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

48 JOURNAL OF THE SOCIETY OF COSMETIC CHEMISTS site where the cosmetic was applied. 5. The morphe of the dermatitis is that of a dermatitis vene- nata namely, erythema, ß edema and sometimes papules and vesicles. 6. Patch tests with the cosmetic on normal parts of the skin should be positive. It must be remembered that patch tests are only performed with cosmetics which are not in- tended to have a primary irri- tant action on the skin. In cases where patch tests may not simulate the manner in which the cosmetic when used remains on the skin, actual usage tests should be per- formed. In case photosensi- tivity is suspected as playing a role in the dermatitis, the site on which the cosmetic was tested should be exposed to the sun for an hour or longer. 7. When the use of the suspected cosmetic is discontinued, the dermatitis should show marked and rapid improve- ment and re-use of the cos• metic after the eruption dis- appears should result in a re- currence of the eruption. DERMATITIS FROM CREAMS Dermatitis from face creams is of rare occurrence. In the last 12 years there are only 5 reported cases in the American medical literature and 1 of these was lead poisoning in an actress from grease paint con- taining 40 per cent white lead. The other 4 cases were due to hyper- sensitivity to petrolatum, trietha- nolamine, methyl heptin carbonate and a case of slate gray pigmenta- tion of the face from the ammoni- ated mercury in a freckle cream. Dermatitis is more likely to occur from freckle creams, bleaching creams, vanishing creams, and cleansing creams than from the so- called nourishing creams. No cases of dermatitis have' been reported from hormone creams. In order to diagnose dermatitis from creams, the suspected cream should be used as a covered patch test on the patient and on a control. The patch can remain on for 24 hours and if no reaction occurs, the site of the patch should be inspected each day for 3 days to observe the appearance of late reactions. If none occur, then the patient should use the cream under supervision on the forearms for 3 or 4 days to ob- serve the effect on the skin. If there still is no effect, then the cream may be dismissed as a cause of dermatitis. If there is a positive patch test on the pati'ent and a nega- tive one on the control, or if the application on the arm causes a dermatitis, then the ingredients o! the cream should be ascertained and similar tests should be performed with each in order to find the actual irritant. Cosmetics other than the cream should be' suspected if no positive results occur from tests with the cream. If tests with the other cosmetics are also negative, then another source for the derma- titis should be sought.