http://informahealthcare.com/cot ISSN: 1556-9527 (print), 1556-9535 (electronic) Cutan Ocul Toxicol, Early Online: 1–3 ! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/15569527.2014.894520

COMMENTARY

Dermatotoxicologic clinical solutions: hair dying in hair dye allergic patients? Ashley Edwards1, Garrett Coman2,3, Nicholas Blickenstaff2,3, and Howard Maibach3

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Touro University, Vallejo, CA, USA, 2School of Medicine, University of Utah, Salt Lake City, UT, USA, and 3Department of Dermatology, University of California San Francisco, San Francisco, CA, USA Abstract

Keywords

This article describes how to identify allergic contact dermatitis resulting from hair dye, and outlines interventions and prevention principles for those who wish to continue dyeing their hair despite being allergic. Hair dye chemicals thought to be the most frequent sensitizers are discussed with instructions for health care providers on how to counsel patients about techniques to minimize exposure to allergenic substances. This framework should allow many patients to continue dyeing their hair without experiencing adverse side effects.

2-methoxymethyl-p-phenylenediamine, allergen, contact dermatitis, desensitization, hair dye, lateral spread, patch testing, PPD History Received 20 November 2013 Revised 28 January 2014 Accepted 11 February 2014 Published online 22 April 2014

Introduction Dyeing hair is an ancient art, with a long history of recorded complications; a 1661 recipe for red hair coloring depicts possible side effects1. ‘‘To make your hair red: Take one handful of Nut-tree leaves, distill them in a glass and with that wet your hairs fifteen days, and they will be red: the colour will last one month. But wet not your face with that water, for it will grow black.’’ Many persevere in hair dyeing despite continued coloration mishaps and allergies because they value the freedom to choose their hair color. This concept is well captured by Malcolm Gladwell2. ‘‘ . . . all of us, when it comes to constructing our sense of self, borrow bits and pieces, ideas and phrases, rituals and products from the world around us-over-the-counter ethnicities that shape, in some small but meaningful way, our identities. Our religion matters, the music we listen to matters, the clothes we wear matter, the food we eat matters, and our brand of hair dye matters, too.’’

Address for correspondence: Garrett Coman, Department of Dermatology, University of California San Francisco, 90 Medical Center Way, Box 0989 Surge Building, San Francisco, CA 941430989, USA. E-mail: [email protected]

With hair dye people construct their image in an attempt to develop a sense of self. It is important that allergic patients be able to color their hair and express themselves without having to suffer complications. We describe how to identify allergic contact dermatitis resulting from hair dye and outline interventions and prevention principles for those with an allergy who wish to continue dyeing their hair.

Diagnosis Clinical history The Clairol advertising copy ‘‘Does she or doesn’t she?’’ explains the clinical problem of identifying contact dermatitis secondary to hair dye. Modern hair dyes are seldom discernable from natural colors, so a detailed medical history is necessary to determine if the patient is using hair dye. The time course for developing dermatitis varies from hours to days following dye exposure. Dermatitis commonly includes itching, burning and a rash localizing to the face or scalp margins. Peculiarly, the exposed scalp often fails to demonstrate visible inflammation3. Presentation and dermatitis severity ranges from redness, subtle swelling and irritation of the eyes to intense edema of the face with exudation of the scalp.

Patch test P-Phenylenediamine (PPD), the first sensitizing culprit identified in hair dye, continues to be used in hair dye,

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albeit at reduced concentrations. Hair dye patch test screening commonly tests for PPD, but there are approximately 100 chemicals permitted for use in hair dye that may not be included. In addition to the five chemicals previously identified by the European hairdressers series, Søsted et al.4 identified 22 hair dye chemicals as possible sensitizers. While there may be limitations due to low concentrations used in the study, this list remains relevant in identifying the specific agent causing allergic dermatitis. It is recommended to have a dermatologist complete a patch test for key chemicals in Table 1. Identification of the putative allergen allows for the consumer to use dyes that do not contain this allergen. A caveat is that we have little information on potential cross reactions to some dyes that have only routinely been used in patch testing4. Patients should be aware that the frequency of PPD allergy in the general adult population is approximately 1–3%, and salon or self-testing for contact sensitization is available with final formulations and PPD to identify individuals who are likely to react upon subsequent hair dyeing5. A skin sensitivity test such as the Colourstart system, has the capacity to provide an alert of a potential adverse reaction prior to the use of a hair dye5. An investigative report by Basketter et al. demonstrated that 90% of those who were moderately to strongly allergic to PPD according to patch testing, were also positive to Colourstart. We note the excellent work of McFadden et al. in that PPD occlusive exposure (presumably to the back) of 5–30 min will produce a positive reaction and that the minimum eliciting dose was 0.10% in most individuals6. Fortunately, perhaps because of occlusion, anatomic differences or limited PPD scalp exposure (when optimally performed), many sensitized patients tolerate hair dying when following the discussed algorithm. Table 1. Patch test recommendations (adapted from Søsted et al.4). Substance (1% in Petrolatum) PPD PTD p-Methylaminophenol p-Aminophenol 4-Amino-2-hydroxytoulene m-aminophenol 2,4-Diaminophenoxyethanol–HCl 4-Amino-m-cresol 1-Hydroxyethyl-4,5-diaminopyrazole sulfate 2-Amino-3-hydroxypyridine 2-Methylresorcinol 3-Nitro-p-hydroxyethyaminophenol N,N0 -Bis(2-hydroxyethyl)-p-phenylenediamine 4-Amino-3-nitrophenol 4-Chlororesorcinol Resorcinol 1-Napthol 2,4,5,6-Tetraaminopyridine 2,7-Naphthalenediol 2-Amino-6-chloro-4-nitophenol 2-Methyl-5-hydroxyethylaminophenol 4-Hydroxypropylamino-3-nitrophenol Acid Violet 43 Disperse Violet 1 HC Blue 2 HC Red 3 Picramic acid

Cutan Ocul Toxicol, Early Online: 1–3

Interventions As PPD is the most common allergen in hair dyes, choosing a synthetic formulation that excludes this ingredient may help these allergic individuals avoid dermatitis7. In addition, semipermanent dyes are more likely to be tolerated than permanent dyes because of lower allergen concentration. The use of herbal or plant products may be less allergenic; some herbal dye products such as henna have low allergic potential but may have additives in the preparation such as diaminotoluenes and diaminobenzenes that can cause contact dermatitis8. Herbal products and PPD-free products are shown in Table 29. Procter & Gamble (P&G) recently commercialized the PPD derivative (2-methoxymethyl-p-phenylenediamine) seen in Table 3, and they believe this hair dye molecule has reduced sensitization properties10.

Prevention principles If the patient finds hair dye without the allergen unacceptable (Table 2), there are techniques to minimize exposure to the dye. It is essential to identify a well-trained and experienced hairdresser with good technique. Self-hair dying is problematic because of difficulty minimizing spread onto the scalp. A common area of skin affected by dermatitis is the scalp margin. In preparation, the hairdresser should apply a barrier of petrolatum to minimize lateral spread of the dye11. The least amount of dye possible should be applied to the hair, minimizing skin and scalp contact. The technician should not be hurried, or rushing to the next client, to again decrease the chance of excessive skin and scalp exposure. The dye should remain for the minimum time required to obtain the desired result. It is prudent to schedule appointments early in the workweek in the event dermatitis occurs. Most reactions develop within days of exposure to hair dye, so an early in week hair appointment affords time to see a healthcare worker if necessary. Table 4 summarizes strategies that can minimize contact dermatitis in hair dye allergic patients. Table 2. Alternative hair dyes free of PPD. Brand Natural Instincts (Clairol) Balsam Color (Clairol) Preference (L’Oreal) Precision Foam Color (John Frieda) Silk Lift (Goldwell) Colorance (Goldwell) Topchic (Goldwell) Elumen (Goldwell) Data from American Contact Dermatitis Society as of October 2013. Note that identification of the putative allergen (PPD, PTD, etc.) allows for the consumer to use permanent and semi-permanent dyes that do not contain this allergen. Table 3. Alternative PPD Derivative. Chemical 2-Methoxymethyl-p-Phenylenediamine (Koleston Perfect Innosense)

Hair dying in hair dye allergic patients

DOI: 10.3109/15569527.2014.894520

Table 4. Strategies to minimize contact dermatitis in hair dye allergic patients.

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Declaration of interest No conflicts of interest.

Strategy 1. 2. 3. 4. 5.

Remain with the same, well-trained hair dresser Dye hair on Monday or Tuesday Apply a barrier of petrolatum (VaselineÕ ) to minimize lateral spread Apply minimal liquid dyes to the hair and not the scalp Allow dye to set for the minimum time allowable

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Conclusion Many patients with a history of contact dermatitis have been previously advised to avoid dyeing their hair. However, with due diligence, understanding individual sensitivities, appropriate preparation and minimal dye exposure, patients can often have the freedom to color their hair without suffering from rash, itchiness or redness. Likelihood of developing hair dye allergic contact dermatitis is related to the intensity of the patch test reaction6. Referencing Table 3, even those with a 3+ positive response can often dye their hair without resultant dermatitis. Furthermore, if the allergen concentration during patch testing reaches a patient’s biological threshold for reaction, the hair dye may not contain the necessary concentration during routine use12. Another possible explanation for the ability to safely dye hair in patch test positive individuals may relate to the difference between single exposure (in dyeing) versus multiple exposures. In use tests (provocative use test/ repeat open application test), clinical dermatitis occurs with repeated applications as long as 3–4 weeks later, whereas hair dying is a single exposure. In general, the stronger the patch test response, the earlier the use test reactions occur12. This suggests that many patients can continue to color their hair with proper counseling and informed (informational) consent.

References 1. Wecker JJ. Eighteen Books of the Secrets of Art & Nature: being the summer and substance of natural philosophy, methodology digested. London: Simon Miller; 1661. 2. Gladwell M. True colors. Hair dye and the hidden history of postwar America. In: Baird S, ed. What the dog saw. New York: Little Brown and Company; 2009. 3. Zhai H, Zheng Y, Fautz R, et al. Reactions of non-immunologic contact urticaria on scalp, face, and back. Skin Res Technol 2011; 18:436–441. 4. Søsted H, Rustemeyer T, Goncalo M, et al. Contact allergy to common ingredients in hair dyes. Contact Dermatitis 2013;69: 32–39. 5. Basketter DA, English J. Pre-testing in hair dye users: an assessment of the Colourstart system. Eur J Dermatol 2009;19: 232–237. 6. McFadden JP, Yeo L, White JL. Clinical and experimental aspects of allergic contact dermatitis to para-phenylenediamine. Clin Dermatol 2011;29:316–324. 7. Scheman A, Cha C, Bhinder M. Alternative hair-dye products for persons allergic to para-phenylenediamine. Dermatitis 2011;22: 189–192. ¨ zta¸s P, Alli N. Allergic contact dermatitis 8. Polat M, Dikilita¸s M, O to pure henna. Dermatol Online J 2009;15:15. Available from: http://escholarship.org/uc/item/78s2j8qw [last accessed 10 Nov 2013]. 9. American Contact Dermatitis Society. Contact Allergy Management Program Database. Available from: http://www. contactderm.org/ [last accessed 9 Oct 2013]. 10. Rust, Rene. Latest innovations: ME+ (2-Methoxymethyl-pPhenylenediamine). Available from: http://www.pg.com/en_US/ downloads/innovation/factsheet_Wella_ME+_final.pdf [last accessed 10 Nov 10 2013]. 11. Ashworth J, Watson WS, Finlay AY. The lateral spread of clobetasol 17-propionate in the stratum corneum in vivo. Br J Dermatol 1988;119:351–358. 12. Zaghi D, Maibach HI. Quantitative relationships between patch test reactivity and use test reactivity: an overview. Cutan Ocul Toxicol 2008;27:241–248.

Dermatotoxicologic clinical solutions: hair dying in hair dye allergic patients?

This article describes how to identify allergic contact dermatitis resulting from hair dye, and outlines interventions and prevention principles for t...
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