THE DIAGNOSIS OF COSMETIC DERMATITIS* By Lous SCHWARTZ, M.D. Medical Director, -U.S. Public Health Service, Bethesda, Md. COSMETICS as a whole are among the most harmless substances with which we come in contact. This is proven by the fact that al- most all civilized people, female and male, use cosmetics in some form or other, and only an insignificant number ever complain of any dele- terious effect of cosmetics on the skin. Nevertheless, the manu- facturers of cosmetics are occa- sionally bothered by complaints from some individuals who claim that a particular cosmetic has caused their skin to become inflamed. Despite the fact that the manufacturer has sold thousands of the same cosmetic and this com- plaint may be the only one of dermatitis, he should make an effort to determine whether the cosmetic is really the cause of the dermatitis, and if it is, then he should endeavor to fir•d the actual substance in the cosmetic to which the complainant is allergic. Careful investigation and accu- rate diagnosis of the causes of re- ported cases of dermatitis and sys- temic poisoning from cosmetics is of great importance not only for the benefit of the patient but also to *Presented at the December 6, 1946, Meeting, New York City. cosmetic manufacturers and should be encouraged by the latter in order to improve their products and safe- guard the public and to protect the good name of cosmetics. Certain substances, which are classed as cosmetics, are known to be primary skin irritants. That is, they will inflame the normal skin if they are permitted to stay on it for a sufficient period, especially in con- siderable quantities. Such sub- stances are: 1. Hair tonics containing irri- tants such as resorcin, can- tharides, sulfur, etc., in an alcoholic solution, 2. Hair wavers and straighteners containing strong alkalis, thioglycollic acid, or in- organic sulfides, 3. Depilatories consisting usually of inorganic sulfides or thioglycollates, 4. Hair bleaches containing alkaline persalts, 5. Freckle removers containing inorganic mercurials, fl. Antiperspirants containing aluminum chloride and sul- fate, 7. Cuticle softeners containing sodium and potassium hy- droxide, or triethanolamine.

DIAGNOSIS OF COSMETIC DERMATITIS 47 Dermatitis which may be caused by most of the other forms of cos- metics such as creams, hair dyes, lipstick, nail lacquers, perfumes, powders, and cleansers are usually due to allergy of the patient to some chemical in the cosmetic which is innocuous to others, or if. it is an irritant it is in such low concentra- tion that it is innocuous to the- normal individual. Skin eruptlong from cosmetics are usually acute or subacute inflamma- tions of the skin on the site to which the cosmetic was applied, charac- terized by erythema, edema, pap- ules, vesicles, and crusts. Chronic changes such as lichenification, in- duration and hyperpigmentation occur but rarely, because in the majority of the cases where the cos- metic is suspected, its use is dis- continued befbre such changes occur. Only in cases where the cosmetic causing the condition is not suspected, as in dermatitis of the neck and face from nail lacquer, or when the cosmetic is wrongly sus- pected and there is another cause, do the signs of chronicity develop. In some cases where there is pruritis, scratching may cause excoriations and secondary infections resembling impetigo. In some rare cases of dermatitis from cosmetics, especially from the hair dyes of the paraphenylene- diamine type where there may be absorption into the system, the eruption which begins at the site of application may become genera- lized. Pigmentations of the skin have been recorded from the long con- tinued use of cosmetics. A gray pigmentation from the long con- tinued use of cosmetics containing mercury (Hydrargyria), and from long continued use of silver (Atrgyria), due to the deposition of these metals in the skin has been reported. Bergamot oil in perfumes has been reported to cause sharply marginated areas of pigmentation on the face and neck (Berlock dermatitis). Photosensitivity in- duced by the oil is supposedly the cause of extra-pigment formation in the affected areas. The hands, wrists, and forearms may become dry, scaly, and fissured from the continued use of strong soaps, shampoos, and alcohol con- taining lotions which defat the skin. Beauticians are sometimes affected by this form of occupational derma- titis. In order to prove the diagnosis of cosmetic dermatitis, the following criteria must be present: 1. The history must show that the dermatitis occurred after the suspected cosmetic was used. 2. That it was not present at any time before. :3. The dermatitis first appeared where the cosmetic was ap- plied, except in cases where the cosmetic was transferred to a more sensitive part, as in the case of nail-lacquer dermatitis. 4. In the large majority of cases, the dermatitis is limited to the