issue 06 all things contact dermatitis™ DECEMBER news & notes 2013

in this issue

To Dye For: PPD and Other Allergenic Ingredients in Hair Dyes P1

Blame it on the Spice Girls: Henna Tattoos and Sensitization to PPD P3

To Dye For: PPD and Other Allergenic Ingredients in Hair Dyes

Dear Reader, This issue focuses on the highly sensitizing allergen, para-phenylenediamine or PPD. It is a common ingredient in hair dyes and the dyes used for temporary tattoos, he blue-black aniline dye, para-phenylenediamine (PPD), is a potent allergen where its unregulated use threatens to Tcommonly found in permanent and semipermanent hair dyes. As many as increase the risk of sensitization around 75% (or more) of women and a third of men may dye their hair at some point the world. We hope these summaries of more in-depth reviews help you explore during their life. The popularity and simplicity of this cosmetic modification the causes of contact dermatitis in your ensure that the risk of being sensitized to PPD is relatively high. Not surprisingly, own practice. that risk increases for hairdressers among whom PPD is a known and robust occupational allergen. In fact, in North America PPD is one of the top 10 We support another venue, a CME- accredited annual patch test workshop, allergens with a prevalence rate of about 5% while in Europe it ranks in the top intended to improve your expertise with five (prevalence rate depending on region, 3.5-7%). PPD even finds its way onto “all things contact dermatitis.” Topics the international top 10 list of pediatric allergens with a prevalence that ranges range from patch test basics and hands-on between 2 to 5%. Common symptoms produced by PPD in hair dyes include exercises to advanced sessions. We are facial or scalp rashes, facial edema, and hand eczema. excited about the third annual workshop, which was held in Phoenix at the end of October. First, the conference was sold out PPD, however, is not the only allergenic ingredient in hair dyes, which may be with more than 150 physicians, nurses, and composed of dozens of chemicals. Recently, a large study of PPD and other medical students in attendance! Second, ingredients in hair dyes in almost 3000 patients with eczema at 12 centers (11 in the overall ratings of the national and Europe and 1 in the United States) was reported. Perhaps not surprisingly, the international speakers were excellent, and rate of positive reactions associated with PPD was the highest—4.5%—followed the comments from attendees speak for themselves: “I am leaving today with so by positive reactions to toluene-2,5-diamine (PTD, 2.8%), p-aminophenol much more knowledge than when I came.” (1.8%), m-aminophenol (1%), and resorcinol (0.1%). Although these four other “...this conference proved, of course, there ingredients are known allergens, they have received far less attention than PPD is much more to learn (about patch testing).” in the literature. Altogether, the frequency of positive reactions to one or more Participants also shared plenty of good of these substances was 5.3%. advice to help us improve the conference, which we are already busy planning for next The concordance between PPD and PTD, p-aminophenol, and m-aminophenol year. Whether you are a beginner or an was high, ranging from 80 to 87%. This finding indicates that PPD can expert, consider joining us next October. effectively screen for allergies to these other chemicals. Nonetheless, testing Together, we can advance the diagnosis of with only PPD could miss about 13 to 20% of individuals with allergies to these allergic contact dermatitis. other ingredients. Consequently, the authors argue for testing with a patient’s Kind Regards, personnel hair dye product to ensure identification of the underlying allergen. Dr. Curt Hamann Continued on next page President & CEO, SmartPractice

1 To Dye For: PPD and Other Allergenic Ingredients in Hair Dyes…continued

Because many patients may be reluctant to stop dyeing their hair, awareness of specific allergens can help patients choose products free of their particular allergen (Tables 1 and 2). If patients refuse to stop dyeing their hair, they should be cautioned to have their hair dyed in a salon by a professional who may minimize contact between PPD-containing products and their skin by the use of appropriate barriers.

The study also tested 22 other ingredients whose allergenic potential was unknown. There were no positive responses to 11 of these substances. Of the remaining 11 ingredients, rates of positive reactions ranged from 0.1 to 2.2%. p-methylaminophenol, which was associated with the highest rate (2.2%), showed no concordance with PPD. Four substances (4-amino-2-hydroxytol- uene; 2,4-diaminophenoxyethanol HCl; 4-amino-m-cresol; and N, N'-(2-hydroxyethyl)-p-phenylenediamine) exhibited almost complete concordance with PPD. This finding is interesting because only one of these substances is classified in the same chemical cluster (i.e., share similar physicochemical properties) as PPD. The implication is that not all cross reactions depend on structural similarities between compounds.

Of the patients with contact allergies to one of the 5 previously known allergens, 14% were hairdressers, reemphasizing the high risk for these workers, many of whom are eventually forced to abandon their career. Although dyeing hair is the main cause of allergies to PPD, sensitization can also result from exposure to henna, leather and fur, textiles, and some industrial rubber products. Concern that patch testing with 1% PPD in petrolatum can lead to active sensitization has even led the German Contact Dermatitis Group to call for patch testing with 0.35% PPD instead. Based on the size of Finn Chambers and other patch test systems, this smaller dose is similar to the dose of PPD/cm2 currently found in T.R.U.E. TEST, which represents an alternative to patch testing with the allergen in petrolatum. Although the debate over the appropriate dose of PPD may take a while to resolve, the consensus that PPD is an important allergen for patch testing remains.

Table 1. PPD-Free Products for Coloring Hair† Table 2. Phenylenediamines and Related Chemicals Product Type of Coloring Product Information Benzenediamine m-benzenediamine Palette by Nature™ Permanent Free of PPD, PPD derivatives, diamino-benzene m-diaminobenzene PTD, amines, ammonia, (United States) Available in all diaminobenzene m-fenylendiamin shades peroxide, resorcinol, parabens, phthalates, benzenediamine ethanedioate m-phenylene diamine and more phenylene diamine m-phenylenediamine Approved by American phenylenediamine meta-aminoaniline Contact Dermatitis Society and Mayo Clinic (CARD) as aminoaniline meta-benzenediamine one of the safes alternatives 6PPD meta-diaminobenzene to conventional hair color for chemically sensitive APCO 2330 metaphenylenediamine individuals aspartyl-pyridoxal-5'-phosphate p-aminoaniline Santotint Light Permanent Free of PPD, ammonia, C02454 p-benzenediamine (Italian) Available in blacks, and paraben browns, auburns, CI developer 11 p-diaminobenzene and blondes developer 11 p-fenylendiamin John Frieda® Temporary Free of PPD developer C p-phenyldiamine Brilliant Color Glaze Available in Contains developer H p-phenylene diamine (United States) brunettes methylchlorothiazolinone developer M p-phenylenediamine (MCI) and methylisothiazolinone (MI) direct Brown BR paraphenylen-diamine Clairol Loving Care® Temporary No PPD direct Brown GG paraphenylenediamine (United States) (6-12 shampoos) Do not confuse with Loving fenylenodwuamina PLP-ASP Care Cream, which does fouramine 1 PPD include PPD m-aminoaniline Renal PF Henna Semi-permanent Must be pure red henna (various countries) without the addition of PPD †This partial list is provided as a courtesy and does not constitute product endorsement. Reasonable efforts have been made to provide reliable data, but SmartPractice® cannot assume responsibility for the validity of all materials or for the consequences of their use. Because product ingredients may change, readers are advised to check the product information currently provided by the manufacturer of each product to verify the ingredients before making recommendations to patients. It is the responsibility of the treating physician, relying on experience and knowledge of the patient, to determine the best treatment for the patient, including product avoidance.

SØsted H, Rustemeyer T, Gonçalo M, et al: Contact allergy to common ingredients in hair dyes. Contact Dermatitis 69: 32-39, 2013

2 Blame it on the Spice Girls: Henna Tattoos and Sensitization to PPD

Red henna, the dried and powdered leaf of the small shrub Lawsonia inermis, has been used to decorate the body for thousands of years and represents little risk to humans. Given that half of the population of India is thought to be exposed to henna at some point during their life, its sensitizing potential appears to be minimal. Although 19 possible cases of allergic contact dermatitis have been reported, the presence of PPD and other aromatic amines as the causative agent(s) cannot be ruled out in some of the cases. Thus red henna is relatively benign. When PPD is added to red henna as a darkening agent, however, the situation changes dramatically.

Black henna tattoos may be perceived as “natural” and elen of Troy is said to have had a face that launched a as safe because the skin does not need to be penetrated Hthousand ships, but the British rock group, The Spice and infectious agents are not introduced. As a result these Girls, may have had the body tattoos that launched a temporary tattoos are especially popular among young thousand cases of allergy to para-phenylenediamine (PPD). people. Yet PPD is an extreme sensitizer—enough so that Specifically, allergic skin reactions to black henna tattoos the German Contact Dermatitis Research Group removed have been increasing since 1997 when these entertainers 1% PPD from their baseline series as discussed in the became extremely popular. As noted in the previous previous article. And the concentrations that consumers are article, hair dyes are the primary source of sensitization to exposed to in henna dyes far exceed 1%. The concentrations PPD. But temporary tattoos, applied by using a paste made of PPD (% wt/wt) in black henna samples tested by the from a mixture of PPD and red henna, are now thought Food and Drug Administration in the United States have to sensitize an estimated 2.5% of those exposed. Given ranged from more than 4 to 27%. Investigations have that only severe cases reach medical attention and that found that PPD concentrations in henna were as high as unregulated temporary tattoos applied by tattoo artisans 29% in the United Arab Emirates and soared to as high as are fashionable at vacation and holiday sites such as beaches 64% in Spain while in Germany the average concentration and amusement parks, the prevalence of sensitization was more than 6%. related to these tattoos is likely underestimated. Continued on next page

Strong Yet Comfortable Protection

• Moisture-resistant tape allows patients Get defined test results to shower and workout

with square • High adhesion keeps patch test panels chambers securely in place

• Thin tape is highly elastic, adding to patient comfort

• Moisture resistant

• Open and easy to pre-load

• Pre-fixed filter paper – ideal for both liquid and petrolatum allergens • Comfortable – elastic polyurethane tape allows for easier movement Available in 3 sizes Part #AL1701L (large), AL1701M (medium), AL1701S (small) Available in strips of 10 (2x5) • 100 strips per box Part # AL71300 EASY ORDERING I 800.878.3837 I smartpractice.com easy ordering l 800.878.3837 l smartpractice.com/dermatology

3 Blame it on the Spice Girls: Henna Tattoos and Sensitization to PPD…continued

Allergic contact dermatitis related to PPD is often confined to the site of the tattoo, appearing within 1-3 days in individuals already sensitized and within 4-14 days in those undergoing initial sensitization. Generalized dermatitis can also occur. Hypo- and depigmention have been reported, and hyperpigmentation lasting more than 6 months is relatively common. Localized hypertrichosis has also been observed. Besides these delayed Type IV reactions, PPD has been associated with life-threatening Type I immediate reactions such as edematous swelling of the airway causing respiratory distress and requiring hospitalization for emergency treatment.

Tattoos are widespread. A survey from Denmark found that a third of the respondents from the general population had tattoos and the proportion increased with related occupations (e.g., hairdressing apprentices) while in the United Kingdom 7% of 4000 adults and 14% of their children had had a temporary tattoo. The risk of sensitization to PPD from tattoos especially becomes a major concern for children. Besides hair dyes and henna tattoos, PPD is common in many products that may need to be avoided: leather, fur, textiles, black rubber, paints, and printing inks to name just a few. Occupational choices may be restricted because PPD is a common allergen in many professions ® such as printing; hairdressing; and the shoe, chemical, Make T.R.U.E. TEST leather, rubber, plastic, paper, and textile industries.

Although not of epidemic proportions, the prevalence of allergic contact dermatitis to PPD continues to increase. your first choice In the European Union (EU), this increase continues despite the launch of a campaign backed by the European for patch testing Commission to educate the public about the serious health Benefits of T.R.U.E. TEST: issues associated with black henna tattoos. In both the • Ready-to-Use: Pre-measured allergens require no staff prep time, EU and the United States, hair color is the only cosmetic eliminate mix-ups, contamination and ensure accuracy allowed to contain PPD. Nonetheless, most countries have • High rate of physician and patient satisfaction no regulations on the use of black henna in tattoos. In his • Effectiveness established in 10 clinical studies recent comprehensive review of henna tattoos on which this discussion is based, de Groot suggests that health legislation easy ordering: 800.878.3837 l truetest.com l smartpractice.com is needed to minimize the opportunities for sensitization to PPD. In the meantime, medical professionals need to be Click here to see the Full Prescribing Information aware of this growing public health problem and how to for T.R.U.E. TEST diagnose allergic contact dermatitis to PPD with patch testing, how to treat its many manifestations, IMPORTANT SAFETY INFORMATION and how to develop strategies to help INDICATIONS AND USAGE: WARNINGS AND PRECAUTIONS their patients avoid the allergen. Ultimately, T.R.U.E. TEST is an epicutaneous patch • Acute allergic reactions, including intensive education of the public will be test indicated for use as an aid in the anaphylaxis, may occur. needed to discourage the use of black diagnosis of allergic contact dermatitis • Sensitization to one or more of the in persons 18 years of age and older allergens may occur with initial or henna tattoos to avoid further sensitization. whose history suggests sensitivity repeat testing. to one or more of the 35 substances • Extreme positive reactions, excited de Groot AC: Side-effects of henna and semi- included on the T.R.U.E. TEST panels. permanent ‘black henna’ tattoos: a full review. skin syndrome, tape reactions, irritant Contact Dermatitis 69: 1-25, 2013 CONTRAINDICATIONS contact dermatitis, persistent reac- • Do not apply to skin of patients with tions, and late reactions at the test a history of severe allergic reaction site may occur. (systemic and/ or local) to any of ADVERSE REACTIONS the allergen components or inactive • The most common adverse reactions substances of T.R.U.E. TEST. (occurring in more than 1% of the • Do not apply to skin that is injured study population) were burning, tape or inflamed. irritation, persistent reactions, erythe- truetest.com l finnchamber.com l allergEAZE.com ma, and hyper/hypo pigmentation.

4 79241-C_1113 © 2013 SmartPractice • All rights reserved