly.

How make-up is routinely used by individuals in the course of daily skin care is not the same as it was used in this study. The tested products were applied to the skin with the intent to be easily identifiable in ambient light in a localized area verses thinly spread to blend with the surrounding skin tone as is typical in make-up use. This variation is important to consider when examining patients as clinical findings may not be as distinct or demarcated as found in this study. Appropriate inquiry and documentation of each of these potential sources when findings are noted is warranted.

In addition to this study’s convenience sample of products, we also used a convenience sample of participants, largely staff employed at one urban hospital setting. The sample was not powered to represent all skin tones and the subjects were predominantly female. We found no references that topical products would interact with alternate light differently based on one’s sex. Variations based on one’s sex and localized fat were noted to impact examination findings when using ALS to examine induced injuries (Scafide, Sheridan et al., 2020). The study by Pollitt et al. (2016) found variation in the ability to detect absorption findings from topical products on dark skin-toned individuals.

Another limitation is the study team did not record white light observations of the tested products. Anecdotally, most of the products when initially applied, did produce a visible ambient light finding on the majority of participants. This was not a universal finding and cannot be quantified for our current data. Similarly, some products were more difficult to remove from some individuals than others. In future research, accurate measurements of the exact volume of the topical products that were applied would be helpful as well which products were more or less visible in ambient light.

Further research is needed to determine if the various ALS products on the market perform similarly to the ALS unit used in this study. We posit that light sources with varying degrees of intensity and filter lens of varying shades in ambient light may impact ALS findings. Further research is needed to explore if these variations have an effect on identifying topical product absorption and fluorescence.

Conclusion

This study adds to the growing body of literature regarding topical products, bruising and ALS examinations. Studies support the efficacy of using 415nm and 450nm wavelengths with yellow and orange filters to significantly improve detection and visualization via absorption of unintentionally and intentionally created bruises (Hughes et al., 2004; Mimasaka et al., 2018; Scafide, Sharma, et al., 2020; Scafide, Sheridan et al., 2020). The findings from this study support the use of the same wavelengths and filters used by Scafide, Sheridan et al. to detect absorption of intentionally applied topical make-up products. In addition, this study found using UV light (approximately 360nm) with clear and yellow googles to be helpful in identifying absorption of intentionally applied make-up products.

While this study excluded participants with observable skin conditions or lesions (e.g., tattoos, fungal infections, psoriasis, scars, sunburn, acne, injury, moles, freckles), in clinical practice, we believe alternate light should be used with all forensic patient examinations. Our findings support the importance of using alternate light as one component of a comprehensive forensic examination including history taking and physical examination. We concur that an ALS, as previously reported, is not a diagnostic tool (Lombardi et al., 2015, Pollitt et al., 2016, Scafide, Sheridan et al., 2020) and positive ALS absorption findings are not pathognomic of bruising. However, positive ALS absorption findings could be documented as being consistent with reported blunt or squeezing force trauma when correlated to the overall clinical findings and history.

TABLE 2.

Participant Demographics (%, [n])

	Makeup Remover Wipe	Soap and Water	Alcohol Wipe	p**
Sex				0.455
Female	35.0 (28)	25.0 (20)	40.0 (32)
Male	36.8 (7)	36.8 (7)	26.3 (5)
Age*	41.4 (36)	35.3 (27)	41.5 (37)	0.101
Skin Color Category				0.082
Very light	40.0 (6)	33.3 (5)	26.7 (4)
Light	29.2 (14)	27.1 (13)	43.8 (21)
Intermediate	50.0 (10)	10.0 (2)	40.0 (8)
Tan	66.7 (4)	0.0 (0)	33.3 (2)
Brown	20.0 (2)	60.0 (6)	20.0 (2)
Dark	0.0 (0)	1 (1)	0.0 (0)

^*mean, n

^**p value for age represents a t-test for difference in means, sex and skin color category chi-square for difference in proportions.