REACTIONS TO EYE COSMETICS 253 previously used product. How the eye cosmetic is removed is also germane. Exposure to a facial cleanser (cream, lotion, wet facial tissue) or eye makeup remover affords opportunity for contact with potential irritants and allergens. Whether or not the consumer has experienced a similar reaction to other brands of the same product is likewise significant. A positive response suggests an ubiquitous ingredient or a hyper-reactive individual. If the history is ambiguous it may be advisable for the patient to submit all her cosmetics for consideration or possible testing. Step II: The Provocative Use Test--the suspected product is applied to the normal skin of the cubital fossa or back of the ear twice daily for a period of five to seven days. A positive reaction serves to identify the causative product. A negative reaction, on the other hand, does not exonerate a product since the eye area is more sensitive than the test site and actual use is only approximated. Step III: Patch testing with the ingredients of the relevant product, i.e., the product incriminated by history and/or identified by the provocative use test. Assuming that the test is properly performed and the results are properly interpreted the causative allergen may be identified or verified by this technique. Patch testing, however, is of little or no help in identifying irritants. Because of the occlusive nature of the method false positive reactions are prevalent. The diagnosis of irritant dermatitis remains a diagnosis of exclusion made by history and negative patch tests for allergy. It should be emphasized that patch testing is a deceptively simple technique that requires experience, particularly in the reading and interpretation of the results. (35, 36). Moreover, precise patch testing information, i.e., concentration and type of vehicle, is lacking for many cosmetic ingredients (37). A good deal of unnecessary and unrewarding testing can be eliminated by a detailed history and the provocative use test. 6. MANAGEMENT OF ALLERGIC AND IRRITANT CONTACT DERMATITIS Comprehensive care includes appropriate topical therapy, discontinuance of the offending cosmetic, a sine qua non, and a suitable replacement or substitute whenever feasible (vide infra) for the individuals who desire to wear eye makeup. Cosmetic manufacturers play an important role by providing appropriate patch test materials when requested and by assisting the physician and/or the consumer in finding an alternate product. While a hit or miss change in brand may resolve some problems, selection of a replacement based on identification of the cause is more likely to succeed (38). a) Replacement products for allergic contact dermatitis Allergen replacement has been proposed by others as a means of circumventing allergic contact dermatitis (39). This principle applies to eye area products with the exception of parabens which are almost uniformly present. While substitution is not possible for parabens, three paraben-free eye area products are currently available: Soft Pressed Eyeshadow ©, Resistant Eyeliner ©, and Basic Eye Emphasizer © which also serves as eyeshadow, lid liner, and brow definer (Clinique). Consumers should be instructed to read ingredients disclosures carefully since formulations are subject to change.

254 JOURNAL OF THE SOCIETY OF COSMETIC CHEMISTS Paraben-sensitive individuals, however, do not necessarily have to avoid paraben- containing cosmetics. According to Fisher, patients sensitized to parabens may nevertheless tolerate paraben-containing cosmetics even on the thin skin of the eyelids provided the product is applied to normal skin not subjected to a dermatitis in the past (40). Substitution products can generally be found for individuals sensitive to antioxidants, resins, and the miscellaneous allergens noted above. It is a matter of becoming thoroughly familiar with the large diversity of available formulations and finding one that does not contain the particular allergen involved. Once an allergen is identified the consumer usually can avoid further problems by carefully reading cosmetic labels. b) Replacement products for irritant contact dermatitis The best approach in the author's experience is to recommend a dissimilar or less complex formulation in the hope of circumventing the causative irritant(s). For example, an individual who does not tolerate waterproof mascara or waterproof eyeliner may very well tolerate their water-based counterparts. In the event that neither type of mascara or eyeliner is tolerable, a cake mascara or a cake eyeliner may be tried. Maybelline Cake Mascara ©, Lumilane Cake Mascara © (Orlane), and Maybelline Ultra Liner Cake Eyeliner © have only half the number of chemicals currently found in water-based and waterproof formulations. The potential for irritation is thus consider- ably reduced. This is not true for Chanel's Compact Mascara which is highly complex. Similarly, individuals who cannot use cream eyeshadow may tolerate pressed powder eyeshadow and vice versa. V. OCULAR INFECTIONS Chronic conjunctivitis and blepharitis due to contaminated eyeliner and mascara have been reported (41). Microorganisms, e.g., S. epidermidis and S. aureus, resident microflora of the outer eye may colonize and proliferate in sufficient numbers in inadequately preserved cosmetics to become pathogenic (42). Such infections are usually mild and respond readily to the withdrawal of the cosmetic, local hygienic measures, and appropriate topical antibiotic therapy. Keratitis that may lead to corneal ulceration and impairment or loss of vision are sequelae of an injured cornea to which contaminated mascara has been applied. Wilson and Ahearn (43) who have done the major work in cosmetic-related eye infections observed seven cases of P. aeruginosa keratitis and corneal ulceration over a period of three years. As of February 1980, 16 cases of corneal ulceration and 32 less serious forms of infection have been documented by the FDA (44). Pseudomonas organisms were implicated in most of the cases with corneal involvement. Wilson and Ahearn's cases had these features in common: a history of trauma to the eye with a cosmetic applicator, isolation of the causative agent from the eye and eye area cosmetic, and cosmetic products that supported reproduction populations of the etiologic agent. Marzulli et al (45), demonstrated the importance of trauma as a predisposing factor. Injury to the cornea by a mascara brush or wand is the most common form of trauma foreign body entry and a fingernail "scratch" are other sources. Pseudomonas keratitis in rabbit and monkey eyes could be achieved consistently only when organisms were