University of Groningen The dark side of -Phenylenediamine Vogel, Tatiana Alexandra IMPORTANT NOTE: You are advised to consult the ublisher's version (ublisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record Publication date: 2016 Link to ublication in University of Groningen/UMCG research database Citation for ublished version (APA): Vogel, T. A. (2016). The dark side of -Phenylenediamine: Biological asects and revalence of contact allergy to an extraordinary molecule [Groningen]: Rijksuniversiteit Groningen Coyright Other than for strictly ersonal use, it is not ermitted to download or to forward/distribute the text or art of it without the consent of the author(s) and/or coyright holder(s), unless the work is under an oen content license (like Creative Commons). Take-down olicy If you believe that this document breaches coyright lease contact us roviding details, and we will remove access to the work immediately and investigate your claim. Downloaded from the University of Groningen/UMCG research database (Pure): htt://www.rug.nl/research/ortal. For technical reasons the number of authors shown on this cover age is limited to 10 maximum. Download date: 22-11-2018
Chater 5 The attitude of atients with a -henylenediamine or 2,5-toluenediamine contact allergy towards hair dyeing Tatiana A. Vogel1, Thalina M. Prins1, A. Dijkstra2, Pieter-Jan Coenraads1, Marie-Lousie A. Schuttelaar1 1 University Medical Center Groningen, University of Groningen, Deartment of Dermatology, Hanzelein 1, 9700 RB Groningen 2 University of Groningen, Deartment of Psychology, Grote Kruisstraat 2/1, 9712 TS Groningen Submitted
Abstract Background: Hair dye allergy rovokes symtoms like itching, scaling, vesicles and bullae and even oedema and shortness of breath. Nevertheless, many allergic atients continue dyeing their hair. Objectives: To identify motivations influencing continued use of hair dye. Methods: 60 individuals comleted a questionnaire, regarding sociodemograhics, exosure to hair dye roducts, original hair colour, motivations for either stoing or continuing dyeing hair. Patch test strength and demograhics were collected from our database. Results: 27 Individuals still dyed their hair and 33 stoed. No differences between sociodemograhic factors were determined. The continuers exected fewer severe comlaints, agreed that itching or redness were worthwhile after dyeing, susected a decrease in their hainess when they had to discontinue dyeing, gave their lives a significant lower grade when they would sto, gave higher oints to the reasons for hair dyeing the colored hair dye looks nicer and it is imortant to look good for work. Self-esteem and aearance did not differ between the grous. Conclusions: Continued hair dye use is not imuted to low self-esteem. Motivations are relatively vague and lie outside the atient s ower to influence, the oinion of continuers and the susected oinion of their loved ones do not influence their behaviour. 72
5. The attitude of atients with a -henylenediamine or 2,5-toluenediamine contact allergy towards hair dyeing Introduction Hair dye is a oular cosmetic roduct nowadays and is not just a manner to cover grey hair anymore as the average age of first dyeing hair is 16 years. One in 5 men and three quarters of the women dye their hair at least once in their lives. 1 Adverse skin reactions due to the use of hair dye are reorted in 5.3 ercent of individuals using hair dye roducts in the general oulation. 1 A notable number of these adverse skin reactions are related to contact allergy to comonents of hair dye roducts, such as -henylenediamine (PPD, 1,4-diaminobenzene, CAS no. 106-50-3) and 2,5-toluenediamine (TDA, 1,4-diamino-2-methylbenzene, CAS no. 95-70-5; synonym -toluenediamine, PTD). 2 Even though allergic contact dermatitis rovokes unleasant symtoms like itching and scaling, many atients with a hair dye allergy seem to continue dyeing their hair. 3 This henomenon is influenced by the severity of the allergic reaction, as 73% of atients with a weak ositive reaction uon atch testing continued dyeing their hair, 49% of the atients had a strong ositive reaction and none of the atients had an extremely strong reaction. 4 Although this henomenon has been observed and reorted often, the underlying reason has not yet been elucidated. In this study we aimed to investigate this henomenon, which seems to arallel an addiction on various levels. A grou of individuals that stoed dyeing their hair after being diagnosed with a PPD or a TDA contact allergy was comared to a grou that continued dyeing, desite their contact allergy. The grous were comared regarding background variables, sychological factors and exected outcomes of their behaviour concerning the use of hair dye roducts. The main objective of this study was to identify motivations that can influence the behaviour, resulting in the continuation of hair dye use in sensitised individuals. Furthermore, we attemted to detect motivations for either stoing or continuing dyeing hair. Patients and Methods Poulation A total of 124 atients with a relevant ositive atch test reaction to either PPD or TDA were selected from our atch test database between January 1994 and March 2015. Data regarding atch test strength, demograhic information (gender, age), rimary site of comlaints and history of atoic dermatitis were collected. Patch testing Patch tests with the Euroean Baseline Series (EBS), containing PPD (TRUE Test anel 1 and 2, Mekos Laboratories AS, Hillerød, Denmark) and our additional Baseline series were erformed. PPD was tested at a refabricated concentration of 0.090 mg/cm 2. Tests were read according to the criteria of the ICDRG on at least D3. From January 1994 until November 2008 a reading on D2 was erformed, while from November 2008 until December 2013 a reading on D7 73
was erformed to re-emt late reactions. Weak (+), strong (++) and extremely strong (+++) ositive atch test reactions were considered as ositive. Questionnaire All included individuals comleted a questionnaire consisting of 68 questions. This questionnaire included questions regarding sociodemograhics, exosure to hair dye roducts, including the length and frequency of hair dye use, and original hair colour. The second art of the questionnaire focused on motivations for either stoing or continuing dyeing hair. Furthermore, the satisfaction of individuals regarding their lives and aearance, beyond called grade of life and grade of looks, resectively, were measured using a 10- oint scale. Only individuals, who comleted the questionnaire, were included for further analyses. Data analysis and statistics Data were analysed using IBM SPSS version 22 for Windows TM. Due to the exlorative character of this study, we decided that a -value of <0.05 was regarded as a significant difference. Descritive statistics were carried out to gain insight into the characteristics of the research oulation. Differences between the grous of individuals, that are those that stoed using hair dye and those that continued after being diagnosed with a contact allergy to PPD or TDA, were calculated. 95% confidence intervals were shown, when aroriate. A Student s t-test was used to comare the means between two grous (e.g. age or grade of life), a Chi square test was used to comare differences in ercentages (e.g. gender). The Fisher s exact test was used instead of a Chi-square test when aroriate. A MANOVA was used to calculate differences between the two grous, with clustered variables, because of the different, artially related, variables. An ANOVA was erformed on the searate variables, with a calculation of the effect size. Using the artial η 2 ( η 2 ) an effect size of less than 0.01 was regarded as a small effect, 0.01-0.06 as a medium effect and above 0.14 as a large effect. Results Socio-demograhics characteristics of the investigated oulation In the 10-year eriod, 124 individuals with a relevant ositive atch test to PPD or TDA were identified. Of those 48 ercent (n=60) comleted the questionnaire and were included for further analyses. 19 individuals (32%) were solely sensitized to PPD, 2 were sensitized to TDA alone, and 28 (47%) were sensitized to both PPD and TDA. 11 Individuals were not atchtested with TDA, as it was not art of our extended Baseline Series in some eriod, but they were at least sensitized to PPD. 74
5. The attitude of atients with a -henylenediamine or 2,5-toluenediamine contact allergy towards hair dyeing Of the 60 individuals that comleted the questionnaire, 27 still dyed their hair and 33 stoed. Of all individuals included in this study, 24 reorted to have grey hair, of which 7 continued dyeing their hair, No differences between the grous with resect to the socio-demograhic factors could be determined (Table 1), excet for the length and frequency of hair dye use, which was significantly longer and more frequent in those who continued dyeing. Individuals who continued dyeing their hair, had on average dyed their hair for more years (=0.04, η 2 =0.07) and more frequently (<0.001, η 2 =0.21) than eole who stoed dyeing. In atients with a PPD sensitization the atch test strength seemed to influence their decision regarding hair dye use. Among the continuers 63 ercent had a weak ositive reaction, while amongst the strong ositive reactors only 15 ercent continued dyeing. The most commonly used tye of hair dye was oxidative hair dye, followed by semiermanent hair dye (used by 75.9 and 13.0 ercent of the samle, resectively). 46.7% of the investigated oulation was aware of the existence of PPD-free hair dyes. However, the continuers were far more aware than the eole that stoed dyeing (70.4 versus 27.3 ercent, resectively). Motivations and oinions regarding hair dye use To investigate the background of the behaviour of those that continued dyeing, comared to those that did not, various questions were answered by both grous (Table 2). Regarding the severity of the exected symtoms after dyeing hair, both grous did exect mild symtoms, redness and itch, though those who stoed dyeing did exect these more often (= 0.001; η 2 = 0.21). Of all investigated individuals, those who continued were less afraid of dysnoea (= 0.05; η 2 = 0.07). These continuers did not exect crusts, erosions or facial oedema, while those who stoed did exect them (resectively < 0.001; η 2 = 0.42 and = 0.002; η 2 = 0.18). Almost half of the hair dye continuing individuals agreed that itching or redness was an accetable symtom after dyeing their hair, while significantly fewer of the individuals that stoed dyeing agreed on this (44.4 and 9.7 ercent resectively, < 0.01; η 2 = 0.16). 75
Table 1: Fixed factors influencing continuous hair dye use. Stoed dyeing (n=33) n (%) Continued dyeing (n=27) n (%) Men 4 (12.1) 1 (3.7) 0.367 Age mean (min-max) I Age >40 years 42.3 (17-66) 16 (48.5) 39.3 (17-58) 14 (51.9) 0.411 0.795 Marital state Unmarried, single 5 (15.2) 2 (7.4) Unmarried, living together 5 (15.2) 5 (18.5) Married 19 (57.6) 17 (63.0) 0.528 a Widowed 2 (6.1) 0 Divorced 1 (3.0) 3 (11.1) Other 1 (3.0) 0 Education Primary school 1 (3) 1 (3.7) Lower secondary education 8 (24.2) 8 (29.6) Higher secondary education 16 (48.5) 8 (29.6) 0.606 b Bachelor 5 (15.2) 5 (18.5) Master 3 (9.1) 5 (18.5) Emloyed (aid work) I 17 (53.1) 18 (66.7) 0.291 a Patch test reaction to PPD neg 1 (3.0) 1 (3.7) + 12 (36.4) 17 (63.0) ++ 12 (36.4) 4 (14.8) +++ 8 (24.2) 5 (18.5) -value 0.160 b Patch test reaction to TDA II neg 10 (33.3) 9 (47.4) + 11 (36.7) 7 (36.8) ++ 8 (26.7) 0 0.464 b +++ 1 (3.3) 3 (15.8) Hair color Brown 8 (24.2) 9 (33.3) Blond 8 (24.2) 6 (22.2) Red 0 0 0.697 a Black 2 (6.1) 3 (11.1) Grey 15 (45.5) 9 (33.3) Reaction to hair dye 28 (84.8) 23 (85.2) 0.630 a Length of use I 2.66 (mean) 3.30 (mean) Occasionally/less than 1 year 9 (28.1) 0 1-5 years 5 (15.6) 5 (18.5) 6-10 years 6 (18.8) 9 (33.3) > 10 years 12 (37.5) 13 (48.1) Frequency of use III 1.18 (mean) 2.58 (mean) Occasionally/less than 1 time a year 11 (34.4) 1 (3.8) 1-5 times a year 16 (50) 13 (50) 6-10 times a year 5 (15.6) 8 (30.8) > 10 times a year 0 4 (15.4) 0.044* b 2 =0.072 0.000* b 2 =0.212 Statistical significant differences were calculated using a Chi-square/Fischer s exact test, b ANOVA, c Student s T-test. <0.05 was regarded as a statistical significant difference (*). If no individual -values are shown, they were not statistically significant. Together with a statistical significant difference the effect size (η 2 ) was shown when aroriate. Missing values: I 1, II 11, III 3 76
5. The attitude of atients with a -henylenediamine or 2,5-toluenediamine contact allergy towards hair dyeing Individuals that continued dyeing their hair, stated they were not influenced by the oinion of others regarding their hair colour (=0.4). Both grous were equally satisfied in their life and equally contented with their aearance (resectively = 0.41 and = 0.34).Those that continued dyeing susected a decrease of their hainess when they would discontinue their behaviour (=0.04). Furthermore, they gave their lives a significant lower grade when they would sto dyeing than those that discontinued dyeing (=0.002). Nevertheless, no differences were observed in the resent grade of life and looks between the grous, though it is remarkable that 42 ercent of the stoers wished to dye again. Concerning the reasons for hair dyeing two imortant differences between the grous were found. Subjects that continued dyeing their hair on average gave higher oints to the colored hair looks nicer (=0.02; η 2 =0.10) and it is imortant to look good at your work (=0.02; η2 =0.10). The subjects that discontinued dyeing their hair, significantly agreed more often on the statement that eole with grey hair are not different (=0.02; η 2 =0.104). The Rosenberg self-esteem score was used to calculate the self-confidence of both grous. The mean score of the grou of individuals that stoed dyeing their hair was 33.7/40 and did not differ from that of the continuers, which was 33.3/40 (= 0.73). 77
Table 2: Attitude of atients towards hair dyeing. Exected symtoms after dyeing Stoed dyeing (n=33) Mean Continued dyeing (n=27) Mean -value Redness, itching 4.54 3.46 0.001* b ( 2 =0.209) Crusts, erosions 4.36 2.42 0.000* b ( 2 =0.416) Oedema face 3.50 2.25 0.002* b ( 2 =0.181) Dysnoea 2.64 1.96 0.050* b ( 2 =0.074) Symtoms worth the effort after dyeing Redness, itching 1.71 2.73 0.002* b ( 2 =0.156) Crusts, erosions 1.32 1.65 0.112 b Oedema face 1.29 1.31 0.914 b Dysnoea 1.26 1.35 0.601 b Others think I should dye my hair 3.75 3.47 0.434 b Hainess would imrove without allergy 2.59 3.00 0.178 b Hainess would imrove if dyeing 3.66 3.11 0.044*b would be ossible Amount of eole near that dye their hair # 8.60 7.24 0.535 c Wish to dye hair again # n (%) 11 (42.3) N/A N/A Grade life # 7.39 7.80 0.190 c Mean difference: 0.4114 (95% CI: -0.2096-1.0325) Grade look # 7.16 7.13 0.951 c Mean difference: -0.0212 (95% CI: -0.7024-0.6600) Grade life when dyeing has stoed # 8.02 6.00 0.002* c Mean difference: -2.0231 (95% CI: -3.2350- -0.8112) Reasons for dyeing hair 0.041* Covering grey hair 2.94 3.29 0.528 Nicer color 3.38 4.04 0.021*( 2 =0.100) Required at work 3.10 3.92 0.020* ( 2 =0.101) Others like it 3.56 3.54 0.856 Looks better 2.81 3.08 0.259 Partner likes it 2.63 3.00 0.294 More shine 3.06 3.39 0.298 Others dye as well 2.19 2.54 0.310 Younger look 3.13 3.40 0.681 Oinion on grey hair 0.439 Old 2.03 2.44 0.307 Smart 2.36 2.35 0.616 Shabby 1.84 2.04 0.422 Unattractive 1.90 2.12 0.462 Life exerienced 2.97 2.62 0.119 Not different 4.31 3.68 0.020* ( 2 =0.104) Lazy 1.66 1.65 0.523 Reutable 3.07 3.04 0.899 Piteous 1.59 1.60 0.844 Not afraid of being herself 3.47 3.08 0.302 Artistic 2.74 2.35 0.125 Rosenberg Self-esteem scale 33.7 33.3 0.730 Questions are answered using a five oint scale (often Likert scale). Likert scales went from 1 (totally disagree) to 5 (totally agree), or vice versa, in which case they are marked (Δ). Statistical significant differences were calculated using a Chi-square/Fischer s exact test, b ANOVA, c Student s T-test. <0.05 was regarded as a statistical significant difference (*). Grade of life and Grade of looks are terms made u referring to the satisfaction of individuals regarding their lives and aearance. If no individual -values are shown, they were not statistically significant. Together with a statistical significant difference the effect size (η 2 ) was shown. The answers under Oinion on grey hair and Reasons for dyeing hair were calculated using a MANOVA. When a statistically significant difference was measured, searate ANOVA test and the effect size (η 2 ) was calculated. N/A: not alicable. 78
5. The attitude of atients with a -henylenediamine or 2,5-toluenediamine contact allergy towards hair dyeing Discussion Socio-demograhics characteristics of the investigated oulation Within the investigated oulation, the majority (85%) stated they had endured clinical symtoms comatible with an allergic reaction caused by hair dye use. 9 out of 60 articiants, however, answered they never exerienced such a reaction, desite all of them were atch tested ositive to PPD or TDA. This henomenon might be influenced by atch test strength, as atients with stronger atch test reactions are more likely to have a clear history of reacting to hair dye or react to more comonents of hair dye. 3,5 This could exlain why some eole were sensitized to PPD or TDA but never exerienced any symtoms of a contact allergy after dyeing their hair. In revious research the atch test reaction strength was associated with a continuous dyeing of hair. Peole with an extremely strong ositive reaction generally tended to sto dyeing their hair, in contrast to those with a strong or weak ositive reaction. 3,4 In contrast to the other studies, more than a third of the articiants with extremely strong ositive reactions continued dyeing, which is even more than within the articiants with strong ositive reactions. A ossible exlanation for this result can be attributed to the use of PPD and TDA-free hair dye roducts, although we were not able to assess this in the resent study. Some of the PPD or TDA sensitized individuals can continue dyeing their hair using these hair dye roducts. 6-8 Remarkably, 5 of the 9 articiants that never exerienced any allergic reaction stoed dyeing their hair. An exlanation can be the advice they received from their doctor and the fact that they were afraid of develoing any of the symtoms in the future. The articiants that stoed dyeing their hair exected statistically significant more as well as more severe comlaints when they would dye their hair, with the most ronounced, strong association between ceasing hair dye use and the resumed aearance of crusts and erosions on the scal. Although symtoms of the contact allergy were in general troublesome, current hair dye users showed a modest association with the accetance of symtoms of redness and itch. It is remarkable that the accetance of comlaints and the foreseen comlaints after dyeing hair among the current hair dye users are diverse. A ossible exlanation for this finding can be that continuers delude themselves with a mismatch between acceted and exected comlaints. Threatening information regarding someone s self-image, enables the individual to ignore or minimize the significance of this threat and a erson s thoughts and outcomes of these thoughts are influenced by a referred conclusion. 9,10 79
Motivations and oinions regarding hair dye use Oinions regarding hair dye use and dyed hair are causative for motivations for the continuation of hair dye use. The reasons for dyeing hair because the color was nicer or it was required by the occuation had a large effect on the decision of the current hair dye use. On the contrary, the oinion of others and the behavior of others were not marked as an imortant reason by both grous. In our oinion, individuals included in the resent study can have rovided us with a socially acceted answer, as these findings are contrasting with the findings of Van Vonderen et al., who found that eer comarisons were a very strong indicator of body dissatisfaction. 11 In our oinion an underexosed reason for dyeing hair is to cover grey hair, although it was not that ronounced in the resent study. Therefore, we susected a larger number of greyhaired individuals among those that continued dyeing. Factors that may influence one s decision on continuing dyeing hair are the thoughts and oinions regarding both grey and dyed hair. These can be regarded to as motivation for continued dyeing of the hair. These factors are more related to the individual s beliefs on attractiveness and beauty, although the oinion of grey hair does not differ between the both grous. This is in line with the fact that both grous agreed that dyeing hair is not an advantage to cover grey hair and that dyed hair does not make one look younger. These differences between the grous might indicate that grey hair is not a reason for the continuation of the use of hair dye. Aart from motivations and oinions, the self-esteem of an individual can contribute to the continued use of hair dye roducts, desite the contact allergy. Self-esteem is also called the overall subjective emotional evaluation of an individual s own value. It consists of the individual s ositive and negative beliefs and emotions that are driven by both internal and external stimuli. 12,13 Regarding the scores on the validated Rosenberg s self-esteem scale no difference between the grous could be determined. There was also a lack of difference between the grade for life and looks between both grous. However, the ones that continued dyeing their hair would grade their lives lower when they stoed dyeing than those that already had stoed dyeing. In our oinion the lack of difference between self-esteem, grade of life and looks are attributable to the ursued use of hair dye roducts. Something similar has also been described for the consideration of cosmetic surgery in individuals with lower self-ratings of hysical attractiveness. 14 This suggestion is suorted by the finding that continuers exected to grade their lives significantly lower when they stoed dyeing their hair. 80
5. The attitude of atients with a -henylenediamine or 2,5-toluenediamine contact allergy towards hair dyeing Conclusion The desire to look attractive can lead to otential harmful behavior, such as the continuation of hair dye use, while having a (sometimes severe) contact allergy. Individuals that were still dyeing their hair estimated significant fewer comlaints when dyeing and a lower grade of life, when they stoed dyeing their hair. Furthermore, in this grou a difference between the exected and the acceted symtoms after dyeing were very distinct. This indicates that the individual s actions are influenced by a referred outcome or result. Aart from this, the individual s motivational thoughts are relatively vague and lie outside the atient s ower to influence, such as a nicer colour of the dyed hair. This study confirms the observation that many atients with a hair dye allergy continue dyeing their hair. For this reason research regarding alternative hair dye molecules is indisensible. Acknowledgement We would like to acknowledge miss dr. W.A. Christoffers, PhD, for her contributions to the questionnaire. 81
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