Cocamidopropyl Betaine — Which Received the Designation of Allergen of the Year in 2004 from the American Contact Dermatitis Society

ALLERGENFocus Sharon E. Jacob, M.D. Sadegh Amini, M.D.

in approximately 25.5% of patients with allergic contact dermatitis.1 This being said, many relevant allergens are not detected with this screening tool alone and, for this reason we decided to expand this column this month to cover one of the notorious allergens — cocamidopropyl betaine — which received the designation of Allergen of the Year in 2004 from the American Contact Dermatitis Society.

THE CONTACT DERMATITIDES Allergic contact dermatitis is an important disease with high impact both in terms of patient morbidity and economics.The contact dermatitides include irritant contact dermatitis, contact urticaria and allergic contact dermatitis. Irritant contact dermatitis, the most common form, accounts for approximately 80% of environmental-occupa- tional based dermatoses. Contact urticaria (wheal and flare reaction) represents an IgE and mast cell- mediated immediate-type hypersensitivity reaction that can lead to anaphylaxis, the foremost example of this being latex Focus on the Non-T.R.U.E. Test Allergen — hypersensitivity.While this is beyond the scope of this section, we acknowledge this form of hypersensitivity due to the severity of the potential reactions and Cocamidopropyl Betaine direct the reader to key sources.2,3 Allergic contact dermatitis affects more than 70 million Americans each BY SHARON E. JACOB, M.D., AND SADEGH AMINI, M.D. year and has a high impact both in terms of patient morbidity and economics. The primary focus of this section is to ince January of 2005, this column has highlighted a different thin-layer highlight the educational component of rapid-use epicutaneous (T.R.U.E.) test allergen each month and intended this important inflammatory disorder. S to answer some of the most frequent questions relating to their origin and most common uses. Each column has also highlighted appropriate products CASE ILLUSTRATION that affected patients should avoid, along with tips to avoid cross-reactions A man presented to the University of and exposures. Miami Contact Dermatitis Clinic with This month, we break from the tradition of this column to discuss a non- an unresolving generalized dermatitis T.R.U.E. test allergen. Although the T.R.U.E. test screens for 46 distinct allergens with itching despite avoiding the and the Balsam of Peru mixture and it is a valuable first-line screening tool to formaldehyde allergen that had been assess for allergic contact dermatitis, it is thought to adequately identify an allergen previously identified by T.R.U.E testing.

12 AUGUST 2006 SKIN & AGING THE HISTORY OF SOAP MAKING THE BIRTH OF PROCTER & GAMBLE According to archaeological excava- While candle maker William Procter tions in Babylon, the oldest inscriptions and soap maker James Gamble formed on the soap making process were found an alliance in 1837, it was the American on clay containers dated at 2800 B.C.4,5 Civil War Army supply contracts The early Egyptians were also well attained by Procter & Gamble (P&G) versed in regular bathing practices. From that catapulted this company to the per- 1500 B.C.,The Ebers Papyrus describes sonal hygiene industry forefront. the combination of animal and plant fats Furthermore, soldiers returning home with alkaline salts to obtain a soap with P&G products introduced the substance for use in the treatment of company to domestic America and diseases and bathing.4,5 made P&G a household name.5,7 It is believed that when animals were In 1879, James Norris Gamble, son of sacrificed and cremated at Mount Sapo the co-founder and a trained chemist, near ancient Rome, melted animal fat developed an inexpensive white soap, (tallow) mixed with wood ashes and clay which was equal in quality to the soil was washed down by the rain into imported castiles. the Tevere River. Roman women Procter & Gamble continued to grow promoted effective washing with this in response to the growing popularity mixture.4-6 By 312 B.C., the Terme Di for perfumed beauty soaps. In 1933 Caracalla aqueduct-based Roman bath- “Ma Perkins”, a radio series program house was built. sponsored by P&G’s Oxydol soap pow- The popularization of soap through- der, aired nationally.The popularity led out the Roman Empire led to the foun- THE EARLY EGYPTIANS P&G brands to sponsor numerous new dation of soap factories, remnants of WERE ALSO WELL VERSED radio series, and hence “soap operas” which can be seen in the ruins of the were born. city of Pompeii, destroyed in 79 A.D. IN REGULAR BATHING Notably,the first major league baseball game aired on television accompanied PRACTICES. FROM 1500 B.C., BATHING BECOMES UNPOPULAR by the first Ivory Soap television com- With the fall of the Roman Empire in THE EBERS PAPYRUS mercial. 476 A.D. came a marked decrease in Procter & Gamble’s invention of bathing and clothes washing — usher- DESCRIBES THE Dreft, the first synthetic detergent for ing in the “darkness” of the Middle COMBINATION OF household use, laid the groundwork for Ages. The populous superstitiously a revolution in cleaning technology and feared that it was the water that contam- ANIMAL AND PLANT FATS the introduction of new product lines inated the inner body with illnesses WITH ALKALINE SALTS TO such as Tide “the washing miracle”, Prell through dilation of the skin’s pores.5 (1946), and Crest — the first fluoride In the 7th century, however, the Arab OBTAIN A SOAP cavity fighting toothpaste soap (1955). trade routes renewed the demand for When P&G celebrated its 150th soaps.And by the 10th century, the soap- SUBSTANCE FOR USE IN anniversary in 1987, the company manufacturing industry boomed once THE TREATMENT OF ranked as the second-oldest company again in southern Europe (Italy, Spain among the 50 largest corporations. 4,5 and France) where raw materials such as DISEASES AND BATHING. Recently, the company introduced olive oil were readily available. Pantene Pro-V, the fastest growing Almost every European city was a detergent shampoo in the world with major producer of soap, with the excep- sales exceeding $30 billion.8 tion of England, which began mass manufacturing soap in the 12th century. rather than combat injuries, were DRAMATIC CHANGE IN SOAP MAKING Of economic interest, governments saved when British nurse Florence Sales alone speak to the competitive enjoyed the heavy luxury tax added to Nightingale realized that hygienic demand for synthetic detergents, but soap for more than nine centuries, until reforms in field hospitals dramatically their creation was a circuitous road.The the levy was lifted in the 19th century. decreased the death rate. soap manufacturing process dramatically When the American Civil War broke changed in 1916 with the advent of the FLORENCE NIGHTINGALE RECOGNIZES out in 1861, this knowledge was put first synthetic detergent developed by THE POWER OF HYGIENE into practice, exposing thousands of the Germans in the First World War to During the Crimean War (1854- Americans to the use of soap and the compensate for the shortage of available 1857), British soldiers, dying of diseases concept of regular bathing. fats. And again, synthetics production

AUGUST 2006 SKIN & AGING 13 boomed with the WWII interruption of Of the 50 principal allergens found References: fat and oil supplies and the military positive in patch tests performed by the 1. Saripalli YV,Achen F,Belsito DV. The detec- demand for all-purpose “built” deter- North American Contact Dermatitis tion of clinically relevant contact allergens using a standard screening tray of twenty-three allergens. gents, containing a dirt removing surface Group from 1995 to 2001, CAPB was J Am Acad Dermatol. 2003 July;49(1):65-9. active agent (surfactant) and a catalyst the twenty-ninth most common.1 2. Cohen DE, Kaufmann JM. Hypersensitivity (builder) in combination. By 2003, the worldwide consumption reactions to products and devices in plastic sur- One of the major advantages these of surfactant detergents and soaps was gery. Facial Plast Surg Clin North Am. 2003;11(2): synthetic surfactants had over soap was more than 27 million metric tons, with 253-65. that they performed much better in cold surfactants accounting for two-thirds 3.Valks R, Conde-Salazar L, Cuevas M.Allergic and hard water (high-metal composi- (18 million tons) of the gross product.5 contact urticaria from natural rubber latex in tion: Ca, Mg, Fe or Mn).Another was the In the face of this multi-billion dollar healthcare and non-healthcare workers. Contact Dermatitis. 2004;50(4):222-4. milder nature of the amphoteric (zwitte- industry, CAPB became the 2004 rionic) betaines. The original betaine Allergen of the Year. 4. Soaps and detergents history.The Soap and Detergent Association.Accessible on the Internet products were introduced to the market at: http://www.cleaning101.com/cleaning/ in 1947 by the Goldschmidt Chemical TESTING FOR CAPB SENSITIVITY history/. Corporation, a leader in textile industry Although patch testing for CAPB 5. History of Washing. Science in the box. detergents. allergy cannot be accomplished with the Accessible on the Internet at: www.scienceinthe- current T.R.U.E. test, it can be box.com. P&G. Copyright 2000, 2001. FIRST BETAINE-BASED HYGIENE PRODUCT performed comprehensively. 6. Routh HB., Bhowmik KR., Parish LC., The betaine technology was intro- Evaluation should include concomi- Witkowski JA. Soaps: From the Phoenicians to duced into the field of personal care and tant testing with manufacturing inter- the 20th Century — A Historical Review. hygiene products when Johnson & mediaries, amidoamine and dimethyl- Clin Dermatol. 1996 Jan-Feb;14(1):3-6. Johnson developed the first cocamido- aminopropylamine because these impu- 7. Kostka KL, McKay DD. Chemists clean Up: propyl betaine (CAPB) detergent-based rities are thought to be responsible for a A history and exploration of the craft of Soap making. How soap came to be common in shampoo: “No more tears” Baby large proportion of CAPB allergies. America. J Chem Ed. 2002 Oct;79(10):1172-5. Shampoo9 (patented in 1967).10 It is important to note that all surfac- 8. Procter & Gamble — Our History. 2005 CAPB’s lipophilic (fat loving) termi- tants have the potential to be irritants, Procter & Gamble All rights reserved.Accessible nal end is manufactured by combining and CAPB is no exception. on the Internet at: http://www.pg.com/ coconut fatty acids of varying length. This irritant reaction has been company/who_we_are/ourhistory.jhtml. The anionic group (carboxylic group) described as mild erythema at the patch 9. Johnson & Johnson History Copyright Johnson and the cationic group (quaternary site, which characteristically improves in & Johnson 1997-2005.All Rights Reserved. ammonium group) give the molecule its 24 to 48 hours. A 96-hour delayed read Accessible on the Internet at: http://www.jnj.com/our_company/ hydrophilic (water loving) end and its is recommended and serial dilution test- history/history_section_1.htm. amphoteric properties.11,12 ing may also be performed, if necessary, 10. Begoun P.Baby Shampoo. Hair-Care Coconut oil, expressed from the to confirm the diagnosis. Formulations in: Don’t go shopping for hair-care kernels of Cocos nucifera seeds, and its products without me. Beginning Press 3rd derivatives (coconut acid, hydrogenated THE VALUE OF THIS PATIENT CASE Edition. 2004 Sep:80. coconut acid and hydrogenated coconut Our patient tested positive for 11. Surfactants: the ubiquitous amphiphiles. oil) are used as cleansers, foaming agents, CAPB component of his body soap chembytes e-zine The Royal Society of or stabilizers in multiple cosmetics and bar. By avoiding CAPB and formalde- Chemistry 2004.All rights reserved.Accessible on the Internet at: http://www.chemsoc.org/ personal hygiene products. hyde, to which he had previously chembytes/ezine/2003/hargreaves_jul03.htm. tested positive, this patient’s full body I 12. de Groot AC, van der Walle HB,Weyland JW. ALLERGIES TO CAPB dermatitis improved. Contact allergy to cocamidopropyl betaine. Case reports of allergy to CAPB were Contact Dermatitis. 1995 Dec;33(6):419-22. published as early as 1983. The first Dr. Jacob is the Director of the Contact 13.Van Haute N, Dooms-Goossens A. Shampoo two case reports were women with Dermatitis Clinic at the University of dermatitis due to cocobetaine and sodium erythematous lesions secondary to their Miami. She’s also an Assistant Clinical lauryl ether sulphate. Contact Dermatitis. cocobetaine-containing shampoos. In Professor in the Department of Dermatology 1983 Mar;9(2):169. both cases, the lesions cleared with and Cutaneous Surgery. 14. Mowad CM Cocamidopropyl betaine allergy. avoidance of cocobetaine shampoos.13 Am J Contact Dermat. 2001 Dec;12(4):223-4. Many cases of CAPB-ACD have been Dr. Amini is a dermatologist who trained 15. Fowler JF,Fowler LM, Hunter JE.Allergy reported in association with shampoos, at the Universidad Central de Venezuela, to cocamidopropyl betaine may be due to liquid soaps, bath gels, toothpastes, con- Caracas,Venezuela. amidoamine: a patch test and product use test study. Contact Dermatitis. 1997 Dec;37(6):276-81. tact lens solutions, make-up removers, and gynecologic and anal hygiene 16. Herlofson BB, Barkvoll P.The effect of two toothpaste detergents on the frequency of products, with a range of incidence Disclosure: The authors have no conflict of interest with any subject matter discussed in recurrent aphthous ulcers. Acta Odontol Scand. 12-16 between 3% to 7.2%. this month’s column. 1996 Jun;54(3):150-3.

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